MRI criteria for the diagnosis of multiple sclerosis: MAGNIMS consensus guidelines

Contribution of the MP2RAGE 7T Sequence in MS Lesions of the Cervical Spinal Cord

BACKGROUND AND PURPOSE

The detection of spinal cord lesions in patients with MS is challenging. Recently, the 3D MP2RAGE sequence demonstrated its usefulness at 3T. Benefiting from the high spatial resolution provided by ultra-high-field MR imaging systems, we aimed to evaluate the contribution of the 3D MP2RAGE sequence acquired at 7T for the detection of MS lesions in the cervical spine.

MATERIALS AND METHODS

Seventeen patients with MS participated in this study. They were examined at both 3T and 7T. The MR imaging examination included a Magnetic Imaging in MS (MAGNIMS) protocol with an axial T2*-WI gradient recalled-echo sequence ("optimized MAGNIMS protocol") and a 0.9-mm isotropic 3D MP2RAGE sequence at 3T, as well as a 0.7-mm isotropic and 0.3-mm in-plane-resolution anisotropic 3D MP2RAGE sequences at 7T. Each data set was read by a consensus of radiologists, neurologists, and neuroscientists. The number of lesions and their topography, as well as the visibility of the lesions from one set to another, were carefully analyzed.

RESULTS

A total of 55 lesions were detected. The absolute number of visible lesions differed among the 4 sequences (linear mixed effect ANOVA, P = .020). The highest detection was observed for the two 7T sequences with 51 lesions each (92.7% of the total). The optimized 3T MAGNIMS protocol and the 3T MP2RAGE isotropic sequence detected 41 (74.5%) and 35 lesions (63.6%), respectively.

CONCLUSIONS

The 7T MP2RAGE sequences detected more lesions than the 3T sets. Isotropic and anisotropic acquisitions performed comparably. Ultra-high-resolution sequences obtained at 7T improve the identification and delineation of lesions of the cervical spinal cord in MS.

A Real-World Experience of Azathioprine Versus First-Line Disease-Modifying Therapy in Relapsing-Remitting Multiple Sclerosis-A Prospective Cohort Study

Azathioprine (AZA) has demonstrated efficacy in multiple randomized control trials (RCTs) for Relapsing-Remitting Multiple Sclerosis (RRMS). However, we still need comparative real-world data with other first-line disease-modifying therapies (DMTs). We aimed to assess AZA's effectiveness regarding relapses, disability progression, time to the first relapse, magnetic resonance imaging (MRI) activity, and safety compared with other approved first-line DMTs in an Indian population in a real-world setting. We conducted a single-center prospective study of treatment-naive RRMS patients between 2017 and 2019. We evaluated the effects of AZA and other approved DMTs on clinical and radiological measures. Among 192 eligible patients (F:M ratio 2.84:1), 68 patients (35.4%) were on AZA, 68 patients (35.4%) were on dimethyl fumarate (DMF), 32 patients (16.7%) on interferon (IFN beta-1a), and 16 patients (8.3%) on teriflunomide (TFL). Four treatment groups were comparable: AZA v/s DMF v/s TFL v/s IFN beta-1a. In primary outcomes, there was no significant difference between the groups in terms of change in the Expanded Disability Status Scale (EDSS) score at three months (p-value = 0.169), six months (p-value = 0.303), 12 months (p-value = 0.082), and 24 months (p-value = 0.639), the number of relapses (p-value = 0.229), and time to the first relapse (p-value > 0.05 in all groups). In the secondary outcome, there was no significant difference between the treatment groups on serial MRI parameters used according to "Magnetic Resonance Imaging in Multiple Sclerosis" (MAGNIMS) 2016 criteria (p-value > 0.05). In safety outcomes, leukopenia was significantly more common in the AZA group (p-value = 0.025), flu-like symptoms (p-value = 0.0001), and injection site reactions (p-value = 0.035) were significantly more common in the IFN beta-1a group. Our study suggests AZA is as effective as other approved DMTs and a good alternative as a first-line treatment for multiple sclerosis's clinical and radiological activity in real-world settings on short follow-up. Based on these results, more randomized controlled trials of AZA v/s DMF or other DMTs are needed for more robust outcomes.

Diagnostic Performance of Adding the Optic Nerve Region Assessed by Optical Coherence Tomography to the Diagnostic Criteria for Multiple Sclerosis

BACKGROUND AND OBJECTIVES

The optic nerve has been recommended as an additional region for demonstrating dissemination in space (DIS) in diagnostic criteria for multiple sclerosis (MS). The aim of this study was to investigate whether adding the optic nerve region as determined by optical coherence tomography (OCT) as part of the DIS criteria improves the 2017 diagnostic criteria.

METHODS

From a prospective observational study, we included patients with a first demyelinating event who had complete information to assess DIS and a spectral domain OCT scan obtained within 180 days. Modified DIS criteria (DIS + OCT) were constructed by adding the optic nerve to the current DIS regions based on validated thresholds for OCT intereye differences. Time to second clinical attack was the primary endpoint.

RESULTS

We analyzed 267 patients with MS (mean age 31.3 years [SD 8.1], 69% female) during a median observation period of 59 months (range: 13-98). Adding the optic nerve as a fifth region improved the diagnostic performance by increasing accuracy (DIS + OCT 81.2% vs DIS 65.6%) and sensitivity (DIS + OCT 84.2% vs DIS 77.9%) without lowering specificity (DIS + OCT 52.2% vs DIS 52.2%). Fulfilling DIS + OCT criteria (≥2 of 5 DIS + OCT regions involved) indicated a similar risk of a second clinical attack (hazard ratio [HR] 3.6, CI 1.4-14.5) compared with a 2.5-fold increased risk when fulfilling DIS criteria (HR 2.5, CI 1.2-11.8). When the analysis was conducted according to topography of the first demyelinating event, DIS + OCT criteria performed similarly in both optic neuritis and nonoptic neuritis.

DISCUSSION

Addition of the optic nerve, assessed by OCT, as a fifth region in the current DIS criteria improves diagnostic performance by increasing sensitivity without lowering specificity.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that adding the optic nerve as determined by OCT as a fifth DIS criterion to the 2017 McDonald criteria improves diagnostic accuracy.

Central and peripheral myeloid-derived suppressor cell-like cells are closely related to the clinical severity of multiple sclerosis

Multiple sclerosis (MS) is a highly heterogeneous demyelinating disease of the central nervous system (CNS) that needs for reliable biomarkers to foresee disease severity. Recently, myeloid-derived suppressor cells (MDSCs) have emerged as an immune cell population with an important role in MS. The monocytic-MDSCs (M-MDSCs) share the phenotype with Ly-6Chi-cells in the MS animal model, experimental autoimmune encephalomyelitis (EAE), and have been retrospectively related to the severity of the clinical course in the EAE. However, no data are available about the presence of M-MDSCs in the CNS of MS patients or its relation with the future disease aggressiveness. In this work, we show for the first time cells exhibiting all the bona-fide phenotypical markers of M-MDSCs associated with MS lesions, whose abundance in these areas appears to be directly correlated with longer disease duration in primary progressive MS patients. Moreover, we show that blood immunosuppressive Ly-6Chi-cells are strongly related to the future severity of EAE disease course. We found that a higher abundance of Ly-6Chi-cells at the onset of the EAE clinical course is associated with a milder disease course and less tissue damage. In parallel, we determined that the abundance of M-MDSCs in blood samples from untreated MS patients at their first relapse is inversely correlated with the Expanded Disability Status Scale (EDSS) at baseline and after a 1-year follow-up. In summary, our data point to M-MDSC load as a factor to be considered for future studies focused on the prediction of disease severity in EAE and MS.

Secondary Central Nervous System Demyelinating Disorders in the Elderly: A Narrative Review

Secondary demyelinating diseases comprise a wide spectrum group of pathological conditions and may either be attributed to a disorder primarily affecting the neurons or axons, followed by demyelination, or to an underlying condition leading to secondary damage of the myelin sheath. In the elderly, primary demyelinating diseases of the central nervous system (CNS), such as multiple sclerosis, are relatively uncommon. However, secondary causes of CNS demyelination may often occur and in this case, extensive diagnostic workup is usually needed. Infectious, postinfectious, or postvaccinal demyelination may be observed, attributed to age-related alterations of the immune system in this population. Osmotic disturbances and nutritional deficiencies, more commonly observed in the elderly, may lead to conditions such as pontine/extrapontine myelinolysis, Wernicke encephalopathy, and demyelination of the posterior columns of the spinal cord. The prevalence of malignancies is higher in the elderly, sometimes leading to radiation-induced, immunotherapy-related, or paraneoplastic CNS demyelination. This review intends to aid clinical neurologists in broadening their diagnostic approach to secondary CNS demyelinating diseases in the elderly. Common clinical conditions leading to secondary demyelination and their clinical manifestations are summarized here, while the current knowledge of the underlying pathophysiological mechanisms is additionally presented.

