Spinal-Cord MRI in Multiple Sclerosis: Conventional and Nonconventional MR Techniques Joseph CJ. Bot, MD, PhD*, Frederik Barkhof, MD, PhD The presence of hyperintense T2 lesions in the brain is a completely nonspecific finding, and many other autoimmune mediated inflammatory disorders (OID) and cerebrovascular diseases are known to produce brain lesions that may mimic multiple sclerosis (MS) on T2-weighted MRI. Multifocal areas of high signal intensity within the cerebral white matter with or without similar areas in the immediate periventricular re- gion also may be seen on T2-weighted MRI in neurologically healthy people. The incidence of white matter abnormalities in the brain increases with age, and studies reported a prevalence of more than 30% in patients over the age of 60. 1 Differential diagnosis between MS and OID or cerebrovascular disease can be difficult on T2- weighted brain examinations, especially if pa- tients also show clinical signs of central nervous system (CNS) involvement. 2 Initial MR diagnostic criteria for MS were based on cerebral MR without inclusion of spinal cord MRI findings. These criteria were based on size, number, contrast enhancement, and location of fo- cal abnormalities. 3–5 The accuracy of these criteria was far from optimal, which resulted in a substan- tial number of misclassifications in a diagnostic setting. 5,6 The spinal cord is frequently involved in MS, with more than 90% of patients who have MS showing abnormalities on T2-weighted MRI. In contrast to the brain, MS-like abnormalities are seldom found in the spinal cord of healthy volun- teers, even past 50 years of age. 1,7 Although spinal cord abnormalities have been reported in OID and cerebrovascular disease, appearance of such ab- normalities may differ from those seen in MS. 8–18 Spinal cord MRI may therefore be of great value, in addition to brain MRI, for the differential diagno- sis of MS. 8,9 This article addresses conventional and quanti- tative techniques for spinal cord MRI in patients who have MS, their relation to clinical and histo- pathologic variables, and the diagnostic value of spinal cord MRI within the McDonald criteria for MS. Search strategy and selection criteria: Data for this review were identified by searches of MEDLINE with the terms ‘‘multiple sclerosis’’, ‘‘magnetic resonance imaging’’, ‘‘spinal cord’’, ‘‘atrophy’’, ‘‘DWI’’, ‘‘spectroscopy’’, ‘‘functional MRI’’ and ‘‘demyelination’’. Further, articles identified through searches of the files of the authors, and through references cited in the articles were used. Only papers published in English were reviewed. Precise information on unpublished or in-press data was obtained through personal communication with researchers who work in the same research groups as the authors. In clinical work-up of clinically isolated syndrome patients imaging of the spinal cord has become a useful tool. Department of Radiology, MR Center for MS Research, VU Medical Center, 1007 MB Amsterdam, The Netherlands * Corresponding author. E-mail address: j.bot@vumc.nl (J.CJ. Bot). KEYWORDS  Multiple sclerosis  Magnetic resonance imaging  Spinal cord  Atrophy  DWI  Spectroscopy  Functional MRI  Demyelination Neuroimag Clin N Am 19 (2009) 81–99 doi:10.1016/j.nic.2008.09.005 1052-5149/08/$ – see front matter ª 2008 Elsevier Inc. All rights reserved. neuroimaging.theclinics.com