From the Guidelines
For an MS work-up, a brain and spinal cord MRI with and without contrast (gadolinium) is recommended, including T1-weighted, T2-weighted, FLAIR, and post-contrast T1-weighted sequences, as outlined in the MAGNIMS consensus guidelines 1. The protocol should cover the entire brain and spinal cord, with particular attention to the cervical and thoracic regions.
- Key sequences include:
- T1-weighted sequences before and after contrast
- Axial T2-weighted and proton-density (or T2-FLAIR) sequences
- Sagittal 2D or isotropic 3D T2-FLAIR sequences
- Thin-slice imaging (3mm or less) is preferred for better detection of small demyelinating lesions, as recommended by the MAGNIMS consensus guidelines 1. The contrast enhancement helps identify active inflammatory lesions, as gadolinium crosses the blood-brain barrier in areas of active inflammation, with a minimum delay of 5 min after contrast injection 1. This comprehensive imaging approach is essential because MS lesions can appear throughout the central nervous system, and their distribution pattern is crucial for diagnosis, as noted in the study by 1. The presence of multiple lesions disseminated in time and space is a key diagnostic criterion for MS. Follow-up MRIs are typically performed annually or when new symptoms develop to monitor disease progression and treatment response, with a standardized follow-up protocol that includes proton density and/or T2 FLAIR and T2 weighted fast or turbo spin echo sequences, as well as a gadolinium enhanced T1 weighted sequence 1.
From the Research
MRI Protocols for MS Workup
The following MRI protocols are recommended for the diagnosis and follow-up of Multiple Sclerosis (MS):
- Brain MR imaging with gadolinium is recommended for the diagnosis of MS 2
- Spinal cord MR imaging is recommended if the brain MR imaging is nondiagnostic or if the presenting symptoms are at the level of the spinal cord 2
- A follow-up brain MR imaging with gadolinium is recommended to demonstrate dissemination in time and ongoing clinically silent disease activity while on treatment, to evaluate unexpected clinical worsening, to re-assess the original diagnosis, and as a new baseline before starting or modifying therapy 2
Specific MRI Sequences
The following specific MRI sequences are recommended:
- 3D T1-weighted, 3D T2-FLAIR, 3D T2-weighted, post-single-dose gadolinium-enhanced T1-weighted sequences, and a DWI sequence for brain MR imaging 2
- Sagittal T1-weighted and proton attenuation, STIR or phase-sensitive inversion recovery, axial T2- or T2*-weighted imaging through suspicious lesions, and, in some cases, postcontrast gadolinium-enhanced T1-weighted imaging for spinal cord MR imaging 2
- Short T1 inversion recovery (STIR) sequence for improved detection of MS lesions within the spinal cord 3
- Diffusion-weighted imaging (DWI) as a potential alternative to contrast-enhanced T1-weighted imaging for demonstrating dissemination in time in MS 4
Comparison of MRI Sequences
Studies have compared the effectiveness of different MRI sequences in detecting MS lesions, including:
- A comparison of sagittal short T1 inversion recovery and T2-weighted FSE sequences for detection of MS spinal cord lesions, which found that STIR sequences improve lesion detection and lesion conspicuity 3
- A comparison of diffusion-weighted imaging and enhanced T1-weighted sequencing in patients with MS, which found that DWI can detect diffusion alterations in active inflammatory lesions, but may not replace contrast-enhanced T1-weighted imaging for demonstrating dissemination in time 5, 4