Absence of Oligoclonal Bands in Multiple Sclerosis: A Call for Differential Diagnosis

BACKGROUND

Immunoglobulin gamma (IgG) oligoclonal bands (OCB) in the cerebrospinal fluid (CSF) are absent in a small group of multiple sclerosis (MS) patients. According to previous research, OCB-negative MS patients differ genetically but not clinically from OCB-positive MS patients. However, whether OCB-negative MS is a unique immunological and clinical entity remains unclear. The absence of OCB poses a significant challenge in diagnosing MS. (1) Objective: The objective of this study was twofold: (1) to determine the prevalence of OCB-negative MS patients in the Uppsala region, and (2) to assess the frequency of misdiagnosis in this patient group. (2) Methods: We conducted a retrospective study using data from the Swedish MS registry (SMSreg) covering 83% of prevalent MS cases up to 20 June 2020 to identify all MS patients in the Uppsala region. Subsequently, we collected relevant information from the medical records of all OCB-negative MS cases, including age of onset, gender, presenting symptoms, MRI features, phenotype, Expanded Disability Status Scale (EDSS) scores, and disease-modifying therapies (DMTs). (3) Results: Out of 759 MS patients identified, 69 had an OCB-negative MS diagnosis. Upon re-evaluation, 46 patients had a typical history and MRI findings of MS, while 23 had unusual clinical and/or radiologic features. An alternative diagnosis was established for the latter group, confirming the incorrectness of the initial MS diagnosis. The average EDSS score was 2.0 points higher in the MS group than in the non-MS group (p = 0.001). The overall misdiagnosis rate in the cohort was 33%, with 22% of misdiagnosed patients having received DMTs. (4) Conclusions: Our results confirm that the absence of OCB in the CSF should raise suspicion of possible misdiagnosis in MS patients and prompt a diagnostic reassessment.

Integrating Neuroimaging Measures in Nursing Research

BACKGROUND

Medical and scientific advancement worldwide has led to a longer lifespan. With the population aging comes the risk of developing cognitive decline. The incorporation of neuroimaging measures in evaluating cognitive changes is limited in nursing research. The aim of this review is to introduce nurse scientists to neuroimaging measures employed to assess the association between brain and cognitive changes.

METHODS

Relevant literature was identified by searching CINAHL, Web of Science, and PubMed databases using the following keywords: "neuroimaging measures," "aging," "cognition," "qualitative scoring," "cognitive ability," "molecular," "structural," and "functional."

RESULTS

Neuroimaging measures can be categorized into structural, functional, and molecular imaging approaches. The structural imaging technique visualizes the anatomical regions of the brain. Visual examination and volumetric segmentation of select structural sequences extract information such as white matter hyperintensities and cerebral atrophy. Functional imaging techniques evaluate brain regions and underlying processes using blood-oxygen-dependent signals. Molecular imaging technique is the real-time visualization of biological processes at the cellular and molecular levels in a given region. Examples of biological measures associated with neurodegeneration include decreased glutamine level, elevated total choline, and elevated Myo-inositol.

DISCUSSION

Nursing is at the forefront of addressing upstream factors impacting health outcomes across a lifespan of a population at increased risk of progressive cognitive decline. Nurse researchers can become more facile in using these measures both in qualitative and quantitative methodology by leveraging previously gathered neuroimaging clinical data for research purposes to better characterize the associations between symptom progression, disease risk, and health outcomes.

Diffusion-Weighted Images and Contrast-Enhanced MRI in the Diagnosis of Different Stages of Multiple Sclerosis of the Central Nervous System

Introduction Multiple sclerosis (MS) is one of the most prevalent disorders of the central nervous system (CNS), and it can be observed in the field of radiological cross-sectional magnetic resonance imaging (MRI). The prevalence of MS in Saudi Arabia has increased as compared to the past few years. MRI is the gold standard non-invasive modality of choice in MS diagnosis according to the National Multiple Sclerosis Society (NMSS), New York City. This study aimed to highlight the significance of using diffusion-weighted images (DWIs) and the use of contrast media in the MS protocol, as well as the importance of identifying the suitable time of imaging after contrast enhancement to detect active lesions. Methods A retrospective cross-sectional study was conducted of 100 MS patients with an age range of 17 to 56 years. The data set included 41 active cases and 59 inactive cases. All patients had an MRI standard protocol of both the brain and spine in addition to DWI sequence and contrast agent (CA) injection, with images taken in early and delayed time. Results Of the patients, 71% were female and 29% were male. Active MS disease was more significant at younger ages than at older ages. Active lesions were significantly enhanced in delayed contrast images and showed high signal intensity in both the DWI and apparent diffusion coefficient (ADC) map, while inactive lesions showed no enhancement after contrast injection and showed an iso-signal intensity in both the DWI and ADC map. Conclusion The use of CA has developed over the years in the diagnosis of MS patients. In this study, the relationship between active lesions, DWI, and delayed contrast enhancement is very strong. In future research, we recommend adding a DWI sequence for the suspected active MS spine lesions in addition to delayed enhancement time in active MS after contrast injection to increase MRI sensitivity toward active MS lesions of the brain and spinal cord as well.

Multiple Sclerosis-A Demyelinating Disorder and Its Dental Considerations-A Literature Review with Own Case Report

Multiple sclerosis (MS) is a chronic, autoimmune condition that primarily affects the myelin sheath covering the neurons of the central nervous system, including those of the brain and spinal cord. Although the etiology is not completely understood, various factors, such as genetic infections and environmental background, play a role in the pathogenesis. Repeated active episodes of MS characterized with marked inflammation results in the scarring of particular nerve segments, and eventually results in functional impairment over a period of time. Based on the clinical course of the disease, four clinical types of MS have been identified, with the relapsing-remitting type being the commonest. MS is known to occur more commonly in females in the age group of 20-40 years. Dysarthria, fatigue, muscle spasm, and numbness are the common presenting symptoms of MS. Diagnosis is generally achieved with MRI brain scans, showing demyelination plaques and lumbar puncture. Treatment of MS's acute phase includes high doses of corticosteroids; whereas preventive treatment of MS includes the prescription of immunosuppressive therapy, including biologics. A large group of MS patients present with oral manifestations, including dysphagia, dysarthria, temporomandibular joint (TMJ) disturbances, facial palsy, and chronic periodontal diseases. Other typical oral manifestations seen in MS patients include trigeminal neuralgia, paresthesia, or orofacial pain. Dental treatment and following drug prescription needs to be tailored to each patient, as there is a possibility of drug interactions. This paper presents a comprehensive, updated review of MS, with emphasis on oral manifestations and dental considerations. Additionally, it presents a case of a 40-year-old female diagnosed with MS that was presented to a dental hospital. The report discusses the oral manifestations and dental management.

Cellular and Molecular Evidence of Multiple Sclerosis Diagnosis and Treatment Challenges

Multiple sclerosis (MS) is a chronic autoimmune disease that impacts the central nervous system and can result in disability. Although the prevalence of MS has increased in India, diagnosis and treatment continue to be difficult due to several factors. The present study examines the difficulties in detecting and treating multiple sclerosis in India. A lack of MS knowledge among healthcare professionals and the general public, which delays diagnosis and treatment, is one of the significant issues. Inadequate numbers of neurologists and professionals with knowledge of MS management also exacerbate the situation. In addition, MS medications are expensive and not covered by insurance, making them inaccessible to most patients. Due to the absence of established treatment protocols and standards for MS care, India's treatment techniques vary. In addition, India's population diversity poses unique challenges regarding genetic variations, cellular and molecular abnormalities, and the potential for differing treatment responses. MS is more difficult to accurately diagnose and monitor due to a lack of specialized medical supplies and diagnostic instruments. Improved awareness and education among healthcare professionals and the general public, as well as the development of standardized treatment regimens and increased investment in MS research and infrastructure, are required to address these issues. By addressing these issues, it is anticipated that MS diagnosis and treatment in India will improve, leading to better outcomes for those affected by this chronic condition.

Evaluation of the Statistical Detection of Change Algorithm for Screening Patients with MS with New Lesion Activity on Longitudinal Brain MRI

BACKGROUND AND PURPOSE

Identification of new MS lesions on longitudinal MR imaging by human readers is time-consuming and prone to error. Our objective was to evaluate the improvement in the performance of subject-level detection by readers when assisted by the automated statistical detection of change algorithm.

MATERIALS AND METHODS

A total of 200 patients with MS with a mean interscan interval of 13.2 (SD, 2.4) months were included. Statistical detection of change was applied to the baseline and follow-up FLAIR images to detect potential new lesions for confirmation by readers (Reader + statistical detection of change method). This method was compared with readers operating in the clinical workflow (Reader method) for a subject-level detection of new lesions.

RESULTS

Reader + statistical detection of change found 30 subjects (15.0%) with at least 1 new lesion, while Reader detected 16 subjects (8.0%). As a subject-level screening tool, statistical detection of change achieved a perfect sensitivity of 1.00 (95% CI, 0.88-1.00) and a moderate specificity of 0.67 (95% CI, 0.59-0.74). The agreement on a subject level was 0.91 (95% CI, 0.87-0.95) between Reader + statistical detection of change and Reader, and 0.72 (95% CI, 0.66-0.78) between Reader + statistical detection of change and statistical detection of change.

CONCLUSIONS

The statistical detection of change algorithm can serve as a time-saving screening tool to assist human readers in verifying 3D FLAIR images of patients with MS with suspected new lesions. Our promising results warrant further evaluation of statistical detection of change in prospective multireader clinical studies.

miRNA 548a-3p as biomarker of NEDA-3 at 2 years in multiple sclerosis patients treated with fingolimod

BACKGROUND

Multiple sclerosis (MS) is a disabling autoimmune demyelinating disorder affecting young people and causing significant disability. In the last decade, different microRNA (miRNA) expression patterns have been associated to several treatment response therapies such as interferon and glatiramer acetate. Nowadays, there is increasing interest in the potential role of miRNA as treatment response biomarkers to the most recent oral and intravenous treatments. In this study, we aimed to evaluate serum miRNAs as biomarkers of No Evidence of Disease Activity (NEDA-3) at 2 years in patients with relapsing remitting MS (RRMS) treated with fingolimod.

MAIN BODY

A Discovery cohort of 31 RRMS patients treated with fingolimod were identified from the CLIMB study and classified as No Evidence of Disease Activity (NEDA-3) or Evidence of Disease Activity (EDA-3) after 2 years on treatment. Levels of miRNA expression were measured at 6 months using human serum miRNA panels and compared in EDA-3 and NEDA-3 groups using the Wilcoxon rank sum test. A set of differentially expressed miRNA was further validated in an independent cohort of 22 fingolimod-treated patients. We found that 548a-3p serum levels were higher levels in fingolimod-treated patients classified as NEDA-3, compared to the EDA-3 group in both the Discovery (n = 31; p = 0.04) and Validation (n = 22; p = 0.03) cohorts 6 months after treatment initiation; miR-548a-3p provided an AUC of 0.882 discriminating patients with NEDA-3 at 2 years in the Validation cohort.

CONCLUSION

Our results show differences in miR-548a-3p expression at 6 months after fingolimod start in patients with MS with NEDA-3 at 2 years. These results provide class III evidence of the use of miR-548a-3p as biomarker of NEDA-3 in patients with fingolimod.

Iron Rim Lesions as a Specific and Prognostic Biomarker of Multiple Sclerosis: 3T-Based Susceptibility-Weighted Imaging

This study aimed to identify the clinical significance of iron rim lesions (IRLs) in distinguishing multiple sclerosis (MS) from other central nervous system (CNS) demyelinating diseases, determine the relationship between IRLs and disease severity, and understand the long-term dynamic changes in IRLs in MS. We retrospectively evaluated 76 patients with CNS demyelinating diseases. CNS demyelinating diseases were classified into three groups: MS (n = 30), neuromyelitis optica spectrum disorder (n = 23), and other CNS demyelinating diseases (n = 23). MRI images were obtained using conventional 3T MRI including susceptibility-weighted imaging. Sixteen of 76 patients (21.1%) had IRLs. Of the 16 patients with IRLs, 14 were in the MS group (87.5%), indicating that IRLs were significantly specific for MS. In the MS group, patients with IRLs had a significantly higher number of total WMLs, experienced more frequent recurrence, and were treated more with second-line immunosuppressive agents than were patients without IRLs. In addition to IRLs, T1-blackhole lesions were observed more frequently in the MS group than in the other groups. IRLs are specific for MS and could represent a reliable imaging biomarker to improve the diagnosis of MS. Additionally, the presence of IRLs seems to reflect more severe disease progression in MS.

Assessing the Equivalence of Brain-Derived Measures from Two 3D T1-Weighted Acquisitions: One Covering the Brain and One Covering the Brain and Spinal Cord

BACKGROUND AND PURPOSE

In MS, it is common to acquire brain and spinal cord MR imaging sequences separately to assess the extent of the disease. The goal of this study was to see how replacing the traditional brain T1-weighted images (brain-T1) with an acquisition that included both the brain and the cervical spinal cord (cns-T1) affected brain- and spinal cord-derived measures.

MATERIALS AND METHODS

Thirty-six healthy controls (HC) and 42 patients with MS were included. Of those, 18 HC and 35 patients with MS had baseline and follow-up at 1 year acquired on a 3T magnet. Two 3D T1-weighted images (brain-T1 and cns-T1) were acquired at each time point. Regional cortical thickness and volumes were determined with FastSurfer, and the percentage brain volume change per year was obtained with SIENA. The spinal cord area was estimated with the Spinal Cord Toolbox. Intraclass correlation coefficients (ICC) were calculated to check for consistency of measures obtained from brain-T1 and cns-T1.

RESULTS

Cortical thickness measures showed an ICC >0.75 in 94% of regions in healthy controls and 80% in patients with MS. Estimated regional volumes had an ICC >0.88, and the percentage brain volume change had an ICC >0.79 for both groups. The spinal cord area measures had an ICC of 0.68 in healthy controls and 0.92 in patients with MS.

CONCLUSIONS

Brain measurements obtained from 3D cns-T1 are highly equivalent to those obtained from a brain-T1, suggesting that it could be feasible to replace the brain-T1 with cns-T1.

Recent Advances in Explainable Artificial Intelligence for Magnetic Resonance Imaging

Advances in artificial intelligence (AI), especially deep learning (DL), have facilitated magnetic resonance imaging (MRI) data analysis, enabling AI-assisted medical image diagnoses and prognoses. However, most of the DL models are considered as "black boxes". There is an unmet need to demystify DL models so domain experts can trust these high-performance DL models. This has resulted in a sub-domain of AI research called explainable artificial intelligence (XAI). In the last decade, many experts have dedicated their efforts to developing novel XAI methods that are competent at visualizing and explaining the logic behind data-driven DL models. However, XAI techniques are still in their infancy for medical MRI image analysis. This study aims to outline the XAI applications that are able to interpret DL models for MRI data analysis. We first introduce several common MRI data modalities. Then, a brief history of DL models is discussed. Next, we highlight XAI frameworks and elaborate on the principles of multiple popular XAI methods. Moreover, studies on XAI applications in MRI image analysis are reviewed across the tissues/organs of the human body. A quantitative analysis is conducted to reveal the insights of MRI researchers on these XAI techniques. Finally, evaluations of XAI methods are discussed. This survey presents recent advances in the XAI domain for explaining the DL models that have been utilized in MRI applications.

Evaluation of transorbital sonography measures of optic nerve diameter in the context of global and regional brain volume in multiple sclerosis

Transorbital sonography (TOS) could be a swift and convenient method to detect the atrophy of the optic nerve, possibly providing a marker that might reflect other quantitative structural markers of multiple sclerosis (MS). Here we evaluate the utility of TOS as a complementary tool for assessing optic nerve atrophy, and investigate how TOS-derived measures correspond to volumetric brain markers in MS. We recruited 25 healthy controls (HC) and 45 patients with relapsing-remitting MS and performed B-mode ultrasonographic examination of the optic nerve. Patients additionally underwent MRI scans to obtain T1-weighted, FLAIR and STIR images. Optic nerve diameters (OND) were compared between HC, MS patients with and without history of optic neuritis (non-ON) using a mixed-effects ANOVA model. The relationship between within-subject-average OND and global and regional brain volumetric measures was investigated using FSL SIENAX, voxel-based morphometry and FSL FIRST. OND was significantly different between HC-MS (HC = 3.2 ± 0.4 mm, MS = 3 ± 0.4 mm; p < 0.019) and we found significant correlation between average OND and normalised whole brain (β = 0.42, p < 0.005), grey matter (β = 0.33, p < 0.035), white matter (β = 0.38, p < 0.012) and ventricular cerebrospinal fluid volume (β = - 0.36, p < 0.021) in the MS group. History of ON had no impact on the association between OND and volumetric data. In conclusion, OND is a promising surrogate marker in MS, that can be simply and reliably measured using TOS, and its derived measures correspond to brain volumetric measures. It should be further explored in larger and longitudinal studies.

Three-dimensional multi-parameter brain mapping using MR fingerprinting

The purpose of this study was to develop and test a 3D multi-parameter MR fingerprinting (MRF) method for brain imaging applications. The subject cohort included 5 healthy volunteers, repeatability tests done on 2 healthy volunteers and tested on two multiple sclerosis (MS) patients. A 3D-MRF imaging technique capable of quantifying T1, T2 and T1ρ was used. The imaging sequence was tested in standardized phantoms and 3D-MRF brain imaging with multiple shots (1, 2 and 4) in healthy human volunteers and MS patients. Quantitative parametric maps for T1, T2, T1ρ, were generated. Mean gray matter (GM) and white matter (WM) ROIs were compared for each mapping technique, Bland-Altman plots and intra-class correlation coefficient (ICC) were used to assess repeatability and Student T-tests were used to compare results in MS patients. Standardized phantom studies demonstrated excellent agreement with reference T1/T2/T1ρ mapping techniques. This study demonstrates that the 3D-MRF technique is able to simultaneously quantify T1, T2 and T1ρ for tissue property characterization in a clinically feasible scan time. This multi-parametric approach offers increased potential to detect and differentiate brain lesions and to better test imaging biomarker hypotheses for several neurological diseases, including MS.

