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W. Smith A, K. Ray S, Das A, Nozaki K, Rohrer B, L. Banik N. Calpain inhibition as a possible new therapeutic target in multiple sclerosis. AIMS MOLECULAR SCIENCE 2017. [DOI: 10.3934/molsci.2017.4.446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Abstract
Brain atrophy occurs at a faster rate in patients with multiple sclerosis (MS) than in healthy individuals. In three randomized, controlled, phase III trials, fingolimod reduced the annual rate of brain volume loss (BVL) in patients with relapsing MS (RMS) by approximately one-third relative to that in individuals receiving placebo or intramuscular interferon beta-1a. Analysis of brain volume changes during study extensions has shown that this reduced rate of BVL is sustained in patients with RMS receiving fingolimod continuously. Subgroup analyses of the core phase III and extension studies have shown that reductions in the rate of BVL are observed irrespective of levels of inflammatory lesion activity seen by magnetic resonance imaging at baseline and on study; levels of disability at baseline; and treatment history. The rate of BVL in these studies was predicted independently by T2 lesion and gadolinium-enhancing lesion burdens at baseline, and correlations observed between BVL and increasing levels of disability strengthened over time. In another phase III trial in patients with primary progressive MS (PPMS), fingolimod did not reduce BVL overall relative to placebo; however, consistent with findings in RMS, there was a treatment effect on BVL in patients with PPMS with gadolinium-enhancing lesion activity at baseline. The association between treatment effects on BVL and future accumulation of disability argues in favor of measuring BVL on a more routine basis and with a more structured approach than is generally the case in clinical practice. Despite several practical obstacles, progress is being made in achieving this goal.
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Rocca MA, Battaglini M, Benedict RHB, De Stefano N, Geurts JJG, Henry RG, Horsfield MA, Jenkinson M, Pagani E, Filippi M. Brain MRI atrophy quantification in MS: From methods to clinical application. Neurology 2016; 88:403-413. [PMID: 27986875 DOI: 10.1212/wnl.0000000000003542] [Citation(s) in RCA: 162] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 10/18/2016] [Indexed: 01/06/2023] Open
Abstract
Patients with the main clinical phenotypes of multiple sclerosis (MS) manifest varying degrees of brain atrophy beyond that of normal aging. Assessment of atrophy helps to distinguish clinically and cognitively deteriorating patients and predicts those who will have a less-favorable clinical outcome over the long term. Atrophy can be measured from brain MRI scans, and many technological improvements have been made over the last few years. Several software tools, with differing requirements on technical ability and levels of operator intervention, are currently available and have already been applied in research or clinical trial settings. Despite this, the measurement of atrophy in routine clinical practice remains an unmet need. After a short summary of the pathologic substrates of brain atrophy in MS, this review attempts to guide the clinician towards a better understanding of the methods currently used for quantifying brain atrophy in this condition. Important physiologic factors that affect brain volume measures are also considered. Finally, the most recent research on brain atrophy in MS is summarized, including whole brain and various compartments thereof (i.e., white matter, gray matter, selected CNS structures). Current methods provide sufficient precision for cohort studies, but are not adequate for confidently assessing changes in individual patients over the scale of months or a few years.
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Affiliation(s)
- Maria A Rocca
- From the Neuroimaging Research Unit (M.A.R., E.P., M.F.), Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan; Department of Medicine, Surgery and Neuroscience (M.B., N.D.S.), University of Siena, Italy; Department of Neurology (R.H.B.B.), Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York; Department of Anatomy and Neuroscience (J.J.G.G.), Section of Clinical Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, the Netherlands; Department of Neurology (R.G.H.), University of California, San Francisco; Xinapse Systems Ltd. (M.A.H.), Colchester, Essex, UK; and FMRIB Centre (M.J.), Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Marco Battaglini
- From the Neuroimaging Research Unit (M.A.R., E.P., M.F.), Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan; Department of Medicine, Surgery and Neuroscience (M.B., N.D.S.), University of Siena, Italy; Department of Neurology (R.H.B.B.), Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York; Department of Anatomy and Neuroscience (J.J.G.G.), Section of Clinical Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, the Netherlands; Department of Neurology (R.G.H.), University of California, San Francisco; Xinapse Systems Ltd. (M.A.H.), Colchester, Essex, UK; and FMRIB Centre (M.J.), Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Ralph H B Benedict
- From the Neuroimaging Research Unit (M.A.R., E.P., M.F.), Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan; Department of Medicine, Surgery and Neuroscience (M.B., N.D.S.), University of Siena, Italy; Department of Neurology (R.H.B.B.), Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York; Department of Anatomy and Neuroscience (J.J.G.G.), Section of Clinical Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, the Netherlands; Department of Neurology (R.G.H.), University of California, San Francisco; Xinapse Systems Ltd. (M.A.H.), Colchester, Essex, UK; and FMRIB Centre (M.J.), Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Nicola De Stefano
- From the Neuroimaging Research Unit (M.A.R., E.P., M.F.), Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan; Department of Medicine, Surgery and Neuroscience (M.B., N.D.S.), University of Siena, Italy; Department of Neurology (R.H.B.B.), Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York; Department of Anatomy and Neuroscience (J.J.G.G.), Section of Clinical Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, the Netherlands; Department of Neurology (R.G.H.), University of California, San Francisco; Xinapse Systems Ltd. (M.A.H.), Colchester, Essex, UK; and FMRIB Centre (M.J.), Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Jeroen J G Geurts
