The role of MRI in the diagnosis of Multiple Sclerosis

Transcription

1 The role of MRI in the diagnosis of Multiple Sclerosis LH is a 34 yo female with a history of relapsing remitting MS presents to the multiple sclerosis clinic for MRI follow up of disease progression. Brice Gaudilliere, PhD (Harvard Medical School year IV) Gillian Lieberman, MD 1

2 Objectives Briefly review the pathogenesis of multiple sclerosis (MS). Introduce the McDonald's MRI criteria for diagnosis of MS. Describe the typical MRI findings and diseaseprogression of MS. Discuss limits and future prospects of MRI diagnosis of MS. 2

3 Multiple Sclerosis 1868: Jean-Martin Charcot describes the Sclérose en Plaque as a new disease linking clinical and postmortem findings. N Engl J Med Sep 28;343(13): MRI Pathology Luxol Fast Blue 3

4 Extravasating T-cells Demyelination Pathogenesis of MS 4 N Engl J Med Mar 2;354(9):942-55

5 Disease Patterns Relapsing remitting (RRMS) Secondary progressive: initial RRMS then progression. Primary progressive: Progression from onset with occasional plateau. Progressive relapsing: Progression from onset with acute relapse. 5

6 Diagnostic criteria for MS POSER criteria (1980s) Two attacks + Two separate clinical lesions = Clinically definite MS Two attacks + one clinical lesion + Labs findings (CSF,OCB, IgG) = Laboratory definite MS 6

7 Diagnostic criteria for MS McDonald s criteria (2001 and 2005) Demonstrate dissemination of clinical events in space and time. Demonstrate dissemination of MRI findings in space and time. Assigns confidence for MS vs Possible MS vs. Not MS based on clinical and MRI findings 7

8 MRI modality of choice for MS Conventional MRI is the most sensitive way to detect MS lesions. Typical MRI lesions correlate well with histopathology: Found in periventricular region, corpus callosum, subcortical region, brainstem, optic nerve and visual pathways. Lesions usually not seen on CT. Use of contrast allows early detection of acute lesions. Specificity 90%, sensitivity 80%, ppv 65%. (<50yo) 8

9 Ant. Horn of lateral ventricules Head of Caudate nucleus Neuroanatomy Genu of Corpus Callosum Ant. And post. Limb of internal capsule Thalamus Putamen Visual Cortex 9

10 companion patient 1: MS lesions on MRI Hypointense lesions on T1WI Hyperintense lesions on T2WI N Engl J Med Sep 28;343(13):

11 Companion patient 2: Fluid attenuated Inversion Recovery (vflair) allows for better visualization of periventricular lesions Hyperintense lesions on T2WI Hyperintense lesions on T2 FLAIR AJNR Am J Neuroradiol 2006; 27:

12 DDx of white matter lesion Ischemia Systemic lupus erythematosus HTLV-I Sarcoidosis Behcet's disease Vasculitides Companion patient 3: axial FLAIR 12

13 Specific MRI findings to narrow the differential Review specific lesions found in MS. Apply McDonald s criteria for dissemination in space and time. 13

14 Classical MS lesions: Dawson s fingers (Patient LH) Sagital FLAIR (PACS, BIDMC) Axial FLAIR (PACS, BIDMC) 14

15 Classical MS lesions : Black holes (patient LH) T2 (PACS, BIDMC) T1 (PACS, BIDMC) 15

16 Dissemination in Space McDonald s MRI criteria: Three of the following are required: At least one gadolinium-enhancing lesion or nine T2 hyperintense lesions At least one infratentorial lesion At least one juxtacortical lesion At least three periventricular lesions Polman CH et al. Ann Neurol. 20 Dec; 58(6):

17 Dissemination in space (Patient LH) Sagital FLAIR (PACS, BIDMC) Sagital T2 (PACS, BIDMC) 17

18 Dissemination in Time: Detection of gadolinium enhancement at least 3 months after the onset of the initial clinical event. Detection of a new T2 lesion Polman CH et al. Ann Neurol. 20 Dec; 58(6):

19 Detection of recent MS lesions Acute MS lesions disrupt the Blood Brain Barrier. Can be seen as Gadolinium-enhancing lesions on T1-Post. Remain for days to months 19

20 Detection of recent MS lesions: T1 post-contrast (Patient LH) 05/10/08 05/10/08 (PACS, BIDMC) (PACS, BIDMC) 20

21 Dissemination in time (Patient LH) AXIALFLAIR (PACS, BIDMC) Sagital T2 (PACS, BIDMC) 21

22 Limitation of traditional MRI Many lesions seen on histopathology are missed on MRI. Conversely the number and size of lesions seen is dependent on field strength and amount of contrast given. Although useful in following the disease, poor correlation between T1, T2, T1-post findings and clinical evolution. AJNR Am J Neuroradiol 1998; 19:

23 Companion patient 7: Volumetric analysis New uses of conventional MRI: subtraction measures for disease follow up. AJNR Am J Neuroradiol 2008; 29: Companion patient 7:Axial FLAIR 23

24 Companion patient 8: Volumetric analysis Measures of diffuse cortical atrophy, some evidence correlating grey matter atrophy and functional impairment Lancet Neurol 2006; 5: Companion patient 8 24

25 Companion patient 9: Diffuse Tensor imaging Diffusion MRI allowing reconstruction of axonal tracts and may provide correlation between circuitry damage and functional impairment. NeuroImage 2005;26:

26 Acknowledgments Rafeeque Bhadelia, MD Rich Rana, MD Maria Levantakis Larry Barbaras Gillian Liberman, MD 26

27 Reference Noseworthy JH et al. N Engl J Med Sep 28;343(13): Frohman EM et al. N Engl J Med Mar 2;354(9): Islam T et al. Neurology Jul 24;69(4): Ge Y., AJNR Am J Neuroradiol 2006; 27: Offenbacher H et al. Neurology 1993 May;43(5): Bakshi R et al. Lancet Neurol Jul;7(7): Polman CH et al. Ann Neurol. 20 Dec; 58(6): Geurts JG et al. Lancet Neurol Sep;7(9): Pagani E et al. NeuroImage 2005;26: Duan Y et al. AJNR Am J Neuroradiol 2008; 29: