doi:10.1093/brain/awz144 BRAIN 2019: 142; 1858–1875 | 1858 REVIEW Assessment of lesions on magnetic resonance Downloaded from https://academic.oup.com/brain/article-abstract/142/7/1858/5519813 by University College London user on 18 October 2019 imaging in multiple sclerosis: practical guidelines Massimo Filippi,1,2,3 Paolo Preziosa,1,3 Brenda L. Banwell,4 Frederik Barkhof,5,6 Olga Ciccarelli,7,8 Nicola De Stefano,9 Jeroen J.G. Geurts,10 Friedemann Paul,11 Daniel S. Reich,12 Ahmed T. Toosy,7 Anthony Traboulsee,13,14 Mike P. Wattjes,15 Tarek A. Yousry,16,17 Achim Gass,18 Catherine Lubetzki,19 Brian G. Weinshenker20 and Maria A. Rocca1,2 MRI has improved the diagnostic work-up of multiple sclerosis, but inappropriate image interpretation and application of MRI diagnostic criteria contribute to misdiagnosis. Some diseases, now recognized as conditions distinct from multiple sclerosis, may satisfy the MRI criteria for multiple sclerosis (e.g. neuromyelitis optica spectrum disorders, Susac syndrome), thus making the diagnosis of multiple sclerosis more challenging, especially if biomarker testing (such as serum anti-AQP4 antibodies) is not informative. Improvements in MRI technology contribute and promise to better define the typical features of multiple sclerosis lesions (e.g. juxtacortical and periventricular location, cortical involvement). Greater understanding of some key aspects of multiple sclerosis pathobiology has allowed the identification of characteristics more specific to multiple sclerosis (e.g. central vein sign, subpial demyelination and lesional rims), which are not included in the current multiple sclerosis diagnostic criteria. In this review, we provide the clinicians and researchers with a practical guide to enhance the proper recognition of multiple sclerosis lesions, including a thorough definition and illustration of typical MRI features, as well as a discussion of red flags suggestive of alternative diagnoses. We also discuss the possible place of emerging qualitative features of lesions which may become important in the near future. 1 Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy 2 Neurology Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy 3 Vita-Salute San Raffaele University, Milan, Italy 4 Division of Neurology, Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA 5 Department of Radiology and Nuclear Medicine, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands 6 Institutes of Neurology and Healthcare Engineering, University College London, London, UK 7 Queen Square MS Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, University College London, UK 8 National Institute for Health Research University College London Hospitals Biomedical Research Center, National Institute for Health Research, London, UK 9 Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy 10 Department of Anatomy and Neurosciences, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands 11 NeuroCure Clinical Research Center and Experimental and Clinical Research Center, Max Delbru¨ ck Center for Molecular Medicine and Charite´ -Universita¨tsmedizin Berlin, Berlin, Germany Received March 20, 2019. Revised April 29, 2019. Accepted May 1, 2019. Advance Access publication June 17, 2019 ß The Author(s) (2019). Published by Oxford University Press on behalf of the Guarantors of Brain. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact [email protected] Guidelines for lesion assessment in MS BRAIN 2019: 142; 1858–1875 | 1859 12 Translational Neuroradiology Section, Division of Neuroimmunology and Neurovirology, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA 13 MS/MRI Research Group, Djavad Mowafaghian Centre for Brain Health, Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada 14 Faculty of Medicine, Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada 15 Department of Neuroradiology, Hannover Medical School, Hannover, Germany 16 Division of Neuroradiology and Neurophysics, UCL Institute of Neurology, London, UK 17 Lysholm Department of Neuroradiology, London, UK Downloaded from https://academic.oup.com/brain/article-abstract/142/7/1858/5519813 by University College London user on 18 October 2019 18 Department of Neurology, Universita¨tsmedizin Mannheim, University of Heidelberg, Mannheim, Germany 19 Sorbonne University, AP-HP Pitie´-Salpe´trie´re Hospital, Department of Neurology, 