- From the Neuroimaging Research Unit (M.A.R., E.P., M.F.), Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan; Department of Medicine, Surgery and Neuroscience (M.B., N.D.S.), University of Siena, Italy; Department of Neurology (R.H.B.B.), Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York; Department of Anatomy and Neuroscience (J.J.G.G.), Section of Clinical Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, the Netherlands; Department of Neurology (R.G.H.), University of California, San Francisco; Xinapse Systems Ltd. (M.A.H.), Colchester, Essex, UK; and FMRIB Centre (M.J.), Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Roland G Henry
- From the Neuroimaging Research Unit (M.A.R., E.P., M.F.), Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan; Department of Medicine, Surgery and Neuroscience (M.B., N.D.S.), University of Siena, Italy; Department of Neurology (R.H.B.B.), Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York; Department of Anatomy and Neuroscience (J.J.G.G.), Section of Clinical Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, the Netherlands; Department of Neurology (R.G.H.), University of California, San Francisco; Xinapse Systems Ltd. (M.A.H.), Colchester, Essex, UK; and FMRIB Centre (M.J.), Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Mark A Horsfield
- From the Neuroimaging Research Unit (M.A.R., E.P., M.F.), Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan; Department of Medicine, Surgery and Neuroscience (M.B., N.D.S.), University of Siena, Italy; Department of Neurology (R.H.B.B.), Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York; Department of Anatomy and Neuroscience (J.J.G.G.), Section of Clinical Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, the Netherlands; Department of Neurology (R.G.H.), University of California, San Francisco; Xinapse Systems Ltd. (M.A.H.), Colchester, Essex, UK; and FMRIB Centre (M.J.), Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Mark Jenkinson
- From the Neuroimaging Research Unit (M.A.R., E.P., M.F.), Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan; Department of Medicine, Surgery and Neuroscience (M.B., N.D.S.), University of Siena, Italy; Department of Neurology (R.H.B.B.), Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York; Department of Anatomy and Neuroscience (J.J.G.G.), Section of Clinical Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, the Netherlands; Department of Neurology (R.G.H.), University of California, San Francisco; Xinapse Systems Ltd. (M.A.H.), Colchester, Essex, UK; and FMRIB Centre (M.J.), Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Elisabetta Pagani
- From the Neuroimaging Research Unit (M.A.R., E.P., M.F.), Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan; Department of Medicine, Surgery and Neuroscience (M.B., N.D.S.), University of Siena, Italy; Department of Neurology (R.H.B.B.), Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York; Department of Anatomy and Neuroscience (J.J.G.G.), Section of Clinical Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, the Netherlands; Department of Neurology (R.G.H.), University of California, San Francisco; Xinapse Systems Ltd. (M.A.H.), Colchester, Essex, UK; and FMRIB Centre (M.J.), Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Massimo Filippi
- From the Neuroimaging Research Unit (M.A.R., E.P., M.F.), Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan; Department of Medicine, Surgery and Neuroscience (M.B., N.D.S.), University of Siena, Italy; Department of Neurology (R.H.B.B.), Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York; Department of Anatomy and Neuroscience (J.J.G.G.), Section of Clinical Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, the Netherlands; Department of Neurology (R.G.H.), University of California, San Francisco; Xinapse Systems Ltd. (M.A.H.), Colchester, Essex, UK; and FMRIB Centre (M.J.), Nuffield Department of Clinical Neurosciences, University of Oxford, UK.
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Alroughani R, Deleu D, El Salem K, Al-Hashel J, Alexander KJ, Abdelrazek MA, Aljishi A, Alkhaboori J, Al Azri F, Al Zadjali N, Hbahbih M, Sokrab TE, Said M, Rovira À. A regional consensus recommendation on brain atrophy as an outcome measure in multiple sclerosis. BMC Neurol 2016; 16:240. [PMID: 27881095 PMCID: PMC5121973 DOI: 10.1186/s12883-016-0762-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 11/15/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Multiple sclerosis (MS) is a chronic autoimmune disease characterized by inflammatory and neurodegenerative processes leading to irreversible neurological impairment. Brain atrophy occurs early in the course of the disease at a rate greater than the general population. Brain volume loss (BVL) is associated with disability progression and cognitive impairment in patients with MS; hence its value as a potential target in monitoring and treating MS is discussed. METHODS A group of MS neurologists and neuro-radiologists reviewed the current literature on brain atrophy and discussed the challenges in assessing and implementing brain atrophy measurements in clinical practice. The panel used a voting system to reach a consensus and the votes were counted for the proposed set of questions for cognitive and brain atrophy assessments. RESULTS The panel of experts was able to identify recent studies, which demonstrated the correlation between BVL and future worsening of disability and cognition. The current evidence revealed that reduction of BVL could be achieved with different disease-modifying therapies (DMTs). BVL provided a better treatment and monitoring strategy when it is combined to the composite measures of "no evidence of disease activity" (NEDA). The panel recommended a set of cognitive assessment tools and MRI methods and software applications that may help in capturing and measuring the underlying MS pathology with high degree of specificity. CONCLUSION BVL was considered to be a useful measurement to longitudinally assess disease progression and cognitive function in patients with MS. Brain atrophy measurement was recommended to be incorporated into the concept of NEDA. Consequently, a consensus recommendation was reached in anticipation for implementation of the use of cognitive assessment and brain atrophy measurements on a regional level.