Sudden Death Associated With Possible Flare-Ups of Multiple Sclerosis After COVID-19 Vaccination and Infection: A Case Report and Literature Review

We present an autopsy case of a 19-year-old man with a history of epilepsy whose unwitnessed sudden death occurred unexpectedly in the night. About 4 years before death, he was diagnosed with unilateral optic neuritis (ON). Demyelinating disease was suspected, but he was lost to follow up after the recovery. Six months before death, he received a second dose of mRNA coronavirus disease 2019 (COVID-19) vaccine. Three months before death, he experienced epileptic seizures for the first time. Seventeen days before death, he was infected with COVID-19, which showed self-limited course under home isolation. Several days before death, he complained of seizures again at night. Autopsy revealed multifocal gray-tan discoloration in the cerebrum. Histologically, the lesions consisted of active and inactive demyelinated plaques in the perivenous area of the white matter. Perivascular lymphocytic infiltration and microglial cell proliferation were observed in both white matter and cortex. The other major organs including heart and lung were unremarkable. Based on the antemortem history and postmortem findings, the cause of death was determined to be multiple sclerosis with suspected exacerbation. The direct or indirect involvement of cortex and deep gray matter by exacerbated multiple sclerosis may explain the occurrence of seizures. Considering the absence of other structural abnormalities except the inflammatory demyelination of the cerebrum, fatal arrhythmia or laryngospasm in the terminal epileptic seizure may explain his sudden unexpected death in the benign circumstances. In this case, the onset of seizure was preceded by COVID-19 vaccination, and the exacerbation of seizure was preceded by COVID-19 infection, respectively. Literature reporting first manifestation or relapse of multiple sclerosis temporally associated with COVID-19 vaccination or infection are reviewed.

Changes in Retinal Thickness and Brain Volume during 6.8-Year Escalating Therapy for Multiple Sclerosis

Background. Different disease-modifying therapies (DMT) for multiple sclerosis (MS) have disparate effects on disability outcomes. Sweden has a leading position globally in initiating high-efficacy DMT instead of escalating DMT from 1st-line to high-efficacy DMT. With optical coherence tomography (OCT), retinal changes can be measured at a few micrometer level. OCT has been increasingly applied in diagnosing MS and monitoring disease course and therapeutic effect. Objective. We investigate the effects of 1st-line versus high-efficacy DMT for MS on retinal and brain atrophy and on functional outcomes during 6.8 years of escalating DMT. Materials and Methods. In this prospective longitudinal observational study, 18 MS patients were followed up for 6.8 years. Twelve of the patients were untreated at baseline. All patients underwent 1st-line DMT for median duration of 2.4 years and then switched to high-efficacy DMT for a median duration of 2.9 years. Findings from neurological examinations, MRI, and OCT measures were registered 2-4 times per year. Results. Ganglion cell-inner plexiform layer (GCIPL) thickness was significantly reduced during 1st-line DMT (73.75 μm, $p<0.01$ ) compared to baseline (76.38 μm). During high-efficacy DMT, thickness reduction was slower (73.27 μm, $p<0.05$ ), and MRI contrast-loading lesions vanished ( $p<0.01$ ). However, brain parenchymal fraction (BPF) decreased during high-efficacy DMT compared to 1st-line DMT. Estimated models showed similar results. Conclusion. GCIPL decline was most profound during 1st-line DMT and diminished during high-efficacy DMT. MRI contrast lesions vanished during high-efficacy DMT. However, brain atrophy continued regardless of high-efficacy DMT.

Cerebrospinal fluid neurofilament light chains and CXCL13 as predictive factors for clinical course of multiple sclerosis

AIM

The aim of this study was to identify whether NfL and CXCL13 cerebrospinal fluid (CSF) concentrations at diagnostic lumbar puncture can predict the course of multiple sclerosis (MS) in terms of relapses, higher expanded disability status scale (EDSS) and magnetic resonance imaging (MRI) activity.

METHODS

We conducted a single-centre prospective observational cohort study at the MS center, University Hospital Ostrava, Czech Republic. CSF NfL (cNfL) and CXCL13 concentrations were examined (ELISA method) in patients with clinically isolated syndrome (CIS) and relapsing-remitting MS (RRMS) at the time of diagnostic lumbar puncture.

RESULTS

A total of 44 patients with CIS or early RRMS were enrolled, 31 (70.5%) of whom were women. The median age at the time of CSF sampling was 31.21 years (IQR 25.43-39.32), and the follow-up period was 54.6 months (IQR 44.03-59.48). In the simple and multiple logistic regression models, CXCL13 levels did not predict relapses, MRI activity or EDSS > 2.5. Similarly, cNfL concentrations did not predict relapses or MRI activity in either model. In the multiple regression, higher cNfL levels were associated with reaching EDSS > 2.5 (odds ratio [OR] 1.002, 95% confidence interval [CI] 1.000 to 1.003).

CONCLUSIONS

Our data did not confirm cNfL and/or CXCL13 CSF levels were predictive factors for disease activity such as relapses and MRI activity at the time of diagnostic lumbar puncture in patients with RRMS. While cNfL CSF levels predicted higher disability only after adjustment for other known risk factors, elevated CSF CXCL13 did not predict higher disability at all.

Automatic Intelligent System Using Medical of Things for Multiple Sclerosis Detection

Malfunctions in the immune system cause multiple sclerosis (MS), which initiates mild to severe nerve damage. MS will disturb the signal communication between the brain and other body parts, and early diagnosis will help reduce the harshness of MS in humankind. Magnetic resonance imaging (MRI) supported MS detection is a standard clinical procedure in which the bio-image recorded with a chosen modality is considered to assess the severity of the disease. The proposed research aims to implement a convolutional neural network (CNN) supported scheme to detect MS lesions in the chosen brain MRI slices. The stages of this framework include (i) image collection and resizing, (ii) deep feature mining, (iii) hand-crafted feature mining, (iii) feature optimization with firefly algorithm, and (iv) serial feature integration and classification. In this work, five-fold cross-validation is executed, and the final result is considered for the assessment. The brain MRI slices with/without the skull section are examined separately, presenting the attained results. The experimental outcome of this study confirms that the VGG16 with random forest (RF) classifier offered a classification accuracy of >98% MRI with skull, and VGG16 with K-nearest neighbor (KNN) provided an accuracy of >98% without the skull.

Faster progression to multiple sclerosis disability is linked to neuronal pathways associated with neurodegeneration: An ethnicity study

Although the causes of multiple sclerosis are largely unknown, genetic and environmental components play an important role. Geographic distribution, varying with latitude, reflects both genetic and environmental influences. We conducted a retrospective exploratory observational study to characterize the disability progression of 2396 Jewish patients with relapsing-remitting multiple sclerosis, followed at the Sheba Multiple Sclerosis Center, Tel-Aviv, Israel; 188 patients who originated in Iraq and 2207 patients who originated in northern Europe. Peripheral blood microarray gene expression analysis was performed in a subgroup of patients to identify molecular pathways associated with faster disability progression. During a follow-up period of 18.8 and 19.8 years, respectively, 51.6% of patients with an Iraqi origin progressed to moderate disability defined as expanded disability status scale (EDSS) score of 3.0 to 5.5, compared to 44.2% of patients with a northern European origin (odds ratio 1.347, 95% CI 1.0-1.815, p = 0.049). An Iraqi origin was associated with increased risk of progression to moderate disability adjusted for sex, disease duration, age at onset, and treatment with immunomodulatory drugs (hazard ratio 1.323; 95% CI, 1.049-1.668, p = 0.02), but not to severe disability defined as EDSS score > = 6.0 (i.e., walking aids are required for a distance of 100 meters, (hazard ratio 1.311; 95% CI, 0.918-1.874, p = 0.136). Gene expression analysis disclosed 98 differentially expressed genes (79 over-expressed and 19 under-expressed) between relapsing-remitting multiple sclerosis patients of Iraqi origin (N = 17) and northern European (N = 34) origin. Interestingly, this gene expression was enriched with genes related to neuronal pathways associated with morphology of axons, branching of neurites, proliferation of neocortical neurons, and formation of myelin sheath, suggesting an augmented process of neurodegeneration in relapsing-remitting multiple sclerosis patients with an Iraqi origin. The study results suggest that relapsing-remitting multiple sclerosis patients with an Iraqi origin progress faster to disability possibly due to an enhanced process of neurodegeneration.

Contrast-enhanced double inversion recovery sequence for patients with multiple sclerosis: feasibility of subtraction images between pre- and post-contrast images

BACKGROUND

Few reports have examined the feasibility of a post-contrast double inversion recovery (DIR) magnetic resonance (MR) sequence in patients with multiple sclerosis (MS) because of partial or complete signal loss of enhancing MS lesions.

PURPOSE

To compare subtracted images of DIR (pre-contrast - post-contrast DIR images) with contrast enhanced T1-weighted (CE-T1W) images in the depiction of contrast enhancement of MS lesions.

