Magnetic Resonance Imaging in Multiple Sclerosis 2021 (MAGNIMS), Consortium of Multiple Sclerosis Centers (CMSC), North American Imaging in Multiple Sclerosis Cooperative (NAIMS), provided updated consensus recommendations on magnetic resonance imaging (MRI) in patients with multiple sclerosis (MS.). ), which can be found in The Lancet Neurology.
A team of researchers from the MAGNIMS, CMSC and NAIMS study groups created the guidelines to provide updates on MRI use for the diagnosis, prognosis and treatment monitoring of MS with detailed instructions on the use of standardized MRI protocols, the use of intravenous gadolinium-based contrast agents (GBCAs) and standardized reporting. They also made recommendations for the use of MRI in patients with MS who are children, pregnant, or in the puerperium. Finally, they made recommendations on new MRI techniques with potential for future clinical relevance.
Use of MRI to determine the diagnosis of MS
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The use of three-dimensional (3D) acquisition techniques as opposed to 2D techniques is preferred and is becoming more and more clinically available for the detection of new lesions when comparing serial MRI scans. The sagittal 3D T2-weighted fluid-attenuated inversion recovery (FLAIR) is considered a core sequence for MS diagnosis and monitoring due to its high sensitivity. If high quality 3D FLAIR images cannot be achieved, the use of high quality 2D pulse sequences can be used as an alternative.
Although 3-T scanners have a higher detection rate for MS lesions and can provide faster detection compared to lower magnetic field strengths, using 1.5 T scanners at diagnosis is still sufficient to detect brain lesions. There is currently no evidence that 3 T-scans lead to an earlier diagnosis of MS. However, scanners with a field strength of less than 1.5 T are not recommended. 7T, which is not often available and mainly used for research purposes, is also not currently recommended in clinical practice.
The use of GBCAs is essential during the initial screening of MS to demonstrate timely dissemination and rule out alternative diagnoses. Double and triple doses of GBCAs are not recommended in clinical practice for safety reasons, and the time delay between contrast administration and T1-weighted exposure should be the same during follow-up exams, ideally 10 minutes but not less than 5 minutes.
For additional or advanced MRI, the panel determined that diffusion-weighted imaging cannot replace gadolinium as an active marker of inflammation. They did not recommend dedicated optic nerve MRI, except in patients with atypical clinical symptoms or in differential diagnoses of neuromyelitis optica spectrum disorders.
If the first MRI does not meet the criteria, a brain MRI every 6 to 12 months is recommended for clinically isolated syndrome and subclinical MS radiologically isolated syndrome. An identical image acquisition is strongly recommended. However, spinal cord MRI is not routinely recommended, and gadolinium is not recommended.
Use of GBCAs in the diagnosis and monitoring of MS
In diagnosis, the use of GBCAs is recommended to visualize prevalence from baseline MRI, to aid in differential diagnosis, to predict disease activity and progression, and to be able to phenotype patients as the disease progresses.
In disease monitoring, some cases where the use of GBCAs is recommended are recommended in the first year of follow-up, when there is no newly obtained baseline MRI scan, when clinical disease activity needs to be identified or confirmed in patients with no current reference MRI- Examination of the brain and for patients with diffuse and confluent chronic MS lesions.
Investigators did not recommend the use of GBCAs in new MRIs, in brief follow-up MRIs to confirm disease activity in patients with isolated MRI activity in previous MRIs, in progressive multifocal leukoencephalopathy screening, or in pregnant patients (strict contraindicated).
The 2021 evidence-based MAGNIMS-CMSC-NAIMS recommendations aimed to simplify and condense brain MRI protocols for monitoring MS to ensure easier application than previous guidelines. The guideline authors also recommended that new MRI examinations without gadolinium be performed at least 3 months after the start of treatment, with annual follow-up examinations without gadolinium.
Compared to earlier guidelines, it was recommended to reduce the repeated use of macrocyclic GBCAs as well. In addition, the authors found that there was insufficient supportive evidence to support the use of spinal cord MRI for routine follow-up visits in monitoring MS disease activity; however, a spinal cord MRI is recommended for diagnosis.
Recommendations for diagnosis, prognosis, and monitoring of disease activity are generally recommended in both pediatric and adult patients with MS.
“[Standardization] and implement new and potentially more sensitive and specific imaging techniques than those currently in use [2] the greatest challenges, but also [2] of greatest opportunities in the near future, especially as new treatments emerge with an emphasis on neuroprotection, remyelination, and neuronal repair, ”the authors concluded.
For more detailed information, see the original consensus recommendations.
Disclosure: Several authors stated links to the pharmaceutical industry. For a full list of the details, see the original article.
relation
Wattjes MP, Ciccarelli O, Reich DS, et al. 2021 MAGNIMS-CMSC-NAIMS consensus recommendations on the use of MRI in patients with multiple sclerosis. Lancet Neurol. Published online June 14, 2021. doi: 10.1016 / S1474-4422 (21) 00095-8
