Is Magnetic Resonance Imaging (MRI) of the brain with or without contrast indicated in patients with Multiple Sclerosis (MS)?

From the Guidelines

MRI brain with contrast is recommended for the diagnosis and monitoring of multiple sclerosis (MS). The preferred protocol is MRI with gadolinium-based contrast agents, as contrast enhancement helps identify active inflammatory lesions that represent breakdown of the blood-brain barrier, a hallmark of acute MS activity 1. Contrast-enhanced MRI allows clinicians to distinguish between old, inactive lesions and new, active ones, which is crucial for treatment decisions. For initial diagnosis, a complete MRI protocol should include T1-weighted images with and without contrast, T2-weighted images, FLAIR sequences, and sometimes diffusion-weighted imaging.

Key Considerations for MRI Protocol

• The use of proton density and/or T2-FLAIR and T2-weighted fast spin-echo sequences can help detect active lesions 1
• A postcontrast T1-weighted sequence is highly recommended as it facilitates visual detection of new active lesions 1
• Follow-up MRI should be performed with the same equipment and the same protocol as the initial scan, with adequate repositioning to ensure accurate assessment of serial scans 1

Frequency of Follow-up MRIs

• The typical frequency for follow-up MRIs is annually for stable patients, but may be more frequent (every 3-6 months) when initiating new treatments or with disease progression 1
• Patients at risk of serious treatment-related adverse events may need to be monitored more frequently, for example, every 3–4 months 1

Safety Considerations

• Gadolinium contrast carries minimal risk for most patients, though caution is needed in those with severe kidney disease or gadolinium allergies 1

From the FDA Drug Label

14 CLINICAL STUDIES

14.1 MRI of the CNS Gadoteridol was evaluated in two multicenter trials of 310 evaluable patients suspected of having neurological pathology.

In another multicenter study of 49 evaluable adult patients with known intracranial tumor with high suspicion of having cerebral metastases, two doses of gadoteridol were administered.

Pediatric Patients Gadoteridol was evaluated in a multicenter study of 103 patients undergoing brain or spine MRI.

The answer to whether Magnetic Resonance Imaging (MRI) of the brain with or without contrast is indicated in patients with Multiple Sclerosis (MS) cannot be directly determined from the provided text, as MS is not explicitly mentioned.

• The studies described in the label involve patients with suspected neurological pathology, intracranial tumors, or cerebral metastases, but do not specifically address MS.
• Therefore, no conclusion can be drawn regarding the use of MRI with or without contrast in patients with MS 2.

From the Research

Indications for MRI with or without Contrast in Multiple Sclerosis

• MRI is the most sensitive technique for detecting inflammatory demyelinating lesions in MS and plays a crucial role in diagnosis and monitoring treatment effectiveness 3.
• The use of gadolinium-based contrast agents (GBCAs) is generally recommended in the diagnostic workup in subjects with suspected MS, but is not necessary for routine monitoring in clinical practice 3, 4, 5.
• Contrast-enhancing lesions on T1-weighted sequences are related to (sub)acute inflammation, while new or enlarging T2 lesions reflect the permanent footprint from a previous acute inflammatory demyelinating event 3.
• Alternative MRI-based approaches for detecting acute focal inflammatory MS lesions are not yet ready to be used in clinical practice 3.

Safety Considerations and Reduction of Contrast Use

• Due to concerns regarding tissue deposition of GBCAs, scientific organizations and regulatory agencies have proposed that these contrast agents should be administered only if clinically necessary 3, 4.
• A multidisciplinary effort to implement a quality improvement project to limit contrast in MS patients receiving follow-up MRIs allowed for improved safety and cost by targeting patients that would benefit from the use of intravenous contrast in real-time 4.
• Routine administration of contrast in follow-up studies is not suggested, especially in patients with non-progressive disease on follow-up non-contrast-enhanced MRI 5.

Role of Contrast-Enhanced and Non-Contrast-Enhanced MRI in MS Follow-Up

• Spinal cord and Gd-enhanced MRI can provide additional information to brain MRI to determine prognosis of MS 6.
• The likelihood of switch from platform to high-efficacy disease modifying treatment (DMT) was higher when including post-Gd acquisitions to brain and/or spinal cord MRI, compared with no MRI 6.
• Non-contrast-enhanced images can be used to identify patients with new or enlarging lesions, allowing for the reduction of contrast use in routine monitoring 4, 5.