Updates to the MRI Protocol and Clinical Guidelines for MS: CMSC Working Group - Episode 2
June Halper, MSN, APC-C, MSCN, FAAN: As a nurse I hear a lot of patients question about the MRI [magnetic resonance imaging] in terms of gadolinium because that was in the news. Do we need gadolinium? Is gadolinium going to become obsolete, or does it still have a place in scanning? Patients and clinicians are confused about the whole issue.
Anthony Traboulsee, MD, FRCPC: We’ve had several meetings both in the European group as well as groups in North America around the topic of gadolinium. One of the concerns that came up was there’s some potential accumulation in the body of gadolinium, although it’s meant to just be excreted after being used. We haven’t seen any concerning toxicity in the central nervous system with that, but, nonetheless, you want to minimize exposure of anything for people who are getting routine MRIs. What we determined was the use of contrast agents, such as gadolinium, are incredibly valuable, particularly in the diagnostic workup of patients. There are lot of different diseases that can sometimes look like multiple sclerosis [MS] and having that additional information that we get from contrast agents is so invaluable. Also, in making an early rapid diagnosis looking for dissemination of time with enhancing lesions, gadolinium is invaluable.
Scott D. Newsome, DO, MSCS, FAAN: I would say early on when you’re following people, at least in my clinical practice, it’s important to see what the early magnitude of inflammatory activity is at the start because that may actually change the way we treat people up front. Do we be more aggressive up front based on the imaging? Personally, if I see a lot of enhancing lesions up front, I’m likely going to head towards a higher efficacy therapy versus a modestly effective drug.
June Halper, MSN, APC-C, MSCN, FAAN: Well, that’s why this program is so important because the clinicians in the community are still questioning based on publications. There is another question that’s come along, and that’s the central vein sign. David, what have you heard about that or do you think it’s going to find its place in the guideline, or is it on wait and hold?
David Li, MD, FRCPC: We discussed it quite a bit at the meeting yesterday because the central vein is a very important component of the findings that we do see on MR [magnetic resonance]. The issue has to do more with the technology available now in terms of some of the sequences that are used to show that central vein consistently and also how one evaluates for the central vein in the lesions. There are still some practical issues of making it clinically feasible. It’s another evolving aspect of it, and it’s one of these matters where I think as we become more familiar with it and use it more, in the research setting it will definitely be translatable into day-to-day practice.
Where we are at in terms of the guidelines is to say that for those sites that are able to do it, they would do it not as part of their core sequence, but it would be a highly recommended part of it for which the sites that are able to do it will be able to do it and provide us with information and the evidence for it. But for the core facilities that are doing it on a day-to-day practice, they would not have the capability of doing it.
June Halper, MSN, APC-C, MSCN, FAAN: Capability, yeah, yeah.
Frederik Barkhof, MD, PhD: That may also be superfluous in many cases. If you have a very typical scan with oval lesions already where you can assume it’s perivenular and you have all the other stigmata in place, you don’t need it. Whereas, if it’s more dubious case where you’re doubting could it be perhaps small-vessel disease or something, then you may want to turn to this additional sequence to make a choice, isn’t it?
David Li, MD, FRCPC: Yeah, I think that’s a very important point because in many of the things that we do, MS has a very typical appearance. Certainly, the MAGNIMS group has been very good at educating us on green flags and red flags. Many of those are really based on the morphology of it. Some of it is central vein, and some of it is not.
Frederik Barkhof, MD, PhD: It’s nice to be able to show it’s around the central vein, but if you see a typical morphology of the lesion, you can safely assume it’s a perivenular lesion, and you don’t need to do it. Or, if you have multiple short segment core lesions already, then your differential diagnosis is almost nailed down and you may want to skip that.
Scott D. Newsome, DO, MSCS, FAAN: Yeah. From my perspective, where the central vein sign may be applicable is over time when you’re following a patient who may have comorbidities, hypertension, diabetes, and they develop new lesions on imaging, and you’re considering, “OK, should I switch therapies because I’m seeing new lesions, even if it’s in typical areas that we see periventricular, etcetera?” That’s where it may be highly valuable because if you don’t see a central vein sign in that context, maybe you’ll step back and say, “OK, this could possibly be a non—MS-related lesion versus if you see a central vein sign,” then that, at least for me, will increase my index of suspicion to say, “OK, this is pretty consistent with MS.” Maybe we need to have that open conversation with patient and say, “OK, maybe we need to switch therapies.”
June Halper, MSN, APC-C, MSCN, FAAN: Here’s a perfect example how research has evolved into a clinical application. I think that’s something we’ve been dreaming about. So, I think our meeting yesterday really showed us that it’s possible.