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Affiliation(s)
- Raed Alroughani
- Division of Neurology, Department of Medicine, Amiri Hospital, Kuwait City, Kuwait.
- Neurology Clinic, Dasman Diabetes Institute, Dasman, Kuwait.
| | - Dirk Deleu
- Division of Neurology (Neuroscience Institute), Hamad General Hospital, Doha, Qatar
| | - Khalid El Salem
- Department of Neurology, Jordan University of Science and Technology, King Abdullah University Hospital, Irbid, Jordan
| | - Jasem Al-Hashel
- Department of Neurology, Ibn Sina Hospital, Kuwait City, Kuwait
| | | | | | - Adel Aljishi
- Department of Neurology, Salmaniya Hospital & AGU, Manama, Bahrain
| | | | - Faisal Al Azri
- Department of Radiology, Sultan Qaboos University Hospital, Muscat, Oman
| | | | | | - Tag Eldin Sokrab
- Division of Neurology (Neuroscience Institute), Hamad General Center, Doha, Qatar
| | - Mohamed Said
- Medical Manger-Gulf Countries, Novartis pharmaceuticals, Dubai, United Arab Emirates
| | - Àlex Rovira
- Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
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155
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A Personalized Approach in Progressive Multiple Sclerosis: The Current Status of Disease Modifying Therapies (DMTs) and Future Perspectives. Int J Mol Sci 2016; 17:ijms17101725. [PMID: 27763513 PMCID: PMC5085756 DOI: 10.3390/ijms17101725] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 09/29/2016] [Accepted: 10/02/2016] [Indexed: 12/20/2022] Open
Abstract
Using the term of progressive multiple sclerosis (PMS), we considered a combined population of persons with secondary progressive MS (SPMS) and primary progressive MS (PPMS). These forms of MS cannot be challenged with efficacy by the licensed therapy. In the last years, several measures of risk estimation were developed for predicting clinical course in MS, but none is specific for the PMS forms. Personalized medicine is a therapeutic approach, based on identifying what might be the best therapy for an individual patient, taking into account the risk profile. We need to achieve more accurate estimates of useful predictors in PMS, including unconventional and qualitative markers which are not yet currently available or practicable routine diagnostics. The evaluation of an individual patient is based on the profile of disease activity.Within the neurology field, PMS is one of the fastest-moving going into the future.
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156
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Reich DS. Imag(in)ing multiple sclerosis: Time to take better pictures. J Neuroimmunol 2016; 304:72-80. [PMID: 27742080 DOI: 10.1016/j.jneuroim.2016.09.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 09/28/2016] [Indexed: 01/20/2023]
Abstract
Magnetic resonance imaging (MRI) has led to the identification of widespread brain abnormalities in multiple sclerosis (MS) that extend far beyond the classic white matter lesion. These findings have generated the idea that MS should be understood as a disease of the whole brain, not just the white matter. While it is no doubt the case that many different pathways are ultimately involved in the destruction of brain tissue that occurs in MS, the implications of the accumulated evidence for understanding disease pathophysiology - and hence the overall significance of these imaging findings - are doubtful. Here, I argue that the principled use of imaging can, in fact, address questions about the genesis of these whole-brain abnormalities, rather than simply describe them.
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Affiliation(s)
- Daniel S Reich
- National Institutes of Health, Translational Neuroradiology Section, Building 10, Room 5C103, 20892-4128 Bethesda, MD, USA.
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157
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Keegan BM, Kaufmann TJ, Weinshenker BG, Kantarci OH, Schmalstieg WF, Paz Soldan MM, Flanagan EP. Progressive solitary sclerosis: Gradual motor impairment from a single CNS demyelinating lesion. Neurology 2016; 87:1713-1719. [PMID: 27638926 DOI: 10.1212/wnl.0000000000003235] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 07/05/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To report patients with progressive motor impairment resulting from an isolated CNS demyelinating lesion in cerebral, brainstem, or spinal cord white matter that we call progressive solitary sclerosis. METHODS Thirty patients were identified with (1) progressive motor impairment for over 1 year with a single radiologically identified CNS demyelinating lesion along corticospinal tracts, (2) absence of other demyelinating CNS lesions, and (3) no history of relapses affecting other CNS pathways. Twenty-five were followed prospectively in our multiple sclerosis (MS) clinic and 5 were identified retrospectively from our progressive MS database. Patients were excluded if an alternative etiology for progressive motor impairment was found. Multiple brain and spinal cord MRI were reviewed by a neuroradiologist blinded to the clinical details. RESULTS The patients' median age was 48.5 years (range 23-71) and 15 (50%) were women. The median follow-up from symptom onset was 100 months (range 15-343 months). All had insidiously progressive upper motor neuron weakness attributable to the solitary demyelinating lesion found on MRI. Clinical presentations were hemiparesis/monoparesis (n = 24), quadriparesis (n = 5), and paraparesis (n = 1). Solitary MRI lesions involved cervical spinal cord (n = 18), cervico-medullary/brainstem region (n = 6), thoracic spinal cord (n = 4), and subcortical white matter (n = 2). CSF abnormalities consistent with MS were found in 13 of 26 (50%). Demyelinating disease was confirmed pathologically in 2 (biopsy, 1; autopsy, 1). CONCLUSIONS Progressive solitary sclerosis results from an isolated CNS demyelinating lesion. Future revisions to MS diagnostic criteria could incorporate this presentation of demyelinating disease.