MATERIAL AND METHODS

In total, 27 patients were included. Two neuroradiologists interpreted both images of CE-T1W imaging and subtracted DIR, and interpretation of the images was classified into a score of 1-5 (from 5, definitely superior contrast of lesions on DIR subtraction compared to conventional CE-T1W imaging, to 1, definitely superior contrast of lesions on CE-T1W imaging. The interrater agreement (κ coefficient) was measured. The signal-to-noise ratio (SNR) and contrast-noise-ratio (CNR) of the lesion were compared.

RESULTS

A significant difference (P < 0.001) in scoring was seen between conventional CE-T1W imaging (2.1 ± 1.5 with one reviewer and 2.4 ± 1.5 with the other) and DIR subtraction (4.4 ± 1.0 with one reviewer and 4.7 ± 0.8 with the other). SNR from conventional CE-T1W imaging (24.8 ± 14.7) was significantly superior to that from DIR subtraction (4.0 ± 1.0; P < 0.001). CNR in DIR subtraction (326.4 ± 250.0) was significantly superior to that in conventional CE-T1W imaging (0.8 ± 5.5; P < 0.001). For interrater agreement in the evaluation of contrast enhancement of the lesions, κ coefficients were 0.84 for conventional CE-T1W imaging and 0.72 for DIR subtraction.

CONCLUSION

Subtracted DIR image enables more obvious contrast enhancement of the MS lesions compared with conventional CE-T1W imaging.

Resting-state functional MRI in multicenter studies on multiple sclerosis: a report on raw data quality and functional connectivity features from the Italian Neuroimaging Network Initiative

The Italian Neuroimaging Network Initiative (INNI) is an expanding repository of brain MRI data from multiple sclerosis (MS) patients recruited at four Italian MRI research sites. We describe the raw data quality of resting-state functional MRI (RS-fMRI) time-series in INNI and the inter-site variability in functional connectivity (FC) features after unified automated data preprocessing. MRI datasets from 489 MS patients and 246 healthy control (HC) subjects were retrieved from the INNI database. Raw data quality metrics included temporal signal-to-noise ratio (tSNR), spatial smoothness (FWHM), framewise displacement (FD), and differential variation in signals (DVARS). Automated preprocessing integrated white-matter lesion segmentation (SAMSEG) into a standard fMRI pipeline (fMRIPrep). FC features were calculated on pre-processed data and harmonized between sites (Combat) prior to assessing general MS-related alterations. Across centers (both groups), median tSNR and FWHM ranged from 47 to 84 and from 2.0 to 2.5, and median FD and DVARS ranged from 0.08 to 0.24 and from 1.06 to 1.22. After preprocessing, only global FC-related features were significantly correlated with FD or DVARS. Across large-scale networks, age/sex/FD-adjusted and harmonized FC features exhibited both inter-site and site-specific inter-group effects. Significant general reductions were obtained for somatomotor and limbic networks in MS patients (vs. HC). The implemented procedures provide technical information on raw data quality and outcome of fully automated preprocessing that might serve as reference in future RS-fMRI studies within INNI. The unified pipeline introduced little bias across sites and appears suitable for multisite FC analyses on harmonized network estimates.

Structured Reporting in Multiple Sclerosis - Consensus-Based Reporting Templates for Magnetic Resonance Imaging of the Brain and Spinal Cord

As a result of technical developments and greater availability of imaging equipment, the number of neuroradiological examinations is steadily increasing [1]. Due to improved image quality and sensitivity, more details can be detected making reporting more complex and time-intensive. At the same time, reliable algorithms increasingly allow quantitative image analysis that should be integrated in reports in a standardized manner. Moreover, increasing digitalization is resulting in a decrease in the personal exchange between neuroradiologists and referring disciplines, thereby making communication more difficult. The introduction of structured reporting tailored to the specific disease and medical issue [2, 3] and corresponding to at least the second reporting level as defined by the German Radiological Society (https://www.befundung.drg.de/de-DE/2908/strukturierte-befundung/) is therefore desirable to ensure that the quality standards of neuroradiological reports continue to be met.The advantages of structured reporting include a reduced workload for neuroradiologists and an information gain for referring physicians. A complete and standardized list with relevant details for image reporting is provided to neuroradiologists in accordance with the current state of knowledge, thereby ensuring that important points are not forgotten [4]. A time savings and increase in efficiency during reporting were also seen [5]. Further advantages include report clarity and consistency and better comparability in follow-up examinations regardless of the neuroradiologist's particular reporting style. This results in better communication with the referring disciplines and makes clinical decision significantly easier [6, 7]. Although the advantages are significant, any potential disadvantages like the reduction of autonomy in reporting and inadequate coverage of all relevant details and any incidental findings not associated with the main pathology in complex cases or in rare diseases should be taken into consideration [4]. Therefore, studies examining the advantages of structured reporting, promoting the introduction of this system in the clinical routine, and increasing the acceptance among neuroradiologists are still needed.Numerous specific templates for structured reporting, e. g., regarding diseases in cardiology and oncology, are already available on the website www.befundung.drg.de . Multiple sclerosis (MS) is an idiopathic chronic inflammatory and neurodegenerative disease of the central nervous system and is the most common non-trauma-based inflammatory neurological disease in young adults. Therefore, it has significant individual and socioeconomic relevance [8]. Magnetic resonance imaging (MRI) plays an important role in the diagnosis, prognosis evaluation, and follow-up of this disease. MRI is established as the central diagnostic method in the diagnostic criteria. Therefore, specific changes are seen on MRI in almost all patients with a verified MS diagnosis [9]. Reporting of MRI datasets regarding the brain and spinal cord of patients with MS includes examination of the images with respect to the relevant medical issue in order to determine whether the McDonald criteria, which were revised in 2017 [10] and define dissemination in time and space clinically as well as with respect to MRI based on the recommendations of the MAGNIMS groups [11, 12], are fulfilled. A more precise definition of lesion types and locations according to the recommendations of an international expert group [13] is discussed in the supplementary material. Spinal cord signal abnormalities are seen in up to 92 % of MS patients [14-16] and are primarily located in the cervical spine [15]. The recommendations of the MAGNIMS-CMSC-NAIMS working group published in 2021 [11] explicitly recommend the use of structured reporting for MS patients.Therefore, a reporting template for evaluating MRI examinations of the brain and spinal cord of patients with MS was created as part of the BMBF-funded DIFUTURE consortium in consensus with neuroradiological and neurological experts in concordance with the recommendations mentioned above [11] and was made available for broad use (https://github.com/DRGagit/ak_befundung). The goal is to facilitate efficient and comprehensive evaluation of patients with MS in the primary diagnostic workup and follow-up imaging. These reporting templates are consensus-based recommendations and do not make any claim to general validity or completeness. The information technology working group (@GIT) of the German Radiological Society and the German Society for Neuroradiology strive to keep the reporting templates presented here up-to-date with respect to new research data and recommendations of the MAGNIMS-CMSC-NAIMS group [11]. KEY POINTS:: · consensus-based reporting templates. · template for the structured reporting of MRI examinations of patients with multiple sclerosis. · structured reporting might facilitate communication between neuroradiologists and referring disciplines. CITATION FORMAT: · Riederer I, Mühlau M, Wiestler B et al. Structured Reporting in Multiple Sclerosis - Consensus-Based Reporting Templates for Magnetic Resonance Imaging of the Brain and Spinal Cord. Fortschr Röntgenstr 2023; 195: 135 - 138.

Combining in vivo proton exchange rate (k ex) MRI with quantitative susceptibility mapping to further stratify the gadolinium-negative multiple sclerosis lesions

Background

Conventional gadolinium (Gd)-enhanced MRI is currently used for stratifying the lesion activity of multiple sclerosis (MS) despite limited correlation with disability and disease activity. The stratification of MS lesion activity needs further improvement to better support clinics.

Purpose

To investigate if the novel proton exchange rate (k _ex ) MRI combined with quantitative susceptibility mapping (QSM) may help to further stratify non-enhanced (Gd-negative) MS lesions.

Materials and methods

From December 2017 to December 2020, clinically diagnosed relapsing-remitting MS patients who underwent MRI were consecutively enrolled in this IRB-approved retrospective study. The customized MRI protocol covered conventional T₂-weighted, T₂-fluid-attenuated-inversion-recovery, pre- and post-contrast T₁-weighted imaging, and quantitative sequences, including k _ex MRI based on direct-saturation removed omega plots and QSM. Each MS lesion was evaluated based on its Gd-enhancement as well as its susceptibility and k _ex elevation compared to the normal appearing white matter. The difference and correlation concerning lesion characteristics and imaging contrasts were analyzed using the Mann-Whitney U test or Kruskal-Wallis test, and Spearman rank analysis with p < 0.05 considered significant.

