Bildmorphologie der Multiplen Sklerose als inflammatorische und degenerative Erkrankung - Diagnosesicherung und Heterogenität im Krankheitsverlauf

Eine effiziente Therapie der Multiplen Sklerose (MS) erfordert eine schnelle und zuverlässige Diagnose der Erkrankung. Die Magnetresonanztomografie (MRT) ist die maßgebliche paraklinische Untersuchung für die Diagnosestellung. Auch wenn es keinen pathognomischen Befund für MS in der MRT gibt, so lassen sich doch MS-typische Morphologien und Lokalisationen herausarbeiten. Die MRT-Kriterien für die Diagnosestellung werden immer praktikabler und übersichtlicher für die klinische Routine, gleichzeitig konnte sowohl die Spezifität als auch Sensitivität verbessert werden. Neben den revidierten McDonald-Kriterien werden neue Kriterien vorgestellt, in denen eine Kontrastmittelgabe nicht zwingend erforderlich ist. Das Kontrastmittelverhalten gibt Möglichkeiten zur Differenzierung zu nichtentzündlichen Differenzialdiagnosen, zeigt aber auch innerhalb der MS unterschiedliche Charakteristika. Die Kriterien zur Erfüllung der räumlichen und zeitlichen Dissemination wurden vereinfacht. Es werden unterschiedliche Pathomechanismen der Erkrankung postuliert, die erwarten lassen, dass sich die große Gruppe der MS-Patienten in Subgruppen unterteilen lässt. Die beiden Hauptkomponenten der Erkrankung, die bildmorphologisch erkennbar sind, aber auch einen unterschiedlichen klinischen Verlauf nehmen, sind Inflammation und Neurodegeneration. Beide Faktoren sind miteinander verknüpft, haben aber auch eine unabhängige Komponente. Es wird eine Stratifizierung vorgestellt, die von verschiedenen zugrunde liegenden Pathomechanismen für die zwei bildmorphologisch fassbaren Hauptkomponenten ausgeht und so eine Subgruppierung in der MR-Bildgebung ermöglicht. Bisherige und bleibende Fragestellung an die MRT bei MS ist die Bearbeitung der MRT-Kriterien zur Diagnosestellung. Eine neue zukünftige Fragestellung an die MRT wird die Heterogenität bzw. Einteilung in Subtypen sein. Dieser Artikel gibt einen Überblick über beide Fragestellungen.

An efficient therapy of MS requires a quick and reliable diagnosis of the disease. MRI is the most leading paraclinical examination for MS diagnosis. Even though there is no pathognomic finding in MRI, there are MS characteristics with respect to morphology and localization. To exclude other neurological disorders and distinguish between different characteristics within MS, the use of contrast agent is advantageous. Postulated MRI criteria have been increasingly adjusted to the clinical routine and have become clearer, more sensitive, and more specific. Different imaging criteria will be introduced. In addition to the McDonald criteria of 2001 and 2005, new criteria will be presented in which the use of contrast agent is replaced by a second MRI and the dissemination in time and space is simplified. Different pathomechanisms which help to separate MS patients into subgroups are postulated. The diverse pathomechanisms also enable the development of new pharmaceuticals to manipulate the immunologic course in different stages. For varying therapy approaches, it is increasingly important to differentiate the heterogeneous appearance forms into subtypes. The two visible main components of the disorder in MRI are inflammation and neurodegeneration and are responsible for different clinical courses. Both are interdependent and independent of each other. We introduce a stratification which uses both components as a function of their different outcomes to compose subgroups. The previous challenge with respect to MRI was to support the diagnosis of MS via MRI criteria. A future problem will be the heterogeneity and classification of subgroups. This article gives an overview of both problems.

Key words

CNS - inflammation - imaging sequences - MR imaging - Multiple sclerosis

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