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Affiliation(s)
- B Mark Keegan
- From the Departments of Neurology (B.M.K., O.H.K., E.P.F.) and Neuroradiology (T.J.K., B.G.W.), Mayo Clinic, Rochester; Department of Neurology (W.F.S.), University of Minnesota, Minneapolis; and Department of Neurology (M.M.P.S.), University of Utah, Salt Lake City.
| | - Timothy J Kaufmann
- From the Departments of Neurology (B.M.K., O.H.K., E.P.F.) and Neuroradiology (T.J.K., B.G.W.), Mayo Clinic, Rochester; Department of Neurology (W.F.S.), University of Minnesota, Minneapolis; and Department of Neurology (M.M.P.S.), University of Utah, Salt Lake City
| | - Brian G Weinshenker
- From the Departments of Neurology (B.M.K., O.H.K., E.P.F.) and Neuroradiology (T.J.K., B.G.W.), Mayo Clinic, Rochester; Department of Neurology (W.F.S.), University of Minnesota, Minneapolis; and Department of Neurology (M.M.P.S.), University of Utah, Salt Lake City
| | - Orhun H Kantarci
- From the Departments of Neurology (B.M.K., O.H.K., E.P.F.) and Neuroradiology (T.J.K., B.G.W.), Mayo Clinic, Rochester; Department of Neurology (W.F.S.), University of Minnesota, Minneapolis; and Department of Neurology (M.M.P.S.), University of Utah, Salt Lake City
| | - William F Schmalstieg
- From the Departments of Neurology (B.M.K., O.H.K., E.P.F.) and Neuroradiology (T.J.K., B.G.W.), Mayo Clinic, Rochester; Department of Neurology (W.F.S.), University of Minnesota, Minneapolis; and Department of Neurology (M.M.P.S.), University of Utah, Salt Lake City
| | - M Mateo Paz Soldan
- From the Departments of Neurology (B.M.K., O.H.K., E.P.F.) and Neuroradiology (T.J.K., B.G.W.), Mayo Clinic, Rochester; Department of Neurology (W.F.S.), University of Minnesota, Minneapolis; and Department of Neurology (M.M.P.S.), University of Utah, Salt Lake City
| | - Eoin P Flanagan
- From the Departments of Neurology (B.M.K., O.H.K., E.P.F.) and Neuroradiology (T.J.K., B.G.W.), Mayo Clinic, Rochester; Department of Neurology (W.F.S.), University of Minnesota, Minneapolis; and Department of Neurology (M.M.P.S.), University of Utah, Salt Lake City
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Smeets D, Ribbens A, Sima DM, Cambron M, Horakova D, Jain S, Maertens A, Van Vlierberghe E, Terzopoulos V, Van Binst AM, Vaneckova M, Krasensky J, Uher T, Seidl Z, De Keyser J, Nagels G, De Mey J, Havrdova E, Van Hecke W. Reliable measurements of brain atrophy in individual patients with multiple sclerosis. Brain Behav 2016; 6:e00518. [PMID: 27688944 PMCID: PMC5036437 DOI: 10.1002/brb3.518] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 05/09/2016] [Accepted: 05/11/2016] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION As neurodegeneration is recognized as a major contributor to disability in multiple sclerosis (MS), brain atrophy quantification could have a high added value in clinical practice to assess treatment efficacy and disease progression, provided that it has a sufficiently low measurement error to draw meaningful conclusions for an individual patient. METHOD In this paper, we present an automated longitudinal method based on Jacobian integration for measuring whole-brain and gray matter atrophy based on anatomical magnetic resonance images (MRI), named MSmetrix. MSmetrix is specifically designed to measure atrophy in patients with MS, by including iterative lesion segmentation and lesion filling based on FLAIR and T1-weighted MRI scans. RESULTS MS metrix is compared with SIENA with respect to test-retest error and consistency, resulting in an average test-retest error on an MS data set of 0.13% (MS metrix) and 0.17% (SIENA) and a consistency error of 0.07% (MS metrix) and 0.05% (SIENA). On a healthy subject data set including physiological variability the test-retest is 0.19% (MS metrix) and 0.31% (SIENA). CONCLUSION Therefore, we can conclude that MSmetrix could be of added value in clinical practice for the follow-up of treatment and disease progression in MS patients.
