MS ECHO Session 2: Role of neuroimaging for MS

diagnosis and MS management

Gary Stobbe, MD Medical Director, MS Project ECHO

Clinical Assistant Professor, UW Neurology

Annette Wundes, MD Medical Director, UW Multiple Sclerosis Center

Associate Professor, UW Neurology

Conflict of Interest:

• Dr. Stobbe – No conflicts of interest to disclose

• Dr. Wundes – No conflicts of interest pertaining to this

presentation – Research funding: Biogen Idec

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Educational Objectives • Review MRI terminology and basics relevant

to MS • Understand MRI criteria for MS diagnosis

and differential • Understand the role of MRI in monitoring MS

disease and response to treatment • Recognize MRI limitations

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MRI terminology and basics

Of interest in MS: •Three types of lesions •Location

T2/FLAIR lesions = overall lesion load

• T2-hyperintense lesions: “white spots” on both brain and spine

• FLAIR lesions (or STIR lesions on spine): “white spots” can be easier picked up b/o spinal fluid is black rather than white

FLAIR T2

By itself just a structural change non-specific – gliosis, small vessel changes, normal aging, demyelinating most lesions do not go away – “burden of disease” (BoD) New lesions over time demonstrate disease progression in MS

Before administration of contrast dye

After administration of contrast dye

Contrast-enhancing lesions = evidence of acute inflammation

(T1 sequence)

T1 black hole = focal loss of nerve fiber/scar

FLAIR for white spots T1 for “black holes”

(AKA “T1 hypodensity”, “T1 hypodense lesions”)

Classical locations and morphology of MS lesions

Periventricular

“Dawson’s fingers”

Subcortical

Spine lesions

Corpus callosum

Case B - Overview • 29 yo single mother, 2011 establishing care with newly diagnosed RRMS • no relevant prior hx/family hx • 2009 diffuse sensory sx neck area, then progressive sx R>L ON, no IVMP b/o

delay in diagnosis ON. Outside brain and C-spine MRI negative. • Mid 2010 abdominal cramping and rectal urgency w/o identified etiology x 3m • Dec 2010 progressive sensory sx RUE, R torso, RLE x 3 weeks • Mar 2011 numbness L hand x 1m • May 2011 R ON, L hand numbness, Lhermitte

Brain MRI: Multifocal WM lesions c/w MS, at least 4 enhancing lesions Neuro-ophthalomology: agree ON 3 day IVMP

Case B FLAIR lesions 2011 (2009 none)

Case B FLAIR lesions 2011 (2009 none)

Case B Contrast-enhancing lesions (at least4)

Case B T1 hypointense lesions (“black hole”)

Diagnostic criteria for MS

DIS (dissemination in space)

≥1 T2lesion in each of ≥ 2 of 4 characteristic locations: • Periventricular • Juxtacortical • Posterior fossa • Spinal cord

*Symptomatic lesions in brainstem and cord syndromes excluded

DIT (dissemination in time)

• Any new T2 lesion -- regardless of timing

• If simultaneously contrast-enhancing and non-enhancing lesion at the same time

Revised Mc Donald MRI criteria: “any two, any new”

Sensitivity 72%, specificity ~90%, Polman et al., Ann Neurology 2011

Differential Diagnosis: Brain MRI findings often nonspecific

There is some overlap of MRI presentations. Context of clinical history and neurological findings on exam matters!

Migraines

Microvascular changes

Multiple sclerosis

(Rule of thumb: 65% of 65yo!)

Images courtesy of UW neuroradiologist D. Shibata

Spine lesions

MS – minimal cord swelling - < 2 vertebral segments - only part of cord in cross section

NMO - longitudinally extensive transverse myelitis (LETM)

MRI progression over time

Relapse Progression MRI

Adapted after Freedman et al, Can J Neurol Sci 31:157 (2004) and Can J Neurol Sci40:307 (2013)

• Provides info re underlying disease progress • New T2/FLAIR lesions or contrast-enhancing lesions?

Be aware of MRI limitations • Quality matters

• MS protocol (see resources for CMSC protocol) • 3 Tesla considered “golden standard” in MS at this point • Direct comparison to prior MRI • Slice thickness • Post-contrast images

• Clinical/ MRI mismatch

• Relevant area scanned, consider spine MRI if needed

• Known to be insensitive for • Cortical lesion load (assume most of your patients have them) • Neuro-degenerative changes • Atrophy difficult to quantify on standard MRI

Resources

• Consortium of MS Centers MRI Protocol for the Diagnosis and Follow-up of MS – Provides guidance on what type of scan to order in setting of new diagnosis,

MS monitoring, technical MRI specifics and recommendation on MRI report for MS work up and monitoring

• Professional Resource Center (www.NationalMSSociety.org/PRC ) – Prototypical MRI findings in MS (ppt, pdf)

http://www.nationalmssociety.org/For-Professionals/Clinical-Care/Diagnosing-MS/Diagnostic-Workup

• For your Patients: MS Navigator Program – 1-800-344-4867 (1-800 FIGHT MS)

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