Age-appropriate or delayed myelination? Scoring myelination in routine clinical MRI

Assessment of myelination is a core issue in paediatric neuroimaging and can be challenging, particularly in settings without dedicated paediatric neuroradiologists. Deep learning models have recently been shown to be able to estimate myelination age in children with normal MRI, but currently lack validation for patients with myelination delay and implementation including pre-processing suitable for local imaging is not trivial. Standardized myelination scores, which have been successfully used as biomarkers for myelination in hypomyelinating diseases, rely on visual, semiquantitative scoring of myelination on routine clinical MRI and may offer an easy-to-use alternative for assessment of myelination. Myelination was scored in 13 anatomic sites (items) on conventional T2w and T1w images in controls (n = 253, 0–2 years). Items for the score were selected based on inter-rater variability, practicability of scoring, and importance for correctly identifying validation scans. The resulting myelination score consisting of 7 T2- and 5 T1-items delineated myelination from term-equivalent to advanced, incomplete myelination which 50 % and 99 % of controls had reached by 19.1 and 32.7 months, respectively. It correctly identified 20/20 new control MRIs and 40/43 with myelination delay, missing one patient with borderline myelination delay at 8.6 months and 2 patients with incomplete T2-myelination of subcortical temporopolar white matter at 28 and 34 months. The proposed myelination score provides an easy to use, standardized, and versatile tool to delineate myelination normally occurring during the first 1.5 years of life. •Assessment of myelination as a core issue in paediatric neuroimaging, potentially challenging and observer-dependent.•Deep learning can estimate myelination age in normal MRI, but not yet validated for myelination delay, not trivial to implement.•Myelination scores: visual, semiquantitative scoring of myelination on routine MRIs, established for hypomyelination research.•Proposed myelination score: standardized, ready-to-go, easy-to-use for MRIs from different scanners and field strengths.