Multiple sclerosis (MS) is a lifelong disease that affects about a million people in the United States.1,2 Since 1998 more than 45,000 veterans have been diagnosed with MS and about 20,000 are evaluated in the Veterans Health Administration (VHA) annually.3
Magnetic resonance imaging (MRI) is a cornerstone for the assessment of persons with multiple sclerosis (pwMS).4-6 MRI assists with disease diagnosis, allowing for timely therapeutic interventions and withthe evaluation of its progression, treatment effect, and safety. 4,5 MRI-based outcomes also are used as primary endpoints in clinical trials.4,5
MS has its clinical onset in early adulthood in most individuals and is diagnosed at a mean age of 30 years.7 As a result, pwMS may receive care and MRIs in different facilities during their lifetime. Mitigating interscan variabilities that can challenge intra- and interperson comparisons is crucial for accurate care. Radiologists may find it difficult to compare scans acquired in different facilities, as dissimilarities in acquisition protocols may mask or uncover focal disease, creating false negative or false positive findings. Moreover, lack of a standardized method to report MRI changes may compromise neurologists’ ability to correctly interpret scans and disease progression.
Accordingly, in October 2019, an international task force of neurologists, radiologists, MRI technologists, and imaging scientists with expertise in MS, including representatives from the VHA, worked together to update guidelines for imaging the brain, spinal cord, and optic nerve in pwMS.8,9 Recognizing the importance of this effort, the VHA Multiple Sclerosis Centers of Excellence (MSCoE), in collaboration with a team of subject matter expert neuroradiologists promptly committed to this effort, advocating the updated consensus recommendations, and favoring their dissemination within the VHA.10
As part of this commitment and dissemination effort, in this report we summarize the core points of the newly proposed MRI guidelines and ways to adapt them for use within the VHA. We then discuss key elements for their successful implementation and dissemination, specifically regarding the clinical operations of VHA.
Updated Guidelines
The 2021 MAGNIMS-CMSC-NAIMS Consensus Recommendations on the Use of MRI in Patients With Multiple Sclerosis covered a broad spectrum of recommendations related to MRI indication, acquisition, and interpretation in MS. The recommendations span 3 major areas: (1) indications for an MRI with/without contrast; (2) summary of the MRI protocol for radiologists and technologists; and (3) interpretation of MRI examinations.
MRI Scan at Different Timepoints of MS
There are 3 crucial milestones within a the lifespan of a pwMS that require an MRI to reach appropriate conclusions and avoid clinical errors. These include the initial diagnosis, the follow-up to monitor disease and/or treatment effect, and the assessment of medication safety.
In the interest of efficiency, MRI protocols may vary slightly depending on these clinical indications. The Table lists core sequences of the updated 2021 consensus recommendations at each timepoint along with the proposed alternatives or preferences from the VHA workgroup.
At the time of diagnosis, both brain and spine (cervical and thoracic) MRIs are recommended. Routine MRI of the optic nerve is considered optional at diagnosis. However, imaging the optic nerve may be useful in specific clinical scenarios when the optic nerve is selectively involved, and the diagnosis or etiology of an optic neuritis is not clear. A repeat brain MRI is advised every 6 to 12 months in patients with clinically or radiologically isolated syndrome who do not fulfill the diagnostic criteria of MS but present risk factors for conversion to MS or paraclinical features of it.