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Affiliation(s)
- Dirk Smeets
- R&Dicometrix Leuven Belgium; BioImaging Lab Universiteit Antwerpen Antwerp Belgium
| | | | | | - Melissa Cambron
- Department of Neurology Center for Neurosciences Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB) Brussel Belgium
| | - Dana Horakova
- Department of Neurology and Center of Clinical Neuroscience Charles University in Prague First Faculty of Medicine and General University Hospital Prague Czech Republic
| | | | | | | | | | - Anne-Marie Van Binst
- Department of Neurology Center for Neurosciences Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB) Brussel Belgium
| | - Manuela Vaneckova
- Department of Radiology 1st Faculty of Medicine and General University Hospital Charles University Prague Czech Republic
| | - Jan Krasensky
- Department of Radiology 1st Faculty of Medicine and General University Hospital Charles University Prague Czech Republic
| | - Tomas Uher
- Department of Neurology and Center of Clinical Neuroscience Charles University in Prague First Faculty of Medicine and General University Hospital Prague Czech Republic
| | - Zdenek Seidl
- Department of Radiology 1st Faculty of Medicine and General University Hospital Charles University Prague Czech Republic
| | - Jacques De Keyser
- Department of Neurology Center for Neurosciences Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB) Brussel Belgium
| | - Guy Nagels
- National Multiple Sclerosis Centrum Melsbroek Belgium
| | - Johan De Mey
- Department of Neurology Center for Neurosciences Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB) Brussel Belgium
| | - Eva Havrdova
- Department of Neurology and Center of Clinical Neuroscience Charles University in Prague First Faculty of Medicine and General University Hospital Prague Czech Republic
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Jokubaitis VG, Butzkueven H. A genetic basis for multiple sclerosis severity: Red herring or real? Mol Cell Probes 2016; 30:357-365. [PMID: 27546889 DOI: 10.1016/j.mcp.2016.08.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 08/17/2016] [Accepted: 08/17/2016] [Indexed: 01/24/2023]
Abstract
Multiple Sclerosis (MS) is an autoimmune degenerative disease of the central nervous system, characterized by multifocal demyelination and neurodegeneration. The genetic architecture of MS is complex, where genetic risk has been attributed to over 100 polymorphic loci each with small odds ratios. MS is a highly heterogeneous disease with numerous clinical and paraclinical endophenotypes. To-date, no genetic variant has been associated with clinical outcome, however, evidence exists that MS outcomes, like risk, are to an extent also controlled by genetic variation. Here we summarise the current evidence for genetic determination of disease outcomes and make recommendations for future research directions.
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Affiliation(s)
- Vilija G Jokubaitis
- Department of Medicine and Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Australia; Department of Neurology, Royal Melbourne Hospital, Melbourne, Australia.
| | - Helmut Butzkueven
- Department of Medicine and Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Australia; Department of Neurology, Royal Melbourne Hospital, Melbourne, Australia; Department of Neurology, Box Hill Hospital, Monash University, Box Hill, Australia
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160
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Ziemssen T, Kern R, Cornelissen C. Study design of PANGAEA 2.0, a non-interventional study on RRMS patients to be switched to fingolimod. BMC Neurol 2016; 16:129. [PMID: 27502119 PMCID: PMC4977700 DOI: 10.1186/s12883-016-0648-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 07/26/2016] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The therapeutic options for patients with Multiple Sclerosis (MS) have steadily increased due to the approval of new substances that now supplement traditional first-line agents, demanding a paradigm shift in the assessment of disease activity and treatment response in clinical routine. Here, we report the study design of PANGAEA 2.0 (Post-Authorization Non-interventional GermAn treatment benefit study of GilEnyA in MS patients), a non-interventional study in patients with relapsing-remitting MS (RRMS) identify patients with disease activity and monitor their disease course after treatment switch to fingolimod (Gilenya®), an oral medication approved for patients with highly active RRMS. METHOD/DESIGN In the first phase of the PANGAEA 2.0 study the disease activity status of patients receiving a disease-modifying therapy (DMT) is evaluated in order to identify patients at risk of disease progression. This evaluation is based on outcome parameters for both clinical disease activity and magnetic resonance imaging (MRI), and subclinical measures, describing disease activity from the physician's and the patient's perspective. In the second phase of the study, 1500 RRMS patients identified as being non-responders and switched to fingolimod (oral, 0.5 mg/daily) are followed-up for 3 years. Data on relapse activity, disability progression, MRI lesions, and brain volume loss will be assessed in accordance to 'no evidence of disease activity-4' (NEDA-4). The modified Rio score, currently validated for the evaluation of treatment response to interferons, will be used to evaluate the treatment response to fingolimod. The MS management software MSDS3D will guide physicians through the complex processes of diagnosis and treatment. A sub-study further analyzes the benefits of a standardized quantitative evaluation of routine MRI scans by a central reading facility. PANGAEA 2.0 is being conducted between June 2015 and December 2019 in 350 neurological practices and centers in Germany, including 100 centers participating in the sub-study. DISCUSSION PANGAEA 2.0 will not only evaluate the long-term benefit of a treatment change to fingolimod but also the applicability of new concepts of data acquisition, assessment of MS disease activity and evaluation of treatment response for the in clinical routine. TRIAL REGISTRATION BfArM6532; Trial Registration Date: 20/05/2015.
