Clinical 3-tesla FLAIR∗ MRI improves diagnostic accuracy in multiple sclerosis

Ilena C. George, Pascal Sati, Martina Absinta, Irene C.M. Cortese, Elizabeth M. Sweeney, Colin D. Shea, Daniel S. Reich

Research output: Contribution to journalArticlepeer-review

25 Scopus citations


Objective: To evaluate clinical fluid-attenuated inversion recovery (FLAIR)∗ 3T magnetic resonance imaging (MRI), which is sensitive to perivenular inflammatory demyelinating lesions, in diagnosing multiple sclerosis (MS). Background: Central veins may be a distinguishing feature of MS lesions. FLAIR∗, a combined contrast derived from clinical MRI scans, has not been studied as a clinical tool for diagnosing MS. Methods: Two experienced MS neurologists evaluated 87 scan pairs (T2-FLAIR/FLAIR∗), separately and side-by-side, from 68 MS cases, 8 healthy volunteers, and 11 individuals with other neurological diseases. Raters judged cases based on experience, published criteria, and a visual assessment of the "40% rule," whereby MS is favored if >40% of lesions demonstrate a central vein. Diagnostic accuracy was determined with area under the receiver operating characteristic curve (AUC), and inter-rater reliability was assessed with Cohen's kappa. Results: Diagnostic accuracy was high: rater 1, AUC 0.94 (95% confidence interval: 0.89, 0.97) for T2-FLAIR, 0.95 (0.92, 0.98) for FLAIR∗; rater 2, 0.94 (0.90, 0.98) and 0.90 (0.85, 0.95). AUC improved when images were considered together: rater 1, 0.99 (0.98, 1.00); rater 2, 0.98 (0.96, 0.99). Inter-rater agreement was substantial for T2-FLAIR (= 0.68) and FLAIR∗ (= 0.74), despite low agreement on the 40% rule (= 0.47) (p ‰ 0. 001 in all cases). Conclusions: Joint clinical evaluation of T2-FLAIR and FLAIR∗ images modestly improves diagnostic accuracy for MS and does not require counting lesions with central veins.

Original languageEnglish
Pages (from-to)1578-1586
Number of pages9
JournalMultiple Sclerosis Journal
Issue number12
StatePublished - 1 Oct 2016
Externally publishedYes


  • MRI
  • central veins
  • diagnosis
  • multiple sclerosis


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