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?