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Affiliation(s)
- Tjalf Ziemssen
- Zentrum für klinische Neurowissenschaften, Klinik und Poliklinik für Neurologie, Universitätsklinikum Carl Gustav Carus Dresden, Technische Universität Dresden, Fetscherstr. 43, D-01307, Dresden, Germany.
| | - Raimar Kern
- Zentrum für klinische Neurowissenschaften, Klinik und Poliklinik für Neurologie, Universitätsklinikum Carl Gustav Carus Dresden, Technische Universität Dresden, Fetscherstr. 43, D-01307, Dresden, Germany
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Atkins HL, Bowman M, Allan D, Anstee G, Arnold DL, Bar-Or A, Bence-Bruckler I, Birch P, Bredeson C, Chen J, Fergusson D, Halpenny M, Hamelin L, Huebsch L, Hutton B, Laneuville P, Lapierre Y, Lee H, Martin L, McDiarmid S, O'Connor P, Ramsay T, Sabloff M, Walker L, Freedman MS. Immunoablation and autologous haemopoietic stem-cell transplantation for aggressive multiple sclerosis: a multicentre single-group phase 2 trial. Lancet 2016; 388:576-85. [PMID: 27291994 DOI: 10.1016/s0140-6736(16)30169-6] [Citation(s) in RCA: 221] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Strong immunosuppression, including chemotherapy and immune-depleting antibodies followed by autologous haemopoietic stem-cell transplantation (aHSCT), has been used to treat patients with multiple sclerosis, improving control of relapsing disease. We addressed whether near-complete immunoablation followed by immune cell depleted aHSCT would result in long-term control of multiple sclerosis. METHODS We did this phase 2 single-arm trial at three hospitals in Canada. We enrolled patients with multiple sclerosis, aged 18-50 years with poor prognosis, ongoing disease activity, and an Expanded Disability Status Scale of 3.0-6.0. Autologous CD34 selected haemopoietic stem-cell grafts were collected after mobilisation with cyclophosphamide and filgrastim. Immunoablation with busulfan, cyclophosphamide, and rabbit anti-thymocyte globulin was followed by aHSCT. The primary outcome was multiple sclerosis activity-free survival (events were clinical relapse, appearance of a new or Gd-enhancing lesion on MRI, and sustained progression of Expanded Disability Status Scale score). This study was registered at ClinicalTrials.gov, NCT01099930. FINDINGS Between diagnosis and aHSCT, 24 patients had 167 clinical relapses over 140 patient-years with 188 Gd-enhancing lesions on 48 pre-aHSCT MRI scans. Median follow-up was 6.7 years (range 3.9-12.7). The primary outcome, multiple sclerosis activity-free survival at 3 years after transplantation was 69.6% (95% CI 46.6-84.2). With up to 13 years of follow-up after aHSCT, no relapses occurred and no Gd enhancing lesions or new T2 lesions were seen on 314 MRI sequential scans. The rate of brain atrophy decreased to that expected for healthy controls. One of 24 patients died of transplantation-related complications. 35% of patients had a sustained improvement in their Expanded Disability Status Scale score. INTERPRETATION We describe the first treatment to fully halt all detectable CNS inflammatory activity in patients with multiple sclerosis for a prolonged period in the absence of any ongoing disease-modifying drugs. Furthermore, many of the patients had substantial recovery of neurological function despite their disease's aggressive nature. FUNDING Multiple Sclerosis Scientific Research Foundation.
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Affiliation(s)
- Harold L Atkins
- Ottawa Hospital Research Institute, Ottawa, ON, Canada; The Ottawa Hospital Blood and Marrow Transplant Program, Ottawa, ON, Canada; Department of Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - Marjorie Bowman
- Ottawa Hospital Research Institute, Ottawa, ON, Canada; The Ottawa Hospital MS Clinic, Ottawa, ON, Canada
| | - David Allan
- Ottawa Hospital Research Institute, Ottawa, ON, Canada; The Ottawa Hospital Blood and Marrow Transplant Program, Ottawa, ON, Canada; Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Grizel Anstee
- The Ottawa Hospital Blood and Marrow Transplant Program, Ottawa, ON, Canada
| | - Douglas L Arnold
- Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University, Montréal, QC, Canada; NeuroRx Research, Montreal, QC, Canada
| | - Amit Bar-Or
- Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University, Montréal, QC, Canada; Neuroimmunology Unit, Montreal Neurological Institute and Hospital, McGill University, Montréal, QC, Canada
| | - Isabelle Bence-Bruckler
- The Ottawa Hospital Blood and Marrow Transplant Program, Ottawa, ON, Canada; Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Paul Birch
- Ottawa Stem Cell Program, Canadian Blood Services, Ottawa, ON, Canada
| | - Christopher Bredeson
- Ottawa Hospital Research Institute, Ottawa, ON, Canada; The Ottawa Hospital Blood and Marrow Transplant Program, Ottawa, ON, Canada; Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jacqueline Chen
- Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University, Montréal, QC, Canada; Department of Neurosciences, Cleveland Clinic, Cleveland, OH, USA
| | - Dean Fergusson
- Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Mike Halpenny
- Ottawa Stem Cell Program, Canadian Blood Services, Ottawa, ON, Canada
| | - Linda Hamelin
- The Ottawa Hospital Blood and Marrow Transplant Program, Ottawa, ON, Canada
| | - Lothar Huebsch
- The Ottawa Hospital Blood and Marrow Transplant Program, Ottawa, ON, Canada; Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Brian Hutton
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Pierre Laneuville
- McGill University Health Center, Montreal, QC, Canada; Division of Oncology, Department of Medicine, McGill University, Montreal, QC, Canada
| | - Yves Lapierre
- Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University, Montréal, QC, Canada
| | - Hyunwoo Lee
- Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University, Montréal, QC, Canada
| | - Lisa Martin
- Ottawa Stem Cell Program, Canadian Blood Services, Ottawa, ON, Canada
| | - Sheryl McDiarmid
- The Ottawa Hospital Blood and Marrow Transplant Program, Ottawa, ON, Canada
| | - Paul O'Connor
- Division of Neurology, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Timothy Ramsay
- Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Mitchell Sabloff
- The Ottawa Hospital Blood and Marrow Transplant Program, Ottawa, ON, Canada; Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Lisa Walker
- School of Psychology, University of Ottawa, Ottawa, ON, Canada; The Ottawa Hospital MS Clinic, Ottawa, ON, Canada
| | - Mark S Freedman
- Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Medicine, University of Ottawa, Ottawa, ON, Canada; The Ottawa Hospital MS Clinic, Ottawa, ON, Canada
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Biberacher V, Schmidt P, Keshavan A, Boucard CC, Righart R, Sämann P, Preibisch C, Fröbel D, Aly L, Hemmer B, Zimmer C, Henry RG, Mühlau M. Intra- and interscanner variability of magnetic resonance imaging based volumetry in multiple sclerosis. Neuroimage 2016; 142:188-197. [PMID: 27431758 DOI: 10.1016/j.neuroimage.2016.07.035] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 07/05/2016] [Accepted: 07/14/2016] [Indexed: 11/26/2022] Open
Abstract
Brain volumetric measurements in multiple sclerosis (MS) reflect not only disease-specific processes but also other sources of variability. The latter has to be considered especially in multicenter and longitudinal studies. Here, we compare data generated by three different 3-Tesla magnetic resonance scanners (Philips Achieva; Siemens Verio; GE Signa MR750). We scanned two patients diagnosed with relapsing remitting MS six times per scanner within three weeks (T1w and FLAIR, 3D). We assessed T2-hyperintense lesions by an automated lesion segmentation tool and determined volumes of grey matter (GM), white matter (WM) and whole brain (GM+WM) from the lesion-filled T1-weighted images using voxel-based morphometry (SPM8/VBM8) and SIENAX (FSL). We measured cortical thickness using FreeSurfer from both, lesion-filled and original T1-weighted images. We quantified brain volume changes with SIENA. In both patients, we found significant differences in total lesion volume, global brain tissue volumes and cortical thickness measures between the scanners. Morphometric measures varied remarkably between repeated scans at each scanner, independent of the brain imaging software tool used. We conclude that for cross-sectional multicenter studies, the effect of different scanners has to be taken into account. For longitudinal monocentric studies, the expected effect size should exceed the size of false positive findings observed in this study. Assuming a physiological loss of brain volume of about 0.3% per year in healthy adult subjects (Good et al., 2001), which may double in MS (De Stefano et al., 2010; De Stefano et al., 2015), with current tools reliable estimation of brain atrophy in individual patients is only possible over periods of several years.
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Affiliation(s)
- Viola Biberacher
- Neurology, Technische Universität München, Ismaninger Str. 22, 81675 Munich, Germany; TUM-Neuroimaging Center, Technische Universität München, Munich, Germany.
| | - Paul Schmidt
- TUM-Neuroimaging Center, Technische Universität München, Munich, Germany; Statistics, Ludwig-Maximilians-Universität München, Ludwigstr. 33, 80539 Munich, Germany
| | - Anisha Keshavan
- Neurology, University of California San Francisco, 675 Nelson Rising Lane, San Francisco, CA 94158, United States
| | - Christine C Boucard
- Neurology, Technische Universität München, Ismaninger Str. 22, 81675 Munich, Germany; TUM-Neuroimaging Center, Technische Universität München, Munich, Germany
| | - Ruthger Righart
- Neurology, Technische Universität München, Ismaninger Str. 22, 81675 Munich, Germany; TUM-Neuroimaging Center, Technische Universität München, Munich, Germany
| | - Philipp Sämann
- Neuroimaging Core Unit, Max Planck Institute of Psychiatry, Kraepelinstr. 2-10, 80804 Munich, Germany
| | - Christine Preibisch
- Neuroradiology, Technische Universität München, Ismaninger Str. 22, 81675 Munich, Germany
| | - Daniel Fröbel
- Neuroradiology, Technische Universität München, Ismaninger Str. 22, 81675 Munich, Germany
| | - Lilian Aly
- Neurology, Technische Universität München, Ismaninger Str. 22, 81675 Munich, Germany
| | - Bernhard Hemmer
- Neurology, Technische Universität München, Ismaninger Str. 22, 81675 Munich, Germany; Munich Cluster for Systems Neurology (SyNergy), Feodor-Lynen-Str. 17, 81377 Munich, Germany
| | - Claus Zimmer
- Neuroradiology, Technische Universität München, Ismaninger Str. 22, 81675 Munich, Germany
| | - Roland G Henry
- Neurology, University of California San Francisco, 675 Nelson Rising Lane, San Francisco, CA 94158, United States
| | - Mark Mühlau
- Neurology, Technische Universität München, Ismaninger Str. 22, 81675 Munich, Germany; TUM-Neuroimaging Center, Technische Universität München, Munich, Germany
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163
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Ibitoye R, Kemp K, Rice C, Hares K, Scolding N, Wilkins A. Oxidative stress-related biomarkers in multiple sclerosis: a review. Biomark Med 2016; 10:889-902. [PMID: 27416337 DOI: 10.2217/bmm-2016-0097] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM To provide an up-to-date review of oxidative stress biomarkers in multiple sclerosis and thus identify candidate molecules with greatest promise as biomarkers of diagnosis, disease activity or prognosis. METHOD A semi-systematic literature search using PubMed and other databases. RESULTS Nitric oxide metabolites, superoxide dismutase, catalase, glutathione reductase, inducible nitric oxide synthase, protein carbonyl, 3-nitrotyrosine, isoprostanes, malondialdehyde and products of DNA oxidation have been identified across multiple studies as having promise as diagnostic, therapeutic or prognostic markers in MS. CONCLUSION Heterogeneity of study design, particularly patient selection, limits comparability across studies. Further cohort studies are needed, and we would recommend promising markers be incorporated into future clinical trials to prospectively validate their potential.
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Affiliation(s)
- Richard Ibitoye
- Institute of Clinical Neurosciences, University of Bristol/Level 1, Learning & Research, Southmead Hospital, Southmead Road, Bristol, BS10 5NB, UK
| | - Kevin Kemp
- Institute of Clinical Neurosciences, University of Bristol/Level 1, Learning & Research, Southmead Hospital, Southmead Road, Bristol, BS10 5NB, UK
| | - Claire Rice
- Institute of Clinical Neurosciences, University of Bristol/Level 1, Learning & Research, Southmead Hospital, Southmead Road, Bristol, BS10 5NB, UK
| | - Kelly Hares
- Institute of Clinical Neurosciences, University of Bristol/Level 1, Learning & Research, Southmead Hospital, Southmead Road, Bristol, BS10 5NB, UK
| | - Neil Scolding
- Institute of Clinical Neurosciences, University of Bristol/Level 1, Learning & Research, Southmead Hospital, Southmead Road, Bristol, BS10 5NB, UK
| | - Alastair Wilkins
- Institute of Clinical Neurosciences, University of Bristol/Level 1, Learning & Research, Southmead Hospital, Southmead Road, Bristol, BS10 5NB, UK
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Sormani MP, Kappos L, Radue EW, Cohen J, Barkhof F, Sprenger T, Piani Meier D, Häring D, Tomic D, De Stefano N. Defining brain volume cutoffs to identify clinically relevant atrophy in RRMS. Mult Scler 2016; 23:656-664. [DOI: 10.1177/1352458516659550] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: To define values of normalized brain volume (NBV) that can be categorized as low, medium, or high, according to baseline characteristics of relapsing-remitting multiple sclerosis (RRMS) patients. Methods: Expected NBV (eNBV) was calculated for each patient based on age, disease duration, sex, baseline Expanded Disability Status Scale (EDSS), and T2-lesion volume, entering these variables into a multiple regression model run on 2342 RRMS patients (pooled FREEDOMS/FREEDOMS-II population). According to the difference between their observed NBV and their eNBV, patients were classified as having low NBV, medium NBV, or high NBV. We evaluated whether these NBV categories were clinically meaningful by assessing correlation with disability worsening. Results: The distribution of differences between observed NBV and eNBV was used to categorize patients as having low NBV, medium NBV or high NBV. Taking the high-NBV group as reference, the hazard ratios (HRs) for 2-year disability worsening, adjusted for treatment effect, were 1.23 (95% confidence interval (CI): 0.92–1.63, p = 0.16) for the medium NBV and 1.75 (95% CI: 1.26–2.44, p = 0.001) for the low NBV. The predictive value of NBV groups was preserved over 4 years. Treatment effect appeared more evident in low-NBV patients (HR = 0.58) than in medium-NBV (HR = 0.72) and in high-NBV (HR = 0.80) patients; however, the difference was not significant ( p = 0.57). Conclusion: RRMS patients can be categorized into disability risk groups based on individual eNBV values according to baseline demographics and clinical characteristics.
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Affiliation(s)
- Maria Pia Sormani
- Biostatistics Unit, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Ludwig Kappos
- Neurological Clinic and Polyclinic, Departments of Medicine, Clinical Research, Biomedicine and Biomedical Engineering, University Hospital Basel, Basel, Switzerland
| | - Ernst-Wilhelm Radue
- Medical Image Analysis Center (MIAC), University Hospital Basel, Basel, Switzerland
| | - Jeffrey Cohen
- Neurological Institute, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Frederik Barkhof
- Department of Radiology, VU University Medical Center, Amsterdam, Netherlands
| | - Till Sprenger
- Department of