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MRI & Multiple Sclerosis
in clinical practice
Robert Lavayssière
Hanoi, Nov 2015
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Summary
Ü Clinical approach
Ü Acquisition protocols
Ü Basic signs
Ü Refinements
Ü Differential diagnosis
Ü Take home
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Epidemiology
• Northern Europe & North America > other regions • Europe: Prevalence: 83/10 000, Incidence: 4,3/100 000 • Sex Ratio: 2W/1M
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Clinical aspects Ü 2 main forms
Ü Relapsing Remitting RR: 58 % Ü Symptoms > 24 h
Ü Interval > 1 month
Ü Complete or partial restoration
Ü Secondary Progressive SP: 27 % Ü Progressive handicap
Ü Progression over 6 months
Ü Other forms Ü Primary Progressive PP: 15 %
Ü Progressive Relapsing: PR
Handicap scale EDSS
RR & SP: earlier beginning 29 vs 40 y M > W in PP form
Partnership between clinicians, neurologist and/or ophtalmologist,
and radiologist
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Imaging Protocols: brain Ü T1 2D or 3D before injection (black
holes, baseline before IV)
Ü Axial Flair 2D or 3D
Ü Sagittal: Flair, T2, STIR
Ü Axial T2 thin slices on Posterior Fossa
Ü T1 3D SE post IV Delay between Gd CA injection and acquisition: 10 minutes
Ü Optional: Magnetization Transfer post-IV, Diffusion, Spectroscopy, SWI
• Many systems, many sequences • 1,5 vs 3T: 3D +++ • Know your system: tricks and traps
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Imaging Protocols: medulla
Ü Inaugural Ü T2 sagittal large FOV no FS Ü STIR sagittal small FOV Ü T1/T1 IV small FOV Ü T2* axial Ü T1 axial post IV
Ü Known MS Ü STIR sagittal small FOV Ü T1 sagittal small FOV Ü T1 sagittal small FOV post
IV, if needed Ü T2* axial
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Safety / (Nephrogenic Systemic Fibrosis)
GFR > 60 mL/
mn
GFR 30-59 mL/
mn
GFR < 30 mL/
mn
High-risk: Omniscan, OptiMark, Magnevist
OK
Warning
Contra-
indicated
Medium risk: MultiHance,
Ablavar, Primovist
OK
OK
Should be avoided
Low-risk: Dotarem, Gadovist, ProHance
OK
OK
Warning
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Evidence of Tissular Gd deposition
Gadolinium deposits in the brains of patients without renal disease: - Xia et al. 2010 - McDonald et al. 2015 - Kanda et al. 2015
Gadolinium deposits in the eyes of NSF patients - Barker-Griffith et al. 2010
Gadolinium deposits in the skin of NSF patients - Thakral & Abraham 2009 - Birka et al. 2015
Gadolinium deposits in the liver, lung, kidney, heart of NSF patients : - Sanyal et al. 2011 - Swaminathan et al. 2008
Gadolinium deposits in the femoral bones of patients after hip surgery: - White et al. 2006 - Darrah et al. 2009 - Goto et al. 2015
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GBCAs and Gd Deposition Ü What we know
Ü Linear GBCAs induce T1 hypersignals in brain. Macrocyclic GBCAs do not
Ü This effect results from gadolinium deposition. It may last for months
Ü It is dose dependent but not strictly limited to multiple (≥ 6) injections
Ü It does not require a blood brain barrier disruption nor renal dysfunction
Ü Long-term retention has also been observed in patients‘s bones and skin
Ü Linear and macrocyclic GBCAs display different tissular kinetic profiles
Ü What we do not know
Ü Has gadolinium deposition any consequence on brain function or integrity?
Ü Are there some more at-risk patients?
Ü How long should we wait until symptoms occur? Should we wait and see?
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New sequence
Ü DDIR
Ü DWI
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3DDIR
DIR=Doubleinversionrecupera4on
Ü TI:450to625ms:SBÜ TI:2600ms:LCSÜ Resolu4on1mm(3D,3T)
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Double inversion recuperation DIR
• Fat and water nulling • Better visualization of
cortical/sub-cortical lesions
• Low S/N • Some artifacts
DIR
FLAIR
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T2* / Imagerie de susceptibilité
SWI et veinules
SWI et veinules
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MS imaged
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Plaques ?
Inflammation Demyelinization Gliosis Axonal loss
T2 High signal High signal High signal High signal T1 Low signal Low signal
Gd + ? Gd -
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MS or not?
Ü High signal intensity zone: NOT specific !
Ü Probably MS Ü Ovoïd (not “nodular/round”) Ü Corpus callosum lesion (sagittal +++) Ü Perpendicular to ventricles Ü Dawson’s digitation Ü (Asymptomatic) medullar lesion (s)
Ü Not MS (importance of clinical information and biology) Ü Contrast enhancement lasting > 3 months Ü Mass effect Ü Meningeal enhancement
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High signal intensity zone in MS
Ü Shape Ü Ovoid Ü Perpendicular to ventricles Ü Variable in size, mm to cms Ü Halo = oedema Ü Confluence
Ü Topography Ü Periventricular: lateral, temporal Ü Sub-cortical: U fibres Ü Optic nerve (STIR,T2 HR) Ü Infra-tentorial:
Ü middle cerebellar peduncle Ü V4 floor Ü Pons
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27 YO F Non specific symptoms Referred by GP for LL weakness Pulmonary embolism post delivery Birth control : pill
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30 YO Female Lower Limb Weakness
3D 1mm thickness
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RR MS 3D 1mm reconstructed
MT
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Cortical and sub cortical: DIR>FLAIR
Nelson et al. Am J Neuroradiol 2007
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Enhancement
Ü “Biomarker”: active inflammation
Ü Early sign, tends to decrease
Ü BBB lesion
Ü Short time span < 3 months, between 3 w to 1 month
Ü Parallel to size of lesion (s)
Ü (No need to inject higher dose) Annular
C shape
Nodular
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HR MR veinographie (SWI)
Venula Plaque
Dawson J. Trans Roy Soc Edinb 1916 Ormerod et al. Brain. 1987
Peri veinous: Dawson’s fingers
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FLAIR/DWI
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Low signal
Ü Acute: oedema. Regression ?
Ü Chronic: “black holes” Ü Destruction/atrophy
Ü Large plaques
Ü Associated with enhancing and non enhancing plaques
Ü May be associated, up to 50 %, with
Ü lipid deposits in macrophages : high signal rings
Ü iron deposits: T2*/SWI signal loss
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Traps and Tricks Fosse postérieure : 2D VS 3D
2D FLAIR HR 3D FLAIR
T2 HR
FLAIR 2D vs 3D : 2D better detection, but more flow artifacts = 3D : PF +++
Posterior fossa, optic nerve: thin slices, T2 HR
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Traps and Tricks
3D T1 SE Better sensitivity Fewer or no flow artifact
From Hodel & al
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2D Vs 3D FLAIR
3D T1 EG 3D DIR 1/5 3D FLAIR 1/5 2D FLAIR 4
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Spectroscopy Acute
Ü Inflammation, demyelinization, neuronal disturbance
Ü Choline, lactate, lipids, myo-inositol increase
Ü NAA, creatin decrease
Ü May precede plaque apparition on MRi
Chronic Ü Gliosis, neuronal loss
Ü (Sub)Normal spectrum, myo-inositol increase
Ü Neuronal loss: NAA decrease in “black holes”
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Medulla
Ü 80 % of RR have medullar lesion (s) at early phase !
Ü Medullar lesion in 75 to 92 % of MSs vs 6% in non MS WM disease.
Ü Look for brain lesion and vice versa
Ü Cervical: 50 %
Ü Postero-lateral, including gray matter: not centered !
Ü Size: limited +++ Ü 2 vertebral height (sag) < Ü Half medulla(axial) <
Ü Often multiple.
Ü High SI on T2, Iso on T1. Gd+ ?
Ü Medulla: normal, swollen, atrophy…
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27 YO F Left LL anesthesia
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Sequelae
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Not so usual
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Optic neuritis STIR
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Pseudo tumour Chol/NAA<2
Long TE
JFR 2010
Chol
NAA
Lactate
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2 weeks later
BALO
J. Balo 1928
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Clinical and Imaging Integration Ü Barkhof
Ü ≥ 9 T2 HI lesions or 1Gd +
Ü 1 sub-cortical
Ü ≥ 3 peri-ventricular lesions
Ü 1 infra-tentorial lesion
80 % patients evolve toward MS
Ü Mac Donald (revised)
Ü Spatial spread: ≥ 1 T2 HI lesion in at least 2 out of 4 localization (periventricular, juxtacortical, infra-tentorial, medulla)
Ü Temporal spreading:
Ü New T2 HI lesion and/or Gd+ at follow up
Ü Simultaneous Gd - and Gd + lesions at the same time
Ü Low reproductibility (Korteweg 2007)
Spreading ?
Temporal Spatial
Clinical (RR/SP)
and/or MRI
Clinical (new symptoms)
and/or MRI
MRI and MS
Ü MS suspected Ü Confirm: CDMS Ü Other diagnosis…
Ü MS not suspected: MS diagnosis suggested
Ü Follow-up, research
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Clinical value ? Follow up
Ü No correlation between handicap and number of lesions & evolution of EDSS
Ü No MRI difference between RR and SP
Ü Initial prognosis ? Ü Worse if multifocal Ü Optic Neuritis : better Ü Transverse myelitis do not evolve
toward MS in most cases
Ü Predictive value G+: Ü Relapse rate: nb G+ initially Ü No correlation between nb G
+ and EDSS score 12/24 months
Ü Poor prognosis/early Tt Ü Inflammatory/heavy lesion
weight Ü Sequela after first strike Ü Severity of the strike
Ü UnderTt ß Interferon: probability of failure % nb of new lesions within one year
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2nd line treatment
Ü Pre Tt requirements : ≥ 1 Gd + lesion or ≥ 9 T2 lesions
Ü Follow-up Tisabri (Natalizumab) Ü Annual JCV* serology -, 3 to 6
months JCV +
Ü MRI evolution ?
Ü Tysabri : sub-clinical LEMP ??? (mortality = about 25 to 30 %)
Ü Gilenya (fingolimod): viral encephalitis (some case report)
(* Polyomavirus)
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Other diagnosis: not MS ???
Importance of clinical input
Ü Age/sex
Ü Type of onset
Ü Associated signs
Ü Infectious
Ü Biology
Multiple diagnosis
Unusual MRI signs for MS ???
Inflammatory/infectious +++
Ü HIV
Ü Neuro-Behcet
Ü Neuro-Sarcoïdis
Ü Lyme disease
Ü Gougerot-Sjögren
Ü Syphilis
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Conclusion
Ü All that shines is not MS J
Ü Integration of clinical (and biological) background with “compatible images”.
Ü Handle with care: beware of words…
Ü Follow-up: treatment ???