Anthony Traboulsee, MD, FRCPC

In October 2019, we cochaired a landmark event organized by the Consortium of Multiple Sclerosis Centers (CMSC). This international effort brought together an expert panel to update the guidelines for a standardized magnetic resonance imaging (MRI) protocol for the diagnosis and follow-up of multiple sclerosis (MS). Presently, there are 2 recommended protocols: guidelines from the CMSC in North America and the Magnetic Resonance Imaging in MS group (MAGNIMS) in Europe.1-5 During this MRI Consensus Guidelines Conference, the aim was to come together to begin developing globally aligned recommendations and to promote more widespread use of a standardized MRI protocol for MS.

The CMSC guidelines for a standardized MRI protocol for the diagnosis and follow-up of patients with MS were first developed in 2001 and have been subsequently updated 5 times.

 The October 2019 consensus conference attendees consisted of neurol- ogists, radiologists, MR technologists, and imaging scientists with an expertise in MS from the United States, Canada, and Europe, including representatives from the CMSC, MAGNIMS, NAIMS (North American Imaging in Multiple Sclerosis Cooperative), the National MS Society, MS Association of America, and representatives from leading MRI manufacturers and commercial image anal- ysis companies. Prior to the meeting, the CMSC also surveyed its members regarding the use of MRI with a consistent standardized protocol, as well as for the use of gadolinium, diffusion-weighted imaging sequences in MS diagnosis and follow-up, and the central vein sign for diagnosis.

The use of MRI is invaluable in the diagnosis and follow-up of patients with MS. Experts agree that a standardized examination is key to the confident and accurate identification of new lesions and activity that facilitates an earlier diagnosis and prompts initiation and/or change in disease-modifying therapy. Annual MRIs that detect new clinically silent disease activity enable health care professionals to treat patients earlier in the disease course and to modify therapy, when needed. As part of the standardized protocol, routine monitoring of patients with MS is recommended.

Using a standardized MRI protocol is of the utmost importance in providing optimal care of patients with MS. By using the same scanner, the same facility, and the same standardized MS MRI protocol with specific core sequences (including defined scan orientation, slice thickness, and coverage) for brain and spinal cord studies, the resultant MRI can be compared with previous studies more easily, effectively, and efficiently. Having 2 scans that are as similar as possible to each other allows the health care provider to more easily detect a new lesion. In addition to improving the ease of comparing scans over time, the use of a standardized protocol will minimize the need for gadolinium. Although gadolinium is helpful in identifying disease activity, its use is not essential.

Peer Exchange: Updates to the MRI Protocol and Clinical Guidelines for MS: CMSC Working Group 

The use of yearly T2-weighted fluid-attenuated inversion recovery sequences using a well-performed standardized MR image is all that is necessary to detect new MS lesions when compared with previous standardized MR imaging studies.

The disease phenotypes as defined by Lublin et al

 include objective criteria of disease activity provided by imaging findings and disease progression. Well-performed standardized MRIs that can be followed and compared longitudinally are important in providing accurate clinical course descriptions,

 with respect to changes in MS lesion activity, lesion, and brain volumes.

In addition to improving patient care, standardizing the MRI protocol will save money. In times of excessive spending in health care, patients may not always receive an MRI that is optimal and able to provide the critical information needed for diagnosis, treatment initiation, monitoring, and follow-up. Repeating subpar MRI scans is a waste of time and money. Another concern is patient time in the scanner. If the goal is to achieve all necessary sequences as efficiently as possible, standardization of the MRI protocol becomes essential. This is an important economic consideration for health care providers, patients, and MRI vendors. With regard to insurance companies, if we provide better care for our patients with MS, it will ultimately be cost saving for patients and their insurance companies (ie, prescribing appropriate disease-modifying therapies and minimizing adverse events).

At the October consensus meeting, representatives from global MRI manufacturers expressed interest in a potential internationally aligned MRI protocol that could be preprogrammed into scanners with the appropriate core sequences for examination of patients with MS, similar to procedures for prostate cancer imaging with recommended protocols being preloaded in MRI scanners. A globally recommended MRI protocol for MS could be preloaded into scanners, and MR technologists could receive training in the use of these standard baseline MRI sequences for patients with MS, and the radiologist’s further optimization preferences could be handled at the time of the scan. Another approach would be to provide exam cards on the CMSC website that could be down- loaded and subsequently uploaded into the MR scanner.

If health care providers for MS demand standardization of an MRI protocol for their patients, the vendors indicated that such a protocol could be implemented into the manufacturers’ software. This is an important effort to explore further with MRI manufacturers and with regulators from the FDA and European Union.

