Regular MRI is a key element in the follow-up of pwMS, particularly those on disease modifying treatment (DMT). Why? Because MRI is significantly more sensitive in detecting MS disease activity than counting relapses and measuring disability using the EDSS (Kurtzke’s Expanded Disability Status Scale). I’m quite precise here referring to the EDSS since other clinical instruments may be better to monitor pwMS over time. Indeed, at Barts Health, we have been collecting a handful of test results other than EDSS for some time, and these feed into management decisions. Check here and here for more.
But let’s not get distracted and rather focus on MRI follow-up. Many of you may be aware that in the UK, treatment decisions for high-efficacy DMTs have to be discussed and agreed at multi-disciplinary team (MDT) meeting consisting of at least two consultant neurologists, an MS nurse specialist, and neuroradiology support to interpret MRI. Involvement of a neuropharmacist is optional – at our centre we are blessed with an outstanding, award-winning one.
In treatment-active MS centres, DMT decisions are commonly based on MRI changes alone. But there are problems: Firstly, MRI scans obtained at different MRI systems are often difficult to compare since the techniques used differ, more or less. However, if you are keen on detecting even small changes, this “more or less” difference between MRI acquisition techniques may be key for a decision to switch (or not!) to a different DMT. Neuroradiologists would then often use phrases like “given the difference in techniques, no changes were detected”.
Secondly, counting MS lesions, or assessing changes in size of such lesions, is one of the most boring activities for any neuroradiologist not involved in MS research, which is the vast majority.
Thirdly, the time allocated to assess MS follow-up scans varies depending on other pressures, and in the NHS there always are other pressures…
We have highlighted the issues related to the first point in two papers, one a perspective on what should be done, and an audit on what is actually happening on the ground – There is a clear need to “unite the Kingdom” in what is being used to obtain images.
The second & third point is increasingly being addressed using artificial intelligence (AI), i.e. assistive software that highlights areas of change thereby guiding the clinician in deciding whether a significant change has indeed taken place or not. As it turns out, AI may well impact on point one above as well !
Over and above MS lesions, these AI-technologies are able to measure whole brain volume, and even segmented white and grey matter volumes to estimate the degree of brain atrophy.
The paper below by Diana Sima and her colleagues is the latest one in a series making the case for using AI-assisted MRI assessment in clinical practice. Using model simulations they assess the potential health economic impact in detecting MRI changes in pwMS.
Click on the title and you can read the paper free of charge. It is a quite challenging read for the non-expert though, and one of the co-authors, Wim van Hecke, therefore provided me with a more accessible summary, which is here:There-is-more-to-MS-disease-activity-than-meets-the-eye
Please note, the authors of this work are all employees of icometrix, including their CEO and CTO, so do read it with conflicts of interest in mind. Having said that, I’m pleased to report that BartsMS, together with colleagues from the University of Nottingham, have submitted a joint bid with icometrix to explore AI-assisted MRI in routine care of pwMS – a project called Assist-MS. More about this soon.
Disclaimer: The opinions expressed here are those of the author and do not necessarily reflect positions of Barts and The London School of Medicine & Dentistry, Queen Mary University of London, or Barts Health NHS Trust.