MRI’s Common Mistakes With Diagnosing And Treating MS


Incorrect MRI Can Delay Proper Treatment For MS

Multiple Sclerosis is usually diagnosed by a few different methods which are a MRI, Spinal Tap, and sometimes an Evoke Potential Test along with a remarkable history of symptoms associated with the disease. The first and most frequently used test is the MRI, Magnetic Resonance Imaging, process. We have all heard about the MRI and if you have never had this test used for you then you probably know someone who has had this performed on some part of their body.

MRI is a test that uses a magnetic field and pulses of radio wave energy to makes pictures of organs and other structures inside the body, and often show problems which other tests like regular X-rays, ultrasounds or CT Scans do not show. Often, a contrast or dye is used to make images more pronounced and easier to see.

With MS, lesions form on the lining of our brain and spinal cord which are what produces our symptoms from where they are located to what size they are. Often, MS is not diagnosed correctly or even missed on the results of the MRI because not all MRI’s are done correctly.  There is a guideline that has been in place for over 10 years by the CMSC, Consortium of MS Center, providing the correct imaging recommendations for field strength, slice thickness, gap, and sequencing, along with the amount of Gadolinium, which is the dye used, and the delay time needed in the sequencing standards. To make it simple, just going for a simple MRI of the brain may very well leave you with an expensive but useless study if not performed by the guidelines which have been established.

When a MRI is ordered, determining what area needs to be tested is reflected by your history of symptoms. The brain covers areas effecting sight, memory, hearing, and speech just to name a few whereas the spinal cord often covers areas, but not limited to, such as bladder and bowel activity, sexual dysfunction, and some of the extremity dysfunction. When providing a history of your symptoms with your Neurologist, it is very important to be as specific as you can even if something you may consider to be insignificant. This will help determine when ordering a MRI study that the correct images are being completed.

What seems to be discouraging to us with MS is if your Neurologist is not specialized in Multiple Sclerosis, he/she may be unfamiliar with the correct protocol for a MRI leaving this in the hands of the radiologist performing the test. Often times, correct imagining is NOT performed due to unskilled radiologists, lack of time to perform the test correctly, or unfortunately the lack of interest to perform the MRI according to the protocol. This leads to inaccurate results provided to your physician which leaves us all vulnerable to not being treated correctly, not getting the correct diagnosis, or not showing how our treatment is working. That equates to inaccurate treatment for what is truly going on with us.

In one Neurologist MS Specialist’s opinion less than 10% of centers do MRI’s properly, meaning following the CMSC MRI protocol.  Some of the key features ignored which are vital to proper imaging include size of slices of the brain. 3 mm slices with no skips oriented in the subcallsoal plan are optimal for lesion detection. The usual MRI Center does 5 mm slices with 2.5 skips which mean they fail to detect all the milder and smaller lesions and miss 1/3 of the brain.

The sagittal Flair images must be done correctly to properly clarify the nature of the lesions. Most centers omit them which shows inexperience. Delay of the post-contrast T1-weighted images for at least 5 minutes is required to properly see enhancement. Few centers do this and it causes them to underestimate the activity of the MS. The weight time cuts into future patients study time causing them a loss of revenue. This is harmful to us because it reveals how active the disease is and if our current therapy is working.  The Long TR thin section proton density images are needed to optimally evaluate brainstem and spinal cord. Unfortunately when these are done, many radiologists do not properly interpret them because of their unfamiliarity with brain anatomy.

Another factor is that many interpreting radiologist needs to be trained adequately in neuroradiology. Many have only a month of training and no specific MS training. Some of the errors seen from this lack of training are where lesions are called “nonspecific” or “microvascular” when in fact they are typical and specific MS lesions, where delay in arriving at a correct diagnosis comes in. Comparison studies need to be obtained and viewed simultaneously, often centers do not take the time to do this even though it is important.

For a MS patient, it is hard to know whether it is an improper MRI test performed, an untrained eye reading the MRI, or an unskilled Neurologist who is not familiar with the CMSC protocol and is not fighting hard to make sure you have a proper test performed.  Speak with your Neurologist to see how knowledgeable he/she is with this protocol and if the center who is performing your test is actively following the guidelines. If you don’t seem comfortable with the results, find a center who does follow them and get a second opinion especially if you are having an increasing amount of symptoms which your current therapy isn’t addressing, or if you haven’t been diagnosed but are showing prevalent MS symptoms.

The link below can be used to print off the CMSC MRI Protocol. When clicking on this link it will take you to the CMSC website. In the search area, type in MS MRI protocol and it will take you to the resource. Print it off and use it when questioning your MRI center and/or physician about their knowledge with your test. This test is expensive, and in this day and time it is up to us to make sure we are receiving the best care possible.

I would like to thank Dr. Samuel Hunter for providing me the most common mistakes made with the MRI.

MS Blogger and Multiple Sclerosis Activist shares her journey living with MS, tips for others living MS and her husband, Steve, offers his insight as a caregiver for MS.