Another outcome of the consensus meeting was re-emphasizing the importance of communication between the neurologist and the radiologist. The clinical question being addressed must be included in the requisition for the MRI. If the neurologist is looking for current activity, use of gadolinium may be recommended because it will indicate new activity that has occurred within the past 4 weeks. However, if the health care provider wants to determine whether any new activity has happened since the patient’s last visit a year ago, a T2-weighted fluid-attenuated scan by itself, without the need for gadolinium, is all that would be necessary. Clinical concern about possible new activity, or if switching therapy is a consideration, should appear on the requisition form so the radiologist’s report can provide the appropriate information about the MRI examination. Similarly, if a diagnosis of MS is being considered on the requisition, the report will focus on providing the necessary details concerning lesion dissemination in space and time.

This year, the CMSC and our guideline consensus group will be undertaking an ambitious plan to disseminate information about the importance and value of a standardized MRI protocol and to educate neurologists, radiologists, MR technicians, MR manufacturers, and patients with MS regarding the need for a globally aligned MRI protocol for MS. We plan to present abstracts, posters, and educational presentations at various medical meetings in 2020. Other methods for dissemination that were discussed include webinars and developing cards with the MRI protocol for distribution to clinicians, radiologists, technicians, MS and MRI centers, as well as patients.

Standardized MRI protocol and clinical guidelines for the diag- nosis and follow-up of MS have been available for over a decade. Although these guidelines are useful and useable, they are not yet widely used. The expert group convened recently by the CMSC is currently updating the MRI guidelines with the vision and action plans for the MRI protocols to be universally useful, useable, and used as the standard of care for patients with MS. In the plans for the coming year is a meeting of representatives from the CMSC, MAGNIMS, and NAIMS to bring together the updated CMSC and MAGNIMS guidelines into 1 international consensus standardized protocol, with special attention to alignment on the core sequences needed for optimal care of patients with MS and to have these guidelines endorsed and adopted internationally by various MS-related organizations, MRI vendors, and MR imaging facilities from around the world.

Lori Saslow (Great Neck, NY) a medical writing consultant on behalf of the CMSC, assisted in editorial preparation and editing.

1. Traboulsee A, Simon JH, Stone L, et al. Revised recommendations of the Consortium of MS Centers Task Force for a standardized MRI protocol and clinical guidelines for the diagnosis and follow-up of multiple sclerosis. 

. 2016;37(3):394-401. doi: 10.3174/ajnr.A4539.

2. The Consortium of MS Centers MRI Task Force. Consortium of MS Centers MRI protocol and clinical guidelines for the diagnosis and follow-up of MS. 2018 Revised guidelines. 2018. https://cdn.ymaws.com/mscare.site-ym.com/resource/collection/9C5F19B9-3489-48B0-A54B-623A1ECEE07B/2018MRIGuidelines_booklet_with_final_changes_0522.pdf. Accessed January 9, 2020.

3.  Rovira À, Wattjes MP, et al, on behalf of the MAGNIMS study group. MAGNIMS consensus guidelines on the use of MRI in multiple sclerosis—clinical implementation in the diagnostic process. 

. 2015;11(8):471-482. doi:10.1038/nrneurol.2015.106.

4. Wattjes MP, Rovira À, et al, on behalf of the MAGNIMS study group. MAGNIMS consensus guidelines on the use of MRI in multiple sclerosis—establishing disease prognosis and monitoring patients. 

. 2015;11(10):597-606. doi:10.1038/nrneurol.2015.157.

5. Arevalo O, Riascos R, Rabiei P, Kamali A, Nelson F. Standardizing magnetic resonance imaging protocols, requisitions, and reports in multiple sclerosis: an update for radiologist based on 2017 magnetic resonance imaging in multiple sclerosis and 2018 consortium of multiple sclerosis centers consensus guidelines. 

. 2019;43(1):1-12. doi: 10.1097/RCT.0000000000000767.

6. Simon JH, Li D, Traboulsee A, et al. Standardized MR imaging protocol for multiple sclerosis: consortium of MS centers consensus guidelines. 

7. Traboulsee A, Li D. Addressing concerns regarding the use of gadolinium in a standardized MRI protocol for the diagnosis and follow-up of multiple sclerosis 

 Published online September 1, 2016. doi:10.3174/ajnr.A4943.

8. Lublin FD, Reingold SC, Cohen JA, et al. Defining the clinical course of multiple sclerosis: the 2013 revisions.

2014;83:278-286. doi: 10.1212/WNL.0000000000000560.

Articles

Leaders of the CMSC Working Group on MRI protocols and clinical guidelines express the need for a unified approach to diagnosing and monitoring multiple sclerosis.

Author | Anthony Traboulsee, MD, FRCPC

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The Importance of a Globally Aligned, Standardized MRI Protocol for MS