Results

A total of 322 MS lesions from 30 patients were identified with 153 Gd-enhanced and 169 non-enhanced lesions. We found that the k _ex elevation of all lesions significantly correlated with their susceptibility elevation (r = 0.30, p < 0.001). Within the 153 MS lesions with Gd-enhancement, ring-enhanced lesions showed higher k _ex elevation than the nodular-enhanced ones' (p < 0.001). Similarly, lesions with ring-hyperintensity in QSM also had higher k _ex elevation than the lesions with nodular-QSM-hyperintensity (p < 0.001). Of the 169 Gd-negative lesions, three radiological patterns were recognized according to lesion manifestations on the k _ex map and QSM images: Pattern I (k _ex ⁺ and QSM⁺, n = 114, 67.5%), Pattern II (only k _ex ⁺ or QSM⁺, n = 47, 27.8%) and Pattern III (k _ex ^- and QSM^-, n = 8, 4.7%). Compared to Pattern II and III, Pattern I had higher k _ex (p < 0.001) and susceptibility (p < 0.05) elevation. The percentage of Pattern I of each subject was negatively correlated with the disease duration (r = -0.45, p = 0.015).

Conclusion

As a potential imaging biomarker for inflammation due to oxidative stress, in vivo k _ex MRI combined with QSM is promising in extending the clinical classification of MS lesions beyond conventional Gd-enhanced MRI.

Data-driven optimization of sampling patterns for MR brain T1ρ mapping

PURPOSE

The goal of this study was to apply a fast data-driven optimization algorithm, called bias-accelerated subset selection, for MR brain T1ρ mapping to generate optimized sampling patterns (SPs) for compressed sensing reconstruction of brain 3D-T1ρ MRI.

METHODS

Five healthy volunteers were recruited, and fully sampled Cartesian 3D-T1ρ MRIs were obtained. Variable density (VD) and Poisson disc (PD) undersampling was used as the input to SP optimization process. The reconstruction used 3 compressed sensing methods: spatiotemporal finite differences, low-rank plus sparse with spatial finite differences, and low rank. The performance of images and T1ρ maps using PD-SP and VD-SP and their optimized sampling patterns (PD-OSP and VD-OSP) were compared to the fully sampled reference using normalized root mean square error (NRMSE).

RESULTS

The VD-OSP with spatiotemporal finite differences reconstruction (NRMSE = 0.078) and the PD-OSP with spatiotemporal finite differences reconstruction (NRMSE = 0.079) at the highest acceleration factors (AF = 30) showed the largest improvement compared to the respective nonoptimized SPs (VD NRMSE = 0.087 and PD NRMSE = 0.149). Prospective undersampling was tested at AF = 4, with VD-OSP NRMSE = 0.057 versus PD-OSP NRMSE = 0.060, with optimized sampling performing better that input PD or VD sampling. For brain T1ρ mapping, the VD-OSP with low rank reconstruction for AFs <10 and VD-OSP with spatiotemporal finite differences for AFs >10 perform better.

CONCLUSIONS

The study demonstrated that the appropriate use of data-driven optimized sampling and suitable compressed sensing reconstruction technique can be employed to potentially accelerate 3D T1ρ mapping for brain imaging applications.

Energy minimization segmentation model based on MRI images

Introduction

Medical image segmentation is an important tool for doctors to accurately analyze the volume of brain tissue and lesions, which is important for the correct diagnosis of brain diseases. However, manual image segmentation methods are time-consuming, subjective and lack of repeatability, it needs to develop automatic and reliable methods for image segmentation.

Methods

Magnetic Resonance Imaging (MRI), a non-invasive imaging technique, is commonly used to detect, characterize and quantify tissues and lesions in the brain. Partial volume effect, gray scale in homogeneity, and lesions presents a great challenge for automatic medical image segmentation methods. So, the paper is dedicated to address the impact of partial volume effect and multiple sclerosis lesions on the segmentation accuracy in MRI. The objective function of the improved model and the post-processing method of lesion filling are researched based on the fuzzy clustering space and energy model.

Results

In particular, an energy-minimized segmentation algorithm is proposed. Through experimental verification, the AR-FCM algorithm can better overcome the problem of low segmentation accuracy of the RFCM algorithm for tissue boundary voxels and improve the segmentation accuracy of this algorithm. Meanwhile, a multi-channel input energy-minimization segmentation method with lesion filling and anatomical mapping is further proposed.

Discussion

The feasibility of the lesion filling strategy using post-processing can be confirmed and the segmentation accuracy is increased by comparison experiments.

Imaging blood-brain barrier dysfunction: A state-of-the-art review from a clinical perspective

The blood-brain barrier (BBB) consists of specialized cells that tightly regulate the in- and outflow of molecules from the blood to brain parenchyma, protecting the brain's microenvironment. If one of the BBB components starts to fail, its dysfunction can lead to a cascade of neuroinflammatory events leading to neuronal dysfunction and degeneration. Preliminary imaging findings suggest that BBB dysfunction could serve as an early diagnostic and prognostic biomarker for a number of neurological diseases. This review aims to provide clinicians with an overview of the emerging field of BBB imaging in humans by answering three key questions: (1. Disease) In which diseases could BBB imaging be useful? (2. Device) What are currently available imaging methods for evaluating BBB integrity? And (3. Distribution) what is the potential of BBB imaging in different environments, particularly in resource limited settings? We conclude that further advances are needed, such as the validation, standardization and implementation of readily available, low-cost and non-contrast BBB imaging techniques, for BBB imaging to be a useful clinical biomarker in both resource-limited and well-resourced settings.

Central vein sign: comparison of multiple sclerosis and leukoaraiosis

BACKGROUND

Leukoaraiosis produces white matter lesions (WML) similar to multiple sclerosis (MS) on brain magnetic resonance imaging (MRI), and the distinction between these two conditions is difficult radiologically. This study aimed to investigate the role of the central vein sign (CVS) in susceptibility-weighted imaging (SWI) sequence in distinguishing MS lesions from leukoaraiosis lesions in Turkish population.

METHODS

In this prospective study, axial SWI and sagittal three-dimensional fluid-attenuated inversion recovery (3DFLAIR) were obtained in 374 consecutive patients. The study consisted of 169 (89 MS patients, 80 patients with leukoaraiosis) patients according to the inclusion and exclusion criteria. Two observers evaluated MR images by consensus, and observers were unaware of the patient's clinical findings. Locations (periventricular, juxtacortical, and deep white matter) and the presence of CVS were investigated for each of the lesions. Differences between patients in the leukoaraiosis and MS groups were investigated using the Mann-Whitney U test or chi-square analysis. In addition, receiver operating characteristic (ROC) analysis was used to analyze the diagnostic performance of CVS.

RESULTS

A total of 1908 WMLs (1265 MS lesions, 643 leukoaraiosis) were detected in 169 patients. The CVS was significantly higher in the MS lesions (p < 0.001). The CVS positivity rate in periventricular WMLs was higher than in juxtacortical WMLs or deep WMLs, both for all patients and for patients with MS (p < 0.001). The area under the curve (AUC) of the ROC analysis was 0.88 (95% confidence interval 0.83-0.93) for CVS in the distinction of MS lesions and leukoaraiosis.

DISCUSSION

The presence of CVS in the SWI sequence can be used as an auxiliary finding for the diagnosis of MS in the differentiation of MS and leukoaraiosis lesions.

Trends in the environmental risks associated with earlier onset in multiple sclerosis

BACKGROUND

Several environmental and lifestyle factors relating to sunlight/vitamin D, body mass index (BMI), and smoking are associated with the risk of developing multiple sclerosis (MS). However, their relation to disease progression, particularly age at symptomatic onset, remains inconsistent, which may be the result of significant changes in human-environment interactions over the last century. This study investigates historical trends in the association between common MS environmental risk factors and age at disease onset.

METHODS

Using a narrative approach, we evaluated the current literature for published studies assessing the association between vitamin-D, BMI, and tobacco smoking exposures with the risk of early/pediatric-onset MS and direct correlations with age at MS onset using MEDLINE, EMBASE, and Web of Science. Measures were plotted by the average calendar year of disease onset for each cohort to examine trends over time. In total, 25, 9, and 11 articles were identified for vitamin D, BMI, and smoking-related exposures, respectively.

RESULTS

Higher sun exposure habits and residential solar radiation were associated with older age at onset. On the contrary, two studies observed a negative correlation between age at onset and serum 25-hydroxyvitamin D (25(OH)D) levels. Higher adolescent BMI was generally associated with younger age at onset, although genetic susceptibility for childhood obesity was not significantly associated. Tobacco smoking was associated with later disease onset, despite being a risk factor for MS. Association with age at onset was inflated for more recent studies relating to smoking, while often weaker for serum vitamin D and BMI.

CONCLUSION

Current findings indicate a likely association between age at onset and environmental risk factors, such as sun exposure, adolescent BMI, and tobacco smoking, in certain populations. However, findings are often inconsistent and assessment of the relationships and potential changes over time require further investigation.

Frequency of myelin oligodendrocyte glycoprotein antibodies in pediatric onset multiple sclerosis

BACKGROUND

Myelin oligodendrocyte glycoprotein antibodies (MOG-Ab) are associated with acute demyelinating syndromes and only rarely detected in multiple sclerosis (MS). As MOG-Ab associated disease is common in childhood, we speculated young patients might be more likely to produce MOG-Ab and investigated the frequency of MOG-Ab seropositivity in pediatric onset MS (POMS).

