FLAIR* to visualize veins in white matter lesions: A new tool for the diagnosis of multiple sclerosis?

T. Campion, R. J. P. Smith, D. R. Altmann, G. C. Brito, B. P. Turner, J. Evanson, I. C. George, P. Sati, D. S. Reich, M. E. Miquel, K. Schmierer

To explore the potential of a post-processing technique combining FLAIR and T2* (FLAIR*) to distinguish between lesions caused by multiple sclerosis (MS) from cerebral small vessel disease (SVD) in a clinical setting. FLAIR and T2* head datasets acquired at 3T of 25 people with relapsing MS (pwRMS) and ten with pwSVD were used. After post-processing, FLAIR* maps were used to determine the proportion of white matter lesions (WML) showing the 'vein in lesion' sign (VIL), a characteristic histopathological feature of MS plaques. Sensitivity and specificity of MS diagnosis were examined on the basis of >45% VIL(+) and >60% VIL(+) WML, and compared with current dissemination in space (DIS) MRI criteria. All pwRMS had >45% VIL(+) WML (range 58-100%) whilst in pwSVD the proportion of VIL(+) WML was significantly lower (0-64%; mean 32±20%). Sensitivity based on >45% VIL(+) was 100% and specificity 80% whilst with >60% VIL(+) as the criterion, sensitivity was 96% and specificity 90%. DIS criteria had 96% sensitivity and 40% specificity. FLAIR* enables VIL(+) WML detection in a clinical setting, facilitating differentiation of MS from SVD based on brain MRI. • FLAIR* in a clinical setting allows visualization of veins in white matter lesions. • Significant proportions of MS lesions demonstrate a vein in lesion on MRI. • Microangiopathic lesions demonstrate a lower proportion of intralesional veins than MS lesions. • Intralesional vein-based criteria may complement current MRI criteria for MS diagnosis.