This document discusses new MRI techniques for diagnosing and monitoring multiple sclerosis (MS). It recommends protocols for baseline and follow-up brain and spinal cord MRIs, including mandatory and optional sequences. Advanced techniques like double inversion recovery, diffusion tensor imaging, and MR spectroscopy are highlighted for improving detection of gray matter lesions and diffuse white matter damage compared to conventional MRI. The document concludes that while conventional MRI is important for MS, advanced techniques provide higher sensitivity and specificity for both lesions and normal-appearing brain tissue, furthering understanding of MS pathophysiology.

1. New MRI Techniques in the Diagnosis
and Monitoring of Multiple Sclerosis:
Dr/ABD ALLAH NAZEER. MD.

2. Baseline MRI protocol.
Brain.
Magnetic field strength: 1.5T or 3T(recommended).
Mandatory:
Axial 2DPD/T2-weighted spin echo or turbo(fast) spin echo
Sagittal FLAIR (preferably 3D).
Axial post-contrast T1-weighted spin echo or turbo(fast)
spin echo
Optional:
Double inversion recovery(preferably 3D) for cortical
lesion detection
High-resolution isotropic 3DT1-weighted gradient echo
for volumetric analysis.
Diffusion and diffusion tensor imaging, Resting state fMRI.

3. Spinal cord
Magnetic field strength: 1.5 T or 3T
Mandatory:
Sagittal 2DPD/T2-weighted spin echo or
turbo(fast) spin-echo
Sagittal 2D contrast- enhanced T1-weighted spine
echo.
Optional:
Sagittal 2D STIR (as an alternative to proton-
density-weighted)
Axial images: 2 D T2 and /or contrast-enhanced
T1-weighted.

4. Follow-up MRI protocol
Brain
Magnetic field strength: 1.5T or 3T(recommended).
Mandatory sequences
Axial 2DPD/T2-weighted spin echo or turbo(fast) spin
echo
Axial contrast-enhanced T1-weighted spin echo or
turbo(fast)spin echo
Optional sequences
Axial(2D or 3D) FLAIR as and alternative to PD,
Double inversion recovery(preferably 3D),
High-resolution isotropic 3DT1-weighted gradient
echo.

5. Double inversion recovery: in this technique, two inversion recovery
pulses (TI-1 and TI-2) are used to suppress liquid and white matter
respectively, increasing contrast between gray and white matter
and between demyelinating lesions and normal brain parenchyma,
and improving MRI sensitivity for identifying gray matter lesions,
gray matter-white matter lesions and infratentorial lesions.
T2 FLAIR image shows ill-defined
cortical hyperintensity. DIR.

6. Diffusion weighted imaging (DWI)
and diffusion tensor imaging (DTI).
Diffusion imaging is based on diffusion, or the random
movement of molecules through a fluid. The diffusivity in
brain tissue is lower than that of free water, called the
apparent diffusion coefficient (ADC). Restricted diffusion
causes increase in ADC values. Active plaques of MS may
demonstrate restricted diffusion on DWI/ADC. Analogous
to MTI, DTI is sensitive to tissue injury and is abnormal in
MS lesions and normal appearing brain tissues.
DTI abnormalities have confirmed that damage to the brain
in MS patients is not limited to focal and macroscopic lesions.

7. MR Spectroscopy.
Proton magnetic resonance spectroscopy (1H-MRS) 1 H-MRS allows
the ability to measure metabolites within the MS lesions and normal
appearing brain tissues. Metabolites for 1 H-MRS include
N-acetylaspartate (NAA), choline (Cho), creatine (Cr), and myoinositol.
A decrease in NAA is associated with axonal damage. Cho is often
increased with myelin damage and inflammation. Increased Cr and
myoinositol levels can also be found in MS lesions. Amino acids which
act as neurotransmitters include glutamate, glutamine, and
γ-aminobutyric acid (GABA), can also be measured. In active enhancing
MS lesions, there is increased Cho, Cr, myoinositol, and glutamate, and
a decrease in NAA. A similar pattern of abnormal metabolites can be
detected in normal appearing brain tissues. In chronic nonenhancing
lesions, NAA is markedly decreased, myoinositol is increased and
glutamate is normal. Decreased NAA/Cr ratio within MS lesions and
normal appearing brain tissues correlates with physical and cognitive
impairment in MS, and has been shown to improve following disease
modifying therapy.

9. Three axial fluid attenuated inversion recovery (FLAIR) images illustrating the
clinicoradiological paradox of multiple sclerosis: a 52-year-old male (benign) relapsing
remitting multiple sclerosis (RRMS) patient, disease duration of 23 years, expanded
disability status scale (EDSS) score of 2.5; b 50-year-old female RRMS patient, disease
duration of 11 years, EDSS score of 3.0, c 53-year-old female primary progressive
multiple sclerosis (PPMS) patient, disease duration of 7 years, EDSS of 4.5

10. Axial 7 T fluid attenuated inversion recovery (FLAIR)* images (combination of
FLAIR and susceptibility-weighted imaging (SWI)) obtained in a multiple sclerosis
(MS) patient (left) and a patient with vasculoischemic small vessel disease (right).
Please note that the MS lesion shows a central vein suggestive of perivenous
inflammation whereas the vascular lesions do not show a central vein.

11. Axial 3D fluid attenuated inversion recovery (FLAIR) images obtained at
7 T and 3 T showing a mixed grey matter-white matter lesion on the 7 T
FLAIR image (arrow). This lesion was not prospectively identified at 3 T.

12. Figure illustrating typical cortical grey matter atrophy in multiple sclerosis (MS):
a 49-year-old female healthy control (HC), and a 50-year-old female relapsing
remitting multiple sclerosis (RRMS) patient (MS), disease duration of 11 years
and expanded disability status scale (EDSS) score of 11 years. Both panels display
an inflated cortical surface produced by Free Surfer software, overlayed with
vertex-wise cortical thickness (grey: < 2 mm; red: 2 mm; yellow: > 4 mm).

13. Sagittal (A), coronal (B), and axial (C) reconstructions of 3D DIR images of the
cervical spinal cord of a 42-year-old female patient with primary-progressive MS.
Elongated lesions in the lateral spinal cord are visible on both sides (arrow).

14. CONCLUSIONS
Multiple sclerosis (MS) is a chronic immune-mediated
degenerative disease of the central nervous system and
is a major cause of acquired disability in young adults.
Conventional MRI plays an important role in diagnosing
and in monitoring the disease course; however, it lacks
sensitivity to gray matter lesions and diffuse damage
throughout the white matter. Advanced MRI techniques
provide higher specificity and sensitivity to both lesions
and normal-appearing gray/white matter contributing
in better understanding of MS Pathophysiology. The
adoption of cutting edge techniques into clinical research
and practice need to be refined and validated due to
several limitations.

15. Thank You.