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Polish Journal of Radiology
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vol. 85

Recommendations of the Polish Medical Society of Radiology and the Polish Society of Neurology for the routinely used magnetic resonance imaging protocol in patients with multiple sclerosis

Marek Sąsiadek
Marcin Hartel
Małgorzata Siger
Katarzyna Katulska
Agata Majos
Ewa Kluczewska
Halina Bartosik-Psujek
Alina Kułakowska
Agnieszka Słowik
Barbara Steinborn
Monika Adamczyk-Sowa
Alicja Kalinowska
Ewa Krzystanek
Robert Bonek
Zbigniew Serafin
Jarosław Sławek
Przemysław Nowacki
Adam Stępień
Sergiusz Jóźwiak
Konrad Rejdak
Krzysztof Selmaj
Jerzy Walecki

Department of General and Interventional Radiology and Neuroradiology, Wroclaw Medical University, Wroclaw, Poland
Medical Diagnostic Centre Voxel, Katowice, Poland
Department of Neurology, Medical University of Lodz, Lodz, Poland
Department of Developmental Neurology, Poznan University of Medical Sciences, Poznan, Poland
Department of Radiological and Isotopic Diagnosis and Therapy, Medical University of Lodz, Lodz, Poland
Department and Institute of Medical Radiology and Radiodiagnostics in Zabrze, Medical University of Silesia in Katowice, Poland
Faculty of Medicine, University of Rzeszow, Rzeszow, Poland
Department of Neurology, Medical University of Bialystok, Bialystok, Poland
Department of Neurology, Jagiellonian University Medical College, University Hospital in Krakow, Krakow, Poland
Department of Neurology in Zabrze, Medical University of Silesia, Zabrze, Poland
Department of Neurology, Division of Neurochemistry and Neuropathology, Poznan University of Medical Sciences, Poznan, Poland
Department of Neurology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
Department of Neurology and Clinical Neuroimmunology, Regional Specialist Hospital, Grudziądz, Poland
Department of Radiology and Diagnostic Imaging, Nicolaus Copernicus University, Collegium Medicum, Bydgoszcz, Poland
Department of Neurology, St. Adalbert Hospital, “Copernicus” Ltd., Gdańsk, Poland
Department of Neurology, Pomeranian Medical University, Szczecin, Poland
Department of Neurology, Military Institute of Medicine, Warsaw, Poland
Department of Paediatric Neurology, Warsaw Medical University, Warsaw, Poland
Department of Neurology, Medical University of Lublin, Lublin, Poland
Department of Neurology, Laboratory of Neuroimmunology, Faculty of Medicine, University of Warmia and Mazury, Olsztyn, Poland
Department of Radiology, Medical Centre for Postgraduate Education, Warsaw, Poland
Pol J Radiol 2020; 85: e272-e276
Online publish date: 2020/05/26
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General comments

It is recommended that patients with multiple sclerosis (MS) undergo magnetic resonance imaging (MRI) with intravenous administration of a paramagnetic contrast medium (gadolinium) solely as a part of the initial diagnostics. A follow-up gadolinium-enhanced MRI with the use of macrocyclic contrast agents is recommended only in cases of clinical progression of the disease, if the need for another differential diagnosis of MS arises, or in other clinically justified cases. The use of linear contrast agents based on gadolinium (GBCA) is not recommended in the follow-up of the treatment of MS in clinically and radiologically stable patients, due to the possible occurrence of long-term side effects associated with the accumulation of a contrast agent within the central nervous system (CNS).

Patients with clinically isolated syndrome (CIS) or suspected MS should undergo head MRI before and after an intravenous administration of a contrast agent (Ta­ble 1), and it is recommended that an additional scanning of the cervical and thoracic sections of the spinal cord is performed (in accordance with a referral/indication of the neurologist) after an intravenous administration of a contrast agent, especially when head MRI does not meet the diagnostic criteria or clinical symptoms suggest the lesions are located in the spinal cord (Table 2). MRI studies of the brain and the cervical section of the spinal cord should be performed during one stay at the MRI department. The thoracic section should be examined immediately in the next procedure, and, if justified, the MRI examination should cover the entire spinal cord [1-6].

