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Post-contrast MRI in multiple sclerosis: Towards a judicious use of gadolinium-based contrast agents

Published:September 14, 2022DOI:https://doi.org/10.1016/j.jns.2022.120422
      We thank the authors of the Letter entitled “Should we stop using post-contrast sequences in the follow-up MRI of patients with multiple sclerosis?” for having appreciated and commented on our work “Impact of post-contrast MRI in the definition of active multiple sclerosis” [
      • Gentili L.
      • Capuano R.
      • Gaetani L.
      • Fiacca A.
      • Bisecco A.
      • D’Ambrosio A.
      • et al.
      Impact of post-contrast MRI in the definition of active multiple sclerosis.
      ]. The issue of gadolinium (Gd) administration in people with MS (PwMS) is still under debate. Post-Gd MRI sequences certainly provide useful diagnostic and prognostic information, predicting treatment response and long-term disability [
      • Bermel R.A.
      • You X.
      • Foulds P.
      • Hyde R.
      • Simon J.H.
      • Fisher E.
      • et al.
      Predictors of long-term outcome in multiple sclerosis patients treated with interferon beta.
      ,
      • Prosperini L.
      • Mancinelli C.
      • Haggiag S.
      • Cordioli C.
      • De Giglio L.
      • De Rossi N.
      • et al.
      Minimal evidence of disease activity (MEDA) in relapsing-remitting multiple sclerosis.
      ]: such aspects were clearly presented in the Discussion section of our study [
      • Gentili L.
      • Capuano R.
      • Gaetani L.
      • Fiacca A.
      • Bisecco A.
      • D’Ambrosio A.
      • et al.
      Impact of post-contrast MRI in the definition of active multiple sclerosis.
      ]. At the same time, potential risks linked to Gd deposition in the central nervous system (CNS) need to be considered when evaluating its repeated use in PwMS, even if the clinical correlates of brain Gd retention have not clearly demonstrated. Accordingly, in 2017, the International Society of Magnetic Resonance in Medicine (ISMRM) urged caution in the use of gadolinium-based contrast agents and suggested that, “per standard practice”, their use should be avoided when not necessary [
      • Gulani V.
      • Calamante F.
      • Shellock F.G.
      • Kanal E.
      • Reeder S.B.
      Gadolinium deposition in the brain: summary of evidence and recommendations.
      ]. In this context, a research priority in MS is to identify the clinical scenario that justify the use of Gd in follow-up MRIs. It is worth noting that, in the absence of new/enlarged lesions in T2/FLAIR sequences, Gd administration allows the detection of a very low percentage of reactivated lesions (e.g. one study found only 1 Gd + pre-existing lesion that appeared unchanged in size on T2/FLAIR sequences in 138 follow-up MRIs [
      • Mattay R.R.
      • Davtyan K.
      • Bilello M.
      • Mamourian A.C.
      Do all patients with multiple sclerosis benefit from the use of contrast on serial follow-up MR imaging? A retrospective analysis.
      ], while another study found that the overall probability of missing Gd + lesions in patients with stable T2 follow-up examinations was 1.7% [
      • Karimian-Jazi K.
      • Wildemann B.
      • Diem R.
      • Schwarz D.
      • Hielscher T.
      • Wick W.
      • et al.
      Gd contrast administration is dispensable in patients with MS without new T2 lesions on follow-up MRI.
      ]). The results reported in our study provide further data in support of the rationalization of Gd administration, since MS phenotype classification in our “active” population [
      • Lublin F.D.
      • Reingold S.C.
      • Cohen J.A.
      • Cutter G.R.
      • Sørensen P.S.
      • Thompson A.J.
      • et al.
      Defining the clinical course of multiple sclerosis: the 2013 revisions.
      ] did not change in about 99% of cases after excluding T1-Gd images [
      • Gentili L.
      • Capuano R.
      • Gaetani L.
      • Fiacca A.
      • Bisecco A.
      • D’Ambrosio A.
      • et al.
      Impact of post-contrast MRI in the definition of active multiple sclerosis.
      ]. According with previous data, therefore, we believe that Gd should not routinely administered in the MRI follow-up of MS patient and that its use could be limited to the situations in which the information provided by post-contrast sequences might impact MS diagnosis and therapeutic decisions. This approach also emerges from the most recent MAGNIMS-CMSC-NAIMS international guidelines that provided recommendations for the judicious use of gadolinium-based contrast agents for specific clinical purposes in MS diagnosis and monitoring [
      • Wattjes M.P.
      • Ciccarelli O.
      • Reich D.S.
      • Banwell B.
      • de Stefano N.
      • Enzinger C.
      • et al.
      2021 MAGNIMS–CMSC–NAIMS consensus recommendations on the use of MRI in patients with multiple sclerosis.
      ]. In the near future, regulatory National Health Agencies might consider these emerging/growing data in order to update the MRI-based access to disease modifying drugs (DMDs).

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