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Presentation1, new mri techniques in the diagnosis and monitoring of multiple sclerosis.

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Presentation1, new mri techniques in the diagnosis and monitoring of multiple sclerosis.

  1. 1. New MRI Techniques in the Diagnosis and Monitoring of Multiple Sclerosis: Dr/ABD ALLAH NAZEER. MD.
  2. 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. 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. 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. 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. 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. 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.
  8. 8. 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
  9. 9. 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.
  10. 10. 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.
  11. 11. 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).
  12. 12. 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).
  13. 13. 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.
  14. 14. Thank You.

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