updates of mri criteria for diagnosis of ms

Updates of MRI Criteria for Diagnosis of MS

Mohammad AboulwafaResearch Fellow Neurologist

Fellowship of ECTRIMS/MAGNIMS in MRI Research

Al-Azhar University

Released by NASA/JPL on July 25, 1976

We tend to See Ambiguous White Matter Hyperintensities

in MRI as MS Lesions

We tend to See Ambiguous White Matter Hyperintensities

in MRI as MS Lesions

MRI is good only when you know well how to use it

Objectives• Briefly outline the proposed update in MRI Criteria for

diagnosis of MS by the MAGNIMS 2016

• Putting the proposed MRI criteria into clinical application

• Relevance of the criteria specifically to Egyptian population

• Presenting the data-driven evidence as simple as possible

Two types of MRI Criteria we Actually Need for Multiple Sclerosis (MS)

Differentiate MS from Other Neurological Disorders (OND)

Differentiate patients who will/will not show subsequent

relapses and damage

e.g MS vs. (Lupus, Vasculitidies)

e.g Relapsing MS vs. Isolated Optic Neuritis

Kim et. al, 2014

The Question that the MRI Criteria Really Answers

• Predicts converters versus non-converters to CDMS

• Differentiates demyelinating vs. non-specific / migraneous changes

Prediction of later on Disease Development (Clinically Definite CDMS)

• Dissemination in time (the disease is ongoing)

• Dissemination in space (the pathology is not isolated)

Early DiagnosisOver Diagnosis

(sensitive, less specific)

Confident DiagnosisLate Diagnosis

(Specific, less sensitive)

McDonald’s 2001

McDonald’s 2005

McDonald’s 2010

AAN criteria Fazekas

Paty

MAGNIMS 2016

MRI in MS Diagnosis• MRI has been proposed as an alternative (surrogate) to clinical events

(2001) Criteria.• McDonald’s 2005, increased value of spinal cord imaging, earlier

diagnosis• McDonald’s 2010, less complex, focuses on lesion location rather than

count,

DIT An Enhancing and Non-enhancing lesions New T2 lesion at any time

DISOne or More lesion at Two or more sites

Symptomatic infratentorial lesions not counted (for space or time dissemination)

2016 Updates Summary

Revised Dissemination of Space

Expand typical locations

Revised lesion count

Revised Non-symptomatic lesion

concept

Expanded application to age groups

Expanded application to ethnic groups

Revised distinction between RRMS

and PPMS

Included Late Pediatric Population (11 years)

Included Latin, African American, and Asian

(after exclusion of NMO)

2016 Updates Summary

Revised Dissemination of Space

Expand typical locations

Revised lesion count

Revised Non-symptomatic lesion

concept

Expanded application to age groups

Expanded application to ethnic groups

Revised distinction between RRMS

and PPMS

Included Late Pediatric Population (11 years)

Included Latin, African American, and Asian

(after exclusion of NMO)

2016 Updates Summary

Revised Dissemination of Space

Expand typical locations

Revised lesion count

Revised Non-symptomatic lesion

concept

Expanded application to age groups

Expanded application to ethnic groups

Revised distinction between RRMS

and PPMS

Included Late Pediatric Population (11 years)

Included Latin, African American, and Asian

(after exclusion of NMO)

Do We Have a Different Disease Profile?

Optic Non Optic Spinal Brainstem Other0

10

20

30

40

50

60

70

80

90

55

45

1620

9

21

79

38

31

7

CIS Presentation (by Percentage of Patients)Egyptian Versus Multicenter European Cohort

Swanton Multicenter Cohort Egyptian Cohort Data Adapted fromSwanton et. al, 2007Zakaria et. al, 2016

Do We have a Different Disease Profile?

