ACTRIMS 2020 News Network: Standardized MRI Protocol for MS

Clyde E. Markowitz, MD: The standardized MRI [magnetic resonance imaging] protocol that has been evolving over the last decade for the most part has given us the capability to try to get patients close to standardized sequences that are used. Because 1 of the things we use MRI for these days is not just the diagnosis of MS [multiple sclerosis] but as a marker of disease activity over time.

We want to be able to say that if we’re going to use it for purely the purpose of a diagnosis, you need to have sequences for that. At least for that you must have an axial and sagittal FLAIR [fluid attenuated inversion recovery] image. You want to be able to do this with very thin slices. It used to be 3-mm requirements, and now we’d like to get it down to 1 mm with no gaps and be able to have continuous information, so you’re able to see and not miss lesions that could be in important areas like the corpus callosum, for instance.

That is a requirement. They have core requirements, and they have some supplemental things you could add to this. Another thing that is particularly important is the use of gadolinium. I think overall, the use of gadolinium has generated a concern for potential toxicities, both the renal toxicity, which we had known about, and now there may be a toxicity with deposition in certain areas of the brain.

Because of that, it’s really more important to use gadolinium as a diagnostic piece, but maybe not so much as a monitoring piece over time, unless indicated. We’re trying to reduce the amount of gadolinium use in that setting. In addition to that, now we’re going to go ahead and use it to monitor for disease activity. We know that clinical activity may show up at a much smaller frequency than MRI activity, so we want to be able to capture any disease activity as soon as possible. In doing so, we want to have a standardized protocol for that.

The challenge we have in the MS community is that they’re upgrading machines all the time, software packages are different, the strength of the magnets are always an issue, and patients’ insurance coverage changes from 1 day to the next. You can use this place, or you can use that place. It makes it really hard to be able to follow an individual patient over time because of these differences in all these pieces that move around.

Make sure patients get the proper sequences for follow-up and alignment. The alignment is key because if you’re going to say you need to align the patient’s head between these 2 points, no matter where you get that scan done—and make sure you have them done with no gaps, thin slices—you might actually be able to use it from other sites. But everybody has to get on board with that because in 1 person’s scan if they made an alignment like this and another 1 is like this and there’s a lesion that’s missed within that conversation, that could be important. Coming up with the most updated protocols for standardizing MRI scans across multiple radiology facilities is going to be really important for us to be able to monitor our patients adequately.

I would love to be able to have radiologists adhere to this. I think that there has to be a strong enough statement coming out from the MS community that this is a requirement. It is not just a good idea. If you’re going to have a standardized protocol such that this is how we use this information to monitor our patients on treatment, you’ve got to follow these guidelines. It’s just the way it is. There’s no wiggle room in that conversation. It’s standardized and you’re going to have to follow this. It’s not that difficult. It’s just that we have to get that message to all the radiology sites, to the radiologist, that this is what is required and needed by the MS community to adequately follow patients.