Diagnosing multiple sclerosis (MS) is challenging, in part because imaging findings in MS partially overlap with MS mimics such as vascular disease, migraine, and neuromyelitis optica spectrum disorder (NMOSD). The central vein sign has been shown to be a highly sensitive and specific biomarker for MS based on results from ultrahigh-field MRI studies, but as ultrahigh-field MRI is not widely available, MRI protocols using 3 Tesla (T) have been proposed. However, only small studies have examined the 3T central vein sign as a biomarker for MS to date. In this multicenter, cross-sectional study, 606 patients with relapsing-remitting MS (RRMS) or an MS-mimicking disease (including clinically isolated syndrome, NMOSD, systemic lupus erythematosus (SLE), cerebral vasculitis, episodic migraine, cluster headache, and small vessel disease) were studied to investigate the sensitivity and specificity of various central vein sign lesion criteria using 3T brain MRI. At baseline, 38.9% of patients had RRMS, 23.4% had cerebral small vessel disease, 19.3% of patients had clinically isolated syndrome, 5.3% had aquaporin-4 antibody-positive NMOSD, 4.8% had migraine, 4.1% had SLE, 3.3% had diabetes mellitus, and 0.8% had cluster headaches. Researchers found that a positive central vein sign was found in 47.4% of RRMS lesions, 54.2% of clinically isolated syndrome lesions, and 15.7% of all other non-MS lesions. For the 35% central vein sign proportion threshold, the specificity for differentiation between MS and clinically isolated syndrome and patients without MS was 82.9%, and the sensitivity was 68.1%. The criteria of three or more central vein sign lesions had a sensitivity of 61.9% and specificity of 89.0%. Finally, the use of optimized T2*-weighted imaging increased the sensitivity and specificity of the 35% central vein sign proportion threshold to 100% and 86.7%, respectively. Overall, this study illustrates that the central vein sign on 3T MRI has a high specificity and moderate sensitivity in differentiating MS from MS-mimicking diseases, however, future prospective studies will be necessary to support the use of this diagnostic test in clinical practice.
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