75013 Paris, France 20 Department of Neurology, Mayo Clinic, Rochester, MN, USA Correspondence to: Prof. Massimo Filippi Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy E-mail: [email protected] Keywords: multiple sclerosis; magnetic resonance imaging; lesions; diagnostic criteria; guidelines These considerations provided the impetus to hold a Introduction workshop in December 2018 in Milan, Italy, which Since their introduction in 2001 up to the recent 2017 re- involved international experts in multiple sclerosis and vision, the McDonald diagnostic criteria for multiple scler- MRI (Supplementary material). The main goal was to for- osis are based on the number, size and location of brain mulate practical guidelines for the correct interpretation and spinal cord lesions believed to be typical of multiple and classification of lesions in multiple sclerosis patients sclerosis. Lesion assessment on conventional T2-weighted that would be helpful both to clinicians involved in mul- and post-contrast T1-weighted MRI sequences has allowed tiple sclerosis care and for research studies, ultimately con- the definition of criteria that support the early diagnosis of tributing to more accurate diagnosis. multiple sclerosis in patients with clinical symptoms char- Three main topics were addressed during the workshop: acteristic of multiple sclerosis (Thompson et al., 2018). (i) re-examination and definition of features characteristic By virtue of the requirement of demonstrating dissemin- for individual multiple sclerosis lesions and for patterns of ation in space and time, these diagnostic criteria are highly their distribution (‘green flags’) as defined in the 2017 re- sensitive, and when met in the context of a typical demye- vision of the McDonald criteria (Thompson et al., 2018); linating event (i.e. subacute optic neuritis, incomplete trans- (ii) depiction of lesion patterns that satisfy current multiple verse myelitis, and brainstem syndromes), have a very high sclerosis diagnostic criteria, but are not characteristic of positive predictive power for distinguishing early relapsing multiple sclerosis. They may be associated with other dis- forms of multiple sclerosis from monophasic clinically iso- eases mimicking multiple sclerosis, an artefact or an inci- lated syndromes (Filippi et al., 2018; Hyun et al., 2018; dental lesion related to a comorbidity and constitute ‘red van der Vuurst de Vries et al., 2018). As currently formu- flags’ for multiple sclerosis diagnosis. Examples include is- lated, before being applied, these diagnostic criteria require chaemic lesions, peculiar patterns of contrast enhancement, the exclusion of alternative causes through clinical evalu- or age-related ‘periventricular capping’ on T2-weighted ation and paraclinical tools (i.e. blood tests, CSF analysis, images. They also encompass distinctive MRI features of neuroimaging and neurophysiology studies). Application of recently recognized antibody-mediated diseases (e.g. neuro- diagnostic criteria in the context of clinical presentations myelitis optica spectrum disorders and anti-MOG-IgG dis- that are not typical of multiple sclerosis increases the risk ease); and (iii) discussion of emerging features of lesions of misdiagnosis (Solomon et al., 2016a, 2019). (e.g. central vein sign, subpial demyelination and lesion Since MRI is exquisitely sensitive in detecting white rims), which are likely, in the near future, to improve spe- matter abnormalities and just two MRI lesions in specific cificity of the diagnostic algorithm for multiple sclerosis. locations are sufficient to fulfill the multiple sclerosis diag- nostic criteria, careful determination of which imaging fea- General considerations when tures and patterns constitute ‘typical’ multiple sclerosis lesions (‘green flags’) and which are atypical (‘red flags’) using MRI for the diagnosis of is crucial. This is especially pertinent for patients with a small number of lesions and for those with co-morbidities multiple sclerosis (e.g. migraine or cerebrovascular disease), in whom the There are general considerations when applying the MRI aspects identification of specific lesion characteristics and patterns of the 2017 revision of the McDonald criteria in the diagnostic will assist with differential diagnosis. work-up of patients with suspected multiple sclerosis: 1860 | BRAIN