European Reports Egyptian Reports0

2

4

6

8

10

12

14

16 15

6

Progressive Onset MS (by Percentage of Patients)Egyptian versus European Report

2016 Updates Summary

Revised Dissemination of Space

Expand typical locations

Revised lesion count

Revised Non-symptomatic lesion

concept

Expanded application to age groups

Expanded application to ethnic groups

Revised distinction between RRMS

and PPMS

Included Late Pediatric Population (11 years)

Included Latin, African American, and Asian

(after exclusion of NMO)

Periventricular Lesion Count

Swanton et. al, 2006

Periventricular Lesion Count

Swanton et. al, 2007

Barkhof’s 3 Periventricular Criterion

Kim et. al, 2014

• A strong predictor of conversion to CDMS

• Periventricular lesions found in many other disorders (up to 30% in Migraine)

MAGNIMS 2016 Update

Three or more Periventricular lesions are required to consider dissemination of space in this region

2016 Updates Summary

Revised Dissemination of Space

Expand typical locations

Revised lesion count

Revised Non-symptomatic lesion

concept

Expanded application to age groups

Expanded application to ethnic groups

Revised distinction between RRMS

and PPMS

Included Late Pediatric Population (11 years)

Included Latin, African American, and Asian

(after exclusion of NMO)

Revised Non-symptomatic lesion concept

153 CIS Patients

ECTRIMS 2014Factors that determine disease course: the symptomatic lesion matters. 1000 CIS subgroup analysis.

Brainstem syndromes with a unique symptomatic lesion in the brainstem or cerebellum have a higher risk of developing MS than patients with 0 lesions. Despite the recommendations of the 2010 McDonald criteria, the symptomatic lesion matters in terms of risk of developing MS and accumulation of disability.

Tintore’ et. al, 2014

MAGNIMS 2016 Update

No distinction needs to be made between symptomatic and asymptomatic MRI lesions

for dissemination in time or space

2016 Updates Summary

Revised Dissemination of Space

Expand typical locations

Revised lesion count

Revised Non-symptomatic lesion

concept

Expanded application to age groups

Expanded application to ethnic groups

Revised distinction between RRMS

and PPMS

Included Late Pediatric Population (11 years)

Included Latin, African American, and Asian

(after exclusion of NMO)

Cortical Lesions• Pathologically Relevant

• Shows more specificity to MS compared to other disorders (e.g NMO and Migraine)

• Identified in more than 30% of CIS patients in a number of studies

Imaging of the Cortical Space

Double Inversion Recovery 3D T1 (MPRAGE)

Practical Considerations• Low inter-observer agreement

• MR imaging shows a small fraction of the actual burden

• Special MRI preparation (1.5 Tesla and at least 3mm slice thickness).

• Definite diagnostic yield value not present (how many patients per one positive result?)

MAGNIMS 2016 Update

When available, advanced MRI techniques should be applied to visualize cortical lesions

Optic Nerve Lesions• Imaging of the Optic nerve

• Mobile• Small• Surrounded by fat

MRI Orbit: STIR

STIR: short tau inversion recovery

Optic Nerve Lesions• Imaging of the Optic nerve

• Mobile• Small• Surrounded by fat

MRI Orbit: T1 with Fat Suppression

Practical Considerations• Special MRI preparation (1.5 Tesla and at ask for specific sequences).

• Definite diagnostic yield value not present (how many patients per one positive result?)

MAGNIMS 2016 Update

The Presence of lesions in the optic nerves should be added as an additional area

2016 Updates Summary

Revised Dissemination of Space

Expand typical locations

Revised lesion count

Revised Non-symptomatic lesion

concept

Expanded application to age groups

Expanded application to ethnic groups

Revised distinction between RRMS

and PPMS

Included Late Pediatric Population (11 years)

Included Latin, African American, and Asian

(after exclusion of NMO)

Primary Progressive MS• One year Progression plus 2 of:

Brain Dissemination in Space

Spinal Cord Dissemination in Space

(2 or more lesions)

Positive Oligoclonal Bands

MAGNIMS 2016 Update

Dissemination in space criteria should be the same for RRMS and PPMS

Selected Readings• MRI criteria for the diagnosis of multiple sclerosis: MAGNIMS consensus guidelines

Filippi et al. 2016 Lancet

• MAGNIMS consensus guidelines on the use of MRI in multiple sclerosis—clinical implementation in the diagnostic process

Rovira et al. 2015 Nature Neurology

• MAGNIMS consensus guidelines on the use of MRI in multiple sclerosis—establishing disease prognosis and monitoring patients

Wattjes et al. 2015 Nature Neurology

• Clinically isolated syndromesMiller et al. 2012 Lancet Neurology

Questions?