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Fall 2009

Standardized Radiology Protocols Improve MS Care

Imaging is central to the diagnosis and treatment of multiple sclerosis, but inconsistent protocols across settings can compromise clinical insights. That's why the UCSF Multiple Sclerosis Center and UCSF Department of Radiology and Biomedical Imaging have worked together to sync their MRI protocols with those of the Consortium of MS Centers and are leading efforts to standardize protocols across settings.

Daniel Pelletier, M.D., has been instrumental in setting the international standards.

"Standardized protocols (head positioning, relative timing with response to contrast, and method and modality used) in a center like ours allow us to get the same images for comparison every time, but I am also a fan of using protocols compatible with those of community neurologists and radiologists," says Pelletier. "Because it's hard to compare two scans if they are not acquired the same way, standardization will enable us to take better care of MS patients."

Technology Offers Precision and Consistency

As they adjusted their protocols, radiologists at the UCSF center sought ways to respect international standards without losing their ability to take advantage of state-of-the-art imaging made possible by their new, advanced scanners.

Those scanners accommodate T1-weighted, T2-weighted, fluid-attenuated inversion recovery (FLAIR) and diffusion sequences, as well as contrast-enhanced images.

"As part of our standardization, we've gone to 3-D gradient echo acquisition for T1 imaging, instead of spin echo," says Christopher Hess, M.D., Ph.D. "There are trade-offs, but we like that gradient echo enables us to study the brain with high spatial resolution. We're also now using 3-D FLAIR technique at the same high resolution, which allows us to detect other pathology related to MS, such as optic neuritis."

Despite these advantages, in revamping the protocols, the team made sure that they could reformat their images in any plane or thickness, so that in many cases, they could compare them with images that other institutions acquired according to different protocols.

"For optimal comparison over time, it's obviously helpful to have all imaging done here, but if referring radiologists send us the data digitally, we can almost always work with it," says Hess.

The push toward electronic records could facilitate this process.

Disease Understanding Prompts Stronger Imaging

Of course, at this point, standardized protocols are only as good as the physicians reading the scans.

"That's why we work closely with the clinical experts here to better understand the disease, and so constantly improve what we can contribute," says Hess. "For example, people think of MS as an isolated white matter disease, but the new protocols are better at showing the burden of gray matter lesions as well. And we're seeing more and more brain and spine scans that suggest demyelinating disease even before the onset of clinical symptoms."

In addition, both Hess and Pelletier expect that the automated computational techniques that Pelletier's laboratory and his collaborators in Radiology are developing will remove some of the guesswork from reading images.

"We are very interested in moving toward quantitative imaging, which enables objective metrics for both brain volumes and lesion counts," says Pelletier.

For more information, contact Daniel Pelletier, M.D. at (415) 353–9471 or Christopher Hess, M.D., Ph.D. at (415) 514–4385.

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