Outline of the module
This module will focus on two clinical topics: MRI in neurology and musculoskeletal imaging. Both diseases classes are a huge burden on society and will become even a larger burden with increasing age of the population of industrial countries. In Neurology (e.g. Stroke, Multiple Sclerosis, Epilepsy, Parkinson and Alzheimer’s diseases), MRI plays a crucial role in detecting diseases before clinical symptoms appear allowing more effective treatment. In addition, it allows differentiating diseases with similar symptoms (i.e. differential diagnosis) and monitoring disease progression. In Musculoskeletal imaging (MSK), the goal is to detect damages to joint at the interface of general tissue and bones (e.g. muscle, menisci, bone, tendon, ligaments, spine …). Diseases of musculoskeletal tissue have impact on the mobility of the person and affect general life quality. MRI is particularly important to image in MSK because of the various image contrasts available to shed light on the type and origin of the damages.
Thus, this module will introduce the aetiology and phenomenology of neurological and musculoskeletal diseases. In addition, the different MRI sequences (T1, T2, T2*, MTR, CSI, UTE …) allowing to characterize the diseases will be discussed. Finally, the students will get examples on selected patient populations to demonstrate how diseases manifest on MR images and how to differentially diagnose them.
Learning objectives
At the end of the module, students will have expert knowledge about the following topics:
• Aetiology of Neurological diseases (e.g. Stroke, Multiple Sclerosis, Epilepsy, Parkinson and Alzheimer’s diseases)
• Causes and biological manifestations of Musculoskeletal damages (e.g. in muscles, menisci, bone, tendon, ligaments, spine …)
• Overview on behavioural testing of neurological and musculoskeletal diseases
• MRI sequences for diagnosis including T1, T2, T2*, MTR, CSI, UTE …
• Practical sessions: MR scanning on selected patient populations
• Processing of MR images to delineate and quantify diseases
• Differential diagnosis on diseases with similar clinical symptoms and/or MR image contrasts
• Magnetic field strength dependency of MRI contrasts and their advantages and disadvantages in diagnosis
• Functional MRI for disease diagnosis
• Clinical benefits of MRI for patients and comparison with other approaches (e.g. CT)
Content
MRI is a versatile tool to assess tissue composition and function due to its property that by manipulating magnetisation and its evolution different tissue features can be probed. For example, susceptibility-weighted MRI measures the magnetic susceptibility of brain tissue determined by iron and myelin concentration. Or, diffusion MRI is sensitive to diffusion of water in the white matter allowing to assess white mater paths and their integrity. Thus, due to this flexibility, MRI is increasingly used to diagnose diseases and to monitor disease progressions and success of interventions.
Next to the module on MRI in Oncology and Cardiology, this module covers the field of clinical MRI with emphasis of Neurology and Musculoskeletal Imaging (MSK). First, the aetiology of neurological diseases will be discussed. In general, neurological diseases can have multiple causes and the diseases can be coarsely divided into vascular, neurodegenerative, white matter and metabolite diseases (and combination of those, as multiple disease origins are not exclusive). The most prominent vascular diseases are stroke, hemorrhage, small vessel diseases, TIA, etc. MRI, especially using contrast agents measuring perfusion and susceptibility-weighted images, is an important tool to diagnose the extent and type of vascular diseases. In white matter diseases (e.g. multiple sclerosis), it is important to evaluate white matter integrity and axonal damages using diffusion and again susceptibility-weighted imaging and quantify metabolites using chemical shift (CSI) and magnetisation transfer (MTR) imaging.
As a concrete example, MS is the most common chronic inflammatory disease of the central nervous system (CNS) in young adults with a prevalence of 1:1,000 people in Europe. Pathologically, MS is a heterogenic chronic immune-mediated inflammatory disorder of the CNS disseminated in space and in time which is characterized by focal and diffuse areas of demyelination within the white and grey matter associated with axonal damage and loss. Magnetic Resonance Imaging (MRI) is the most sensitive diagnostic tool in the detection of focal and diffuse changes of MS in vivo and has become the most important clinical method in the diagnosis of MS within diagnostic criteria. Furthermore, in patients presenting with a clinically isolated syndrome (CIS) suggestive of MS, MRI has gained an important prognostic value in terms of predicting the conversion to clinically definite MS and long-term disability.
In the field of neurodegenerative diseases are most relevant Epilepsy, Parkinson and Alzheimer’s diseases. The diseases are associated with white and grey matter lesions which can be appraised with the MRI techniques mentioned above, in addition voxel based morphometry to calculate grey matter thinning. For all these neurological diseases functional MRI can add value to evaluate losses of sensory and cognitive function related with the disease. In summary, MRI is an important tool – and in some diseases currently the most important tool – to diagnose and monitor neurological diseases due to its flexibility to probe different biochemical processes.
The musculoskeletal tissue (e.g. in muscles, menisci, bone, tendon, ligaments, spine, etc.) can be damaged due to sport injuries and aging and some genetic diseases, to name few examples of the origins of musculoskeletal damages. All the above MR image techniques can also be employed to image musculoskeletal tissue. However, bones are difficult to image using MRI (as other hard tissues) due to its fast relaxation of the magnetisation. Novel methods, such as ultra-short echo time imaging (UTE), can used to examine bone integrity.
To summarise, the clinical field of neurology and musculoskeletal imaging will be introduced including aetiology, diagnosis, MRI contrasts. In addition, practical examples on patients scanned on our MRI instruments will be used to teach how to diagnose different diseases.
Overview of tasks and lectures
There will be 10 lectures of 2 hours distributed over 5 days.
• Introduction into Neurology and MSK
• Overview of MRI sequences and contrasts relevant to neurology and MSK
• Neurology: Vascular diseases I
• Neurology: Vascular diseases II (subcortical and cortical Stroke, hemorrhage, CADASIL …)
• Neurology: Degeneration I (white matter diseases, e.g. Multiple Sclerosis,)
• Neurology: Degeneration II (Epilepsy, Parkinson, Alzheimer’s)
• MSK: Bone microarchitecture
• MSK: Joint imaging
• MSK: Cartilage, Arthritis
• Summary and Introduction of post-module assignments
Position within the programme
This module is the second module on clinical MRI (see module on oncology and cardiology). In addition, knowledge of other modules (MR Physics I, MR spectroscopy, Sequences for MR physics, Pharmacological MRI, Anatomical and function Image basics) will deepen the understanding of background knowledge for clinical practice.
Teaching format
Structure
The module is a one week-long residential module consisting of 10 lectures of 2 hours. Each day, the students will in addition perform data acquisition on the scanners located at the UM (3, 7 and 9.4 Tesla) and subsequent clinical image interpretation guided by tutors. Furthermore, the residential part is combined with a preparatory reading phase and post-module marked assignments.
Grading
Passing the module requires an 85% attendance to the lectures and practical sessions, and a satisfactory completion of the practical sessions and the module assignments. The module assignments will be summarised by the students in a written form which will be evaluated by the module coordinator(s).