MATERIAL AND METHODS

Patients who experienced their first acute demyelinating event before age 18 years and were diagnosed with MS during follow-up were included in this single-center study. Patient data were retrieved from clinical records. Serum samples obtained and frozen at clinical visits were analyzed for MOG-Ab by a live cell-based assay (CBA) measuring delta mean fluorescence intensity (MFI) and MFI ratio. The control group consisted of patients referred to pediatric neurology for headache or vertigo and who had no neurological disorder (n = 48). Another control group consisted of patients with systemic inflammatory disorders systemic lupus erythematosus (n = 17) and juvenile idiopathic arthritis (n = 13) diagnosed in the rheumatology clinic.

RESULTS

The patient group (n = 122, F/M: 90/32, mean age 17.8 ± 2.6 years) were initially diagnosed as: MS, 62/122 (50.8%), clinically isolated syndrome, 43/122 (35.2%), radiologically isolated syndrome, 9/122 (7.3%), and acute disseminated encephalomyelitis 8/122 (6.5%). All received the final diagnosis of POMS. Serum was sampled 22.4 ± 29.2 (0-132) months after the first episode. None of the control groups had MOG-Ab positivity while 2/122 (1.6%) POMS cases had MOG-Abs, and a third patient had positive MFI and a MFI ratio slightly below the cut-off. These three patients' initial and final diagnoses were MS, their annualized relapsing rates (ARRs) were 0.4-0.6, and most recent Expanded Disability Status Scale was 0.

CONCLUSION

Low titers of MOG-Ab can be detected in a small number of POMS patients at similar frequency with adult MS. Our POMS cases with MOG-Abs presented brainstem-cerebellar findings or seizures and had low ARR. Further series and longer follow-up will define whether these cases differ significantly from MOG-Ab negative POMS cases.

Diagnostik der Neuromyelitis-optica-Spektrum-Erkrankung (NMOSD) und der MOG-Antikörper-assoziierten Erkrankung (MOGAD)

Die Aquaporin-4-Antikörper-positive Neuromyelitis-optica-Spektrum-Erkrankung (engl. NMOSD) und die Myelin-Oligodendrozyten-Glykoprotein-Antikörper-assoziierte Erkrankung (engl. MOGAD) sind Autoimmunerkrankungen des zentralen Nervensystems. Typische Erstmanifestationen sind bei Erwachsenen Optikusneuritis und Myelitis. Eine Beteiligung auch von Hirn und Hirnstamm, spätestens im weiteren Verlauf, ist häufig. Während die NMOSD nahezu immer schubförmig verläuft, nimmt die MOGAD gelegentlich einen monophasischen Verlauf. Die Differenzialdiagnostik ist anspruchsvoll und stützt sich auf u. a. auf radiologische und serologische Befunde. Die Abgrenzung von der häufigeren neuroinflammatorischen Erkrankung, Multiple Sklerose (MS), ist von erheblicher Bedeutung, da sich Behandlung und langfristige Prognose von NMOSD, MOGAD und MS wesentlich unterscheiden. Die vielfältigen Symptome und die umfangreiche Diagnostik machen eine enge Zusammenarbeit zwischen Ophthalmologie, Neurologie und Radiologie erforderlich. Dieser Artikel gibt einen Überblick über typische MRT-Befunde und die serologische Antikörperdiagnostik bei NMOSD und MOGAD. Zwei illustrative Fallberichte aus der ärztlichen Praxis ergänzen die Darstellung.

Neuroprotection and neuroregeneration: roles for the white matter

Efficient strategies for neuroprotection and repair are still an unmet medical need for neurodegenerative diseases and lesions of the central nervous system. Over the last few decades, a great deal of attention has been focused on white matter as a potential therapeutic target, mainly due to the discovery of the oligodendrocyte precursor cells in the adult central nervous system, a cell type able to fully repair myelin damage, and to the development of advanced imaging techniques to visualize and measure white matter lesions. The combination of these two events has greatly increased the body of research into white matter alterations in central nervous system lesions and neurodegenerative diseases and has identified the oligodendrocyte precursor cell as a putative target for white matter lesion repair, thus indirectly contributing to neuroprotection. This review aims to discuss the potential of white matter as a therapeutic target for neuroprotection in lesions and diseases of the central nervous system. Pivot conditions are discussed, specifically multiple sclerosis as a white matter disease; spinal cord injury, the acute lesion of a central nervous system component where white matter prevails over the gray matter, and Alzheimer's disease, where the white matter was considered an ancillary component until recently. We first describe oligodendrocyte precursor cell biology and developmental myelination, and its regulation by thyroid hormones, then briefly describe white matter imaging techniques, which are providing information on white matter involvement in central nervous system lesions and degenerative diseases. Finally, we discuss pathological mechanisms which interfere with myelin repair in adulthood.

Structure of the Motor Descending Pathways Correlates with the Temporal Kinematics of Hand Movements

Simple Summary

How hand motor behavior relates to the microstructure of the underlying subcortical white matter pathways is yet to be fully understood. Here we consider two well-known examples of our everyday motor repertoire, reaching and reach-to-grasp, by looking at their temporal unfolding and at the microstructure of descending projection pathways, conveying motor information from the motor cortices towards the more ventral regions of the nervous system. We combine three-dimensional kinematics, describing the temporal profile of hand movements, with diffusion imaging tractography, exploring the microstructure of specific segments of the projection pathways (internal capsule, corticospinal and hand motor tracts). The results indicate that the level of anisotropy characterizing these white matter tracts can influence the temporal unfolding of reaching and reach-to-grasp movements.

Abstract

The projection system, a complex organization of ascending and descending white matter pathways, is the principal system for conveying sensory and motor information, connecting frontal and sensorimotor regions with ventral regions of the central nervous system. The corticospinal tract (CST), one of the principal projection pathways, carries distal movement-related information from the cortex to the spinal cord, and whether its microstructure is linked to the kinematics of hand movements is still an open question. The aim of the present study was to explore how microstructure of descending branches of the projection system, namely the hand motor tract (HMT), the corticospinal tract (CST) and its sector within the internal capsule (IC), can relate to the temporal profile of reaching and reach-to-grasp movements. Projection pathways of 31 healthy subjects were virtually dissected by means of diffusion tractography and the kinematics of reaching and reach-to-grasp movements were also analyzed. A positive association between Hindrance Modulated Orientation Anisotropy (HMOA) and kinematics was observed, suggesting that anisotropy of the considered tract can influence the temporal unfolding of motor performance. We highlight, for the first time, that hand kinematics and the visuomotor transformation processes underlying reaching and reach-to-grasp movements relate to the microstructure of specific projection fibers subserving these movements.

Neural diffusion tensor imaging metrics correlate with clinical measures in people with relapsing-remitting MS

BACKGROUND AND PURPOSE

Diffusion tensor imaging (DTI) can detect microstructural changes of white matter in multiple sclerosis (MS) and might clarify mechanisms responsible for disability. Thus, we aimed to compare DTI metrics in relapsing-remitting MS patients (RRMS) with healthy controls (HCs), and explore the correlations between DTI metrics, total brain white matter (TBWM) and white matter lesion (WML) with clinical parameters compared to volumetric measures.

MATERIAL AND METHODS

37 RRMS patients and 19 age/sex-matched HCs were included. All participants had clinical assessments, structural and diffusion scans on a 3T MRI. Volumetric and white matter DTI metrics; fractional anisotropy (FA), mean, radial and axial diffusivities (MD, RD and AD) were estimated and correlated with clinical parameters. The mean group differences were calculated using t-tests, and univariate correlations with Pearson correlation coefficients.

RESULTS

Compared to HCs, statistically significant increases in MD (+3.6%), RD (+4.8%), AD (+2.7%) and a decrease in FA (-4.3%) for TBWM in RRMS was observed (p < .01). MD and RD in TBWM and AD in WML correlated moderately with disability status. Volumetric segmentation indicated a decrease in the total brain volume, GM and WM(-5%) with a reciprocal increase in CSF(+26%) in RRMS(p < .01). Importantly, DTI parameters showed a medium correlation with cognitive domains in contrast to white matter-related volumetric measurements in RRMS(Pearson correlation, p < .05).

CONCLUSIONS

Our study shows a correlation of DTI metrics with clinical symptoms of MS, in particular cognition. More generally, these findings indicated that DTI is a useful and unique technique for evaluating the clinical features of white matter disease and warrants further investigation into its clinical role.

Association of cerebrospinal inflammatory profile with radiological features in newly diagnosed treatment-naïve patients with multiple sclerosis

Objective

Multiple sclerosis (MS) is an immune-mediated demyelinating disease of the central nervous system. Without reliable diagnostic biomarkers, the clinical and radiological heterogeneity of MS makes diagnosis difficult. Although magnetic resonance imaging (MRI) is a major diagnostic tool for MS, the association of MRI findings with the inflammatory profile in cerebrospinal fluid (CSF) has been insufficiently investigated. Therefore, we focused on CSF profile of MS patients and examined its association with MRI findings.