MRI is particularly important in the diagnosis of primary progressive MS according to current disease diagnosis criteria (see Appendix).

In patients with multifocal damage to the nervous system involving the symptomatology associated with both brain and spinal cord impairment, in order to shorten the diagnostic time, according to a referring neurologist’s recommendation, it is possible to perform simultaneously an MRI of the head and of a selected section of the spinal cord using a combined protocol (Table 3).

Recommendations for disease progression follow-up based on MRI:
Head MRI to show new/enlarging demyelinating lesions (Table 1) at least every 12 months during the first years of treatment and possibly less frequently later in patients with complete clinical stability. Cervical and/or thoracic spinal cord scan is recommended, according to a neurologist’s referral/indication. For patients under 18 years of age, the MRI protocol for brain and spinal cord examination remains unchanged, the same as in the adult population [7-12].

Brain magnetic resonance imaging protocol for patients with multiple sclerosis

In order to use the same scanning planes during the follow- up examinations, it is recommended to achieve slices in the true midline plane. For this purpose, once three localisation slices have been performed, five slices with a thickness of 3 mm should be planned as accurately as possible in the sagittal plane on T2-weighted images. The planned slices should be set exactly parallelly to the longitudinal cerebral fissure using the localisation slices, in the transverse and frontal planes. The third of the five slices should pass through the median fissure as accurately as possible.

Axial slices should be set on the thus obtained midline slice in parallel to the lower limits of the rostrum (anterior commissure – AC) and splenium of the corpus callosum (posterior commissure – PC), according to the AC-PC reference line (Figure 1).

NOTE! During the follow-up examinations, when the scanning plan is set in the reference to the corpus callosum, it is necessary to compare the angulation of the planned slices with the angulation of the slices in the previous study. Some scanners do not offer the possibility to remember a single slice, which is the best for such a comparison; in which case the slice should be carefully defined as shown in the Figure 1. A radiological report should include the standard terminology used in brain assessment.

Assessment of focal lesions:
1. Location (supratentorial region: cortical, paracortical, central white matter, periventricular, subtentorial, corpus callosum, brainstem, spinal cord).
2. Size – when multiple lesions are detected, the range of the longest dimension from–to. In the case of multiple lesions, the size of the largest lesions only should be reported. According to the current definition, demyelinating lesions are defined as lesions ≥ 3 mm in diameter.
3. The number of demyelinating lesions – specify according to the following scheme: 1, 2, 3–8,  9.
4. The nature of the lesion, i.e. specify whether the appearance is typical for MS demyelination, or whether differential diagnosis is required, e.g. ischaemic lesion.
5. Whether the lesions are disseminated in space (DIS) and meet the 2017 McDonald criteria (see Appendix and Table 4).
6. Comparison to the previous head and spinal cord MRI (if such an examination was conducted). In patients with suspected MS, comparison to the previous MRI to assess disease activity and eligibility for treatment. In on-treatment patients, comparison to the previous examination and baseline examination performed prior to treatment initiation.
7. Activity assessment, i.e. the number of contrast-enhancing foci in the current examination and the number of new/enlarging lesions compared to the baseline and the previous examination – please specify according to the scheme: 1, 2, 3-8,  9.
8. Assessment of brain atrophy. It is recommended that expressions such as “brain atrophy” or “cerebral atrophy” be avoided in the text. If possible, provide current whole brain volume, grey matter volume, white matter volume, corpus callosum volume, and the volume of the right and left thalami.
Volumetric analysis of the brain should be performed using certified software; in the future, it can alternatively be carried out by a central centre in order to standardise the results.

Conflict of interest

The authors report no conflict of interest.


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