Recommended Neuroimaging Protocol for Multiple Sclerosis
Brain MRI with gadolinium enhancement is the cornerstone of neuroimaging for both diagnosis and monitoring of multiple sclerosis patients, while spinal cord imaging should be performed selectively based on clinical presentation and disease course.
Standard Brain MRI Protocol
Core Sequences
- 3D T1-weighted imaging
- 3D T2-FLAIR (fluid-attenuated inversion recovery)
- 3D T2-weighted imaging
- Post-gadolinium T1-weighted imaging (minimum 5-minute delay after contrast administration)
- Diffusion-weighted imaging (DWI)
Technical Specifications
- Field strength: Minimum 1.5T (higher field strengths may reveal more lesions)
- For 2D sequences: ≤3mm slice thickness with 1×1mm in-plane resolution
- For 3D sequences: 1mm³ voxel size
- Consistent imaging protocol across follow-up scans
Spinal Cord MRI Protocol (When Indicated)
Core Sequences
- Sagittal T1-weighted imaging
- Sagittal proton density/STIR or phase-sensitive inversion recovery
- Axial T2 or T2*-weighted imaging through suspicious lesions
- Post-gadolinium T1-weighted imaging (in selected cases)
Monitoring Frequency
Standard Monitoring
- Baseline brain MRI at diagnosis
- Follow-up brain MRI at least annually for all MS patients 1
- More frequent monitoring (every 3-4 months) for patients requiring enhanced pharmacovigilance
Special Situations
- For natalizumab-treated patients at high risk of PML (JCV seropositive, treatment duration ≥18 months): Brain MRI every 3-4 months using protocol including FLAIR, T2-weighted and DWI sequences 1
- For natalizumab-treated patients at low risk of PML (JCV seronegative): Annual brain MRI 1
- For patients switching disease-modifying drugs (DMDs): Brain MRI at the time of discontinuation and after starting new treatment 1
- For patients switching from natalizumab to other therapeutics: Enhanced monitoring with brain MRI every 3-4 months for up to 12 months 1
When to Use Spinal Cord Imaging
- At initial diagnosis if brain MRI is nondiagnostic 2
- When presenting symptoms are at the level of the spinal cord 2
- Not recommended for routine follow-up monitoring as:
- Spinal cord MRI is less sensitive than brain MRI for detecting disease activity 1
- Technical challenges make standardization difficult 1
- Most spinal cord lesions are clinically symptomatic 1
- Strong correlation exists between brain and spinal cord lesion development 1
- New isolated spinal cord lesions occur in only <2% of clinically stable MS patients 3
Clinical Relevance of MRI Findings
Key Prognostic Indicators
- Baseline lesion number and topography (especially infratentorial lesions) predict conversion to definite MS and disability accumulation 1
- Contrast-enhancing lesions indicate acute inflammation 1
- Chronic T1 hypointense lesions ("black holes") persisting >6 months may predict disability progression 1
- Brain volume changes correlate with cognitive impairment, fatigue, and disability progression 1
Pitfalls and Caveats
- Pseudoatrophy: Anti-inflammatory drugs can cause excessive brain volume decrease within first 6-12 months of treatment, followed by stabilization 1
- Technical consistency: Follow-up scans should use the same MRI system and imaging protocol as baseline scans to ensure accurate comparison 1
- Timing of contrast: Minimum 5-minute delay between gadolinium administration and T1 acquisition is necessary 1
- Clinical correlation: MRI findings should always be interpreted alongside clinical assessments, as MRI lesions alone weakly correlate with clinical status 4
- Spinal cord limitations: While spinal cord lesions are associated with increased risk of disability, routine spinal cord imaging adds limited value for most stable patients 3
By following this protocol, clinicians can effectively monitor disease activity, treatment efficacy, and potential treatment-related adverse effects in MS patients, ultimately improving morbidity, mortality, and quality of life outcomes.