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The contribution of enhancing lesions in monitoring multiple sclerosis treatment: is gadolinium always necessary?

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MRI is highly sensitive for monitoring of disease activity and treatment efficacy in MS. Patients treated with disease modifying therapy (DMT), who experience MRI activity, including contrast-enhancing lesions (CEL) or new/enlarged T2 lesions, should be evaluated for a switch to more effective treatment. Due to recent evidence of gadolinium (Gd) accumulation in the brain after repeated administration of Gd-based contrast agents, FDA recommended to limit its use.


To investigate the proportion of cases in which MRI activity would be detectable only using contrast-enhanced T1-weighted sequences.Secondary aims were to assess the presence of clinical or demographic variables associated with reactivation of pre-existing lesions and to analyse therapeutic consequences of different types of MRI lesions.


We retrospectively evaluated brain MRI scans, performed between 2014 and 2018, in patients treated with DMT for at least 6 months.


We analysed 906 scans in 255 patients. New/enlarged T2 lesions were detected in 13.7% of cases, CEL in 3.5%, CEL without new T2 lesions (old lesions reactivated) in 1.1%. No variables were associated with old lesions reactivated. CEL with T2 equivalent were at higher risk of DMT switch, compared with new/enlarged T2 lesions without corresponding CEL (OR 4.0, 95% CI 1.5–10.4, p  = 0.005).


Reactivation of pre-existing lesions is limited to a tiny fraction of MRI studies. Gd + T1-weighted images could be omitted, in patients treated with DMT for at least 6 months, without relevant loss of information.

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Availability of data and material

The data that support the findings of this study are available from the corresponding author upon reasonable request.


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This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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Correspondence to Elena Tsantes.

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Conflicts of interest

E. Tsantes served on scientific advisory boards for Roche, Almirall and Merck & Co; has received funding for travel from Biogen, Merck & Co, Sanofi Genzyme, Roche, Novartis and Mylan. E. Curti served on scientific advisory boards for Merck & Co and Novartis; has received funding for travel from Biogen, Merck & Co, Teva Pharmaceutical Industries, Sanofi Genzyme, Roche and Novartis. C. Ganazzoli has nothing to disclose. F. Puci has nothing to disclose. V. Bazzurri has received funding for travel from Sanofi Genzyme, Biogen and Roche. A. Fiore has received funding for travel from Sanofi Genzyme and Biogen. G. Crisi has nothing to disclose. F. Granella has received research grants for his Institution from Biogen and Sanofi Genzyme; has served on scientific advisory boards for Biogen, Novartis, Sanofi Genzyme, Roche and Merck Serono; and has received funding for travel from Biogen, Merck Serono and Sanofi Genzyme.

Ethical statement

The study was approved  by the local ethics committee (Comitato Etico Area Vasta Emilia Nord, 484/2018/OSS/AOUPR) and performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.

Informed consent

All the patients provided written informed consent.

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Tsantes, E., Curti, E., Ganazzoli, C. et al. The contribution of enhancing lesions in monitoring multiple sclerosis treatment: is gadolinium always necessary?. J Neurol 267, 2642–2647 (2020).

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