Which findings on MRI suggest multiple sclerosis (MS)?

Updated: Aug 07, 2018
  • Author: Djamil Fertikh, MD; Chief Editor: James G Smirniotopoulos, MD  more...
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MRI far exceeds CT scanning in the ability to demonstrate intramedullary pathology; MRI is currently used for the first-line investigation of spinal MS. [18] Depending on their age, MS plaques appear on unenhanced, T1-weighted images as areas of slightly low to low signal intensity. Spinal plaques may appear as nodules, rings, or arcs and generally are less than 2 vertebral bodies in length. [19] Plaques usually demonstrate prompt enhancement after the administration of a gadolinium-based contrast agent, which most often indicates active disease. [20] The enhancement may last 2-8 weeks. Classic chronic lesions do not demonstrate contrast enhancement. (See the image below.)

Sagittal, T1-weighted image following gadolinium c Sagittal, T1-weighted image following gadolinium contrast showing arciform enhancement along the edge of the plaque, typical of demyelination.

Most MS plaques appear hyperintense on T2-weighted images. The spinal cord may or may not be focally enlarged. Enlargement of the cord is usually seen with active disease. Larger active lesions may have extensive edema with associated cord expansion. Chronic lesions often demonstrate focal cord atrophy. Spinal lesions usually coexist with more severe concomitant brain plaques. As many as 20% of spinal MS lesions are isolated. Spinal cord narrowing due to atrophic changes is present in 10% of patients with spinal cord involvement. [21] (See the images below.)

Sagittal, T2-weighted magnetic resonance image of Sagittal, T2-weighted magnetic resonance image of the cervical spinal cord in a woman aged 27 years showing a fusiform area of increased signal intensity representing a multiple sclerosis plaque.
Axial, T2-weighted magnetic resonance image in a w Axial, T2-weighted magnetic resonance image in a woman aged 27 showing a multiple sclerosis plaque located in the left dorsolateral region of the left hemicord.
Sagittal, T2-weighted image showing areas of signa Sagittal, T2-weighted image showing areas of signal hyperintensity in the cervical spinal cord and pons.
Axial, T2-weighted image showing a large area of s Axial, T2-weighted image showing a large area of signal hyperintensity in the right lateral aspect of the cord.
Sagittal, T2-weighted image showing a focal area o Sagittal, T2-weighted image showing a focal area of spinal cord atrophy in a patient with long-standing multiple sclerosis.

Tumefacient MS may mimic a neoplasm; a demyelinating process should always be considered if a masslike lesion is encountered. As is the case in the brain, a ring or arc of enhancement can often be found, as opposed to a more nodular or masslike enhancement. Follow-up studies are helpful.

Although not widely implemented, newer methods may be more specific in evaluating MS plaques. [22] These methods include magnetization transfer and diffusion, as well as proton MR spectroscopy (MRS). [23, 24, 25]

Typically, fast-FLAIR (fluid-attenuated inversion recovery) sequences have been shown to have a lower sensitivity than do fast spin-echo sequences (FSE) for depicting spinal cord MS lesions. [26, 27, 28]

Studies have suggested that more cervical cord MS lesions can be revealed with magnetization transfer–prepared gradient-echo and fast-STIR (short TI inversion recovery) sequences than with FSE sequences, with fast-STIR demonstrating the greatest sensitivity. [27, 29, 30, 31, 32]

In one study, 3.5-mm axial T2-weighted images with full spinal cord coverage showed 22% more lesions in patients with MS than 3-mm sagittal scans, especially for lesions with small axial diameters. In the study, 449/509 lesions (88.2%) were detected on 3.5-mm axial scans and 337/509 (66.2%) on 3-mm sagittal scans. Only 277/449 (61.7%) axial lesions were also detected on sagittal images. [2]

Gadolinium-based contrast agents have been linked to the development of nephrogenic systemic fibrosis (NSF), also known as nephrogenic fibrosing dermopathy (NFD). The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MR angiography (MRA) scans. NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness.

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