Methods

Concentrations of 26 cytokines and chemokines were determined in CSF of 28 treatment-naïve MS patients and 12 disease-control patients with aquaporin-4 antibody-seropositive neuromyelitis optica spectrum disorder (NMOSD).

Results

High levels of interleukin (IL)-6, IL-17A, B-cell activating factor (BAFF), a proliferation inducing ligand (APRIL), and CD40 ligand were correlated with the absence of at least one of the following three MRI findings in MS: an ovoid lesion, three or more periventricular lesions, and a nodular and/or ring-shaped contrast-enhancing lesion. The multivariate analysis revealed that elevated IL-17A was an independent predictor of absence of ovoid lesion and periventricular lesions less than three. MS patients were classified into a group with all three MRI findings (MS-full) and a group with less than three (MS-partial). The discriminant analysis model distinguished three groups: MS-full, MS-partial, and NMOSD, with 98% accuracy.

Conclusion

The CSF inflammatory profile was associated with radiological findings of treatment-naïve MS. This result indicates the possible utility of combined CSF and MRI profiling in identifying different MS phenotypes related to the heterogeneity of underlying immune processes.

Detection of lesions in the optic nerve with magnetic resonance imaging using a 3D convolutional neural network

BACKGROUND

Optic neuritis (ON) is one of the first manifestations of multiple sclerosis, a disabling disease with rising prevalence. Detecting optic nerve lesions could be a relevant diagnostic marker in patients with multiple sclerosis.

OBJECTIVES

We aim to create an automated, interpretable method for optic nerve lesion detection from MRI scans.

MATERIALS AND METHODS

We present a 3D convolutional neural network (CNN) model that learns to detect optic nerve lesions based on T2-weighted fat-saturated MRI scans. We validated our system on two different datasets (N = 107 and 62) and interpreted the behaviour of the model using saliency maps.

RESULTS

The model showed good performance (68.11% balanced accuracy) that generalizes to unseen data (64.11%). The developed network focuses its attention to the areas that correspond to lesions in the optic nerve.

CONCLUSIONS

The method shows robustness and, when using only a single imaging sequence, its performance is not far from diagnosis by trained radiologists with the same constraint. Given its speed and performance, the developed methodology could serve as a first step to develop methods that could be translated into a clinical setting.

Application of the International Interocular Difference Thresholds into Practice: Localising the Patient Experience

Demyelinating diseases of the central nervous system (CNS) often have neuro-ophthalmological manifestations, and retinal examination can be helpful in making the diagnosis. The latest iteration of optical coherence tomography (OCT)-based criteria for optic neuritis in multiple sclerosis has been developed in the research realm, but its application to clinical practice, and to the more uncommon demyelinating diseases requires further study. The ability to use OCT data to distinguish between various CNS demyelinating disorders could provide additional paraclinical tools to accurately diagnose patients. Furthermore, neuro-ophthalmological testing can define the extent of inflammatory damage in the CNS, independent of patient-reported history. New referrals for OCT at a tertiary multiple sclerosis and neuro-immunology referral centre (n = 167) were analysed retrospectively for the self-reporting of optic neuritis, serological test results, and diagnosis. Only approximately 30% of patients with a clinical history of unilateral optic neuritis solely had a unilateral optic neuropathy, nearly 40% of those subjects actually having evidence of bilateral optic neuropathies. Roughly 30% of patients reporting a history of bilateral optic neuritis did not have any evidence of structural disease, with 20% of these patients having a separate, intervenable diagnosis noted on macular scans. OCT is a useful adjunct diagnostic tool in the evaluation of demyelinating disease and has the ability to aid in a more accurate diagnosis for patients. Application of the international interocular difference thresholds to a clinical patient population generally reproduces the original results, emphasising their appropriateness. The analysis distinguishing the demyelinating diseases needs to be replicated in a blinded, multi-centre setting.

Magnetic Resonance Imaging in Primary Progressive Multiple Sclerosis Patients : Review

The recently developed effective treatment of primary progressive multiple sclerosis (PPMS) requires the accurate diagnosis of patients with this type of disease. Currently, the diagnosis of PPMS is based on the 2017 McDonald criteria, although the contribution of magnetic resonance imaging (MRI) to this process is fundamental. PPMS, one of the clinical types of MS, represents 10%-15% of all MS patients. Compared to relapsing-remitting MS (RRMS), PPMS differs in terms of pathology, clinical presentation and MRI features. Regarding conventional MRI, focal lesions on T2-weighted images and acute inflammatory lesions with contrast enhancement are less common in PPMS than in RRMS. On the other hand, MRI features of chronic inflammation, such as slowly evolving/expanding lesions (SELs) and leptomeningeal enhancement (LME), and brain and spinal cord atrophy are more common MRI characteristics in PPMS than RRMS. Nonconventional MRI also shows differences in subtle white and grey matter damage between PPMS and other clinical types of disease. In this review, we present separate diagnostic criteria, conventional and nonconventional MRI specificity for PPMS, which may support and simplify the diagnosis of this type of MS in daily clinical practice.

Differentiating central nervous system demyelinating disorders: The role of clinical, laboratory, imaging characteristics and peripheral blood type I interferon activity

Objective: While multiple sclerosis (MS) is considered the cornerstone of autoimmune demyelinating CNS disorders, systemic autoimmune diseases (SADs) are important MS mimickers. We sought to explore whether distinct clinical, laboratory, and imaging characteristics along with quantitation of peripheral blood type I interferon (IFN) activity could aid in differentiating between them.

Methods: A total of 193 consecutive patients with imaging features suggesting the presence of CNS demyelinating disease with or without relevant clinical manifestations underwent full clinical, laboratory, and imaging evaluation, including testing for specific antibodies against 15 cellular antigens. Expression analysis of type I IFN-inducible genes (MX-1, IFIT-1, and IFI44) was performed by real-time PCR, and a type I IFN score, reflecting type I IFN peripheral activity, was calculated. After joint neurological/rheumatological evaluation and 1 year of follow-up, patients were classified into MS spectrum and CNS autoimmune disorders.

Results: While 66.3% (n = 128) of the patients were diagnosed with MS spectrum disorders (predominantly relapsing–remitting MS), 24.9% (n = 48) were included in the CNS autoimmune group, and out of those, one-fourth met the criteria for SAD (6.7% of the cohort, n = 13); the rest (18.1% of the cohort, n = 35), despite showing evidence of systemic autoimmunity, did not fulfill SAD criteria and comprised the “demyelinating disease with autoimmune features” (DAF) subgroup. Compared to the MS spectrum, CNS autoimmune patients were older, more frequently females, with increased rates of hypertension/hyperlipidemia, family history of autoimmunity, cortical dysfunction, anti-nuclear antibody titers ≥1/320, anticardiolipin IgM positivity, and atypical for MS magnetic resonance imaging lesions. Conversely, lower rates of infratentorial and callosal MRI lesions, CSF T2 oligoclonal bands, and IgG-index positivity were observed in CNS autoimmune patients. Patients fulfilling SAD criteria, but not the DAF group, had significantly higher peripheral blood type I IFN scores at baseline compared to MS spectrum [median (IQR)]: 50.18 (152.50) vs. −0.64 (6.75), p-value: 0.0001.

Conclusion: Our study suggests that underlying systemic autoimmunity is not uncommon in patients evaluated for possible CNS demyelination. Distinct clinical, imaging and laboratory characteristics can aid in early differentiation between MS and CNS-involving systemic autoimmunity allowing for optimal therapeutic strategies. Activated type I IFN pathway could represent a key mediator among MS-like-presenting SADs and therefore a potential therapeutic target.

Central vein sign in patients with inflammatory lesion of the upper cervical spinal cord on susceptibility weighted imaging at 3 tesla. Preliminary results

BACKGROUND

A central vein sign (CVS) has been described in vivo in patients with MS but also in other inflammatory lesion of the brain such as neuromyelits optica spectrum disease and others. Recently, it has been used to differentiate patients with MS from other inflammatory lesions of the brain.

OBJECTIVE

It was the goal of this study to demonstrate the feasibility of the depiction of the CVS in patients with inflammatory lesion of the upper cervical spinal cord using susceptibility weighted imaging (SWI).

METHODS

Consecutive patients with inflammatory lesions of the upper cervical spinal cord were included. Patients were scanned using a 3 T Philips Ingenia CX. The presence of the CVS was assessed by two raters. Demographic and clinical parameters were compared between patients with and those without a CVS.

RESULTS

20 patients could be included. 15 patients had a diagnosis of MS. A CVS was present in 8 patients (40%). Agreement between the two raters was substantial (κ = 0.79). Time from first manifestation was significantly different (14 vs. 2 years, p = 0.021) between patients with CVS and without CVS.

CONCLUSION

The depiction of the CVS in the upper cervical spine is feasible. More research is necessary to evaluate these preliminary results and the value of the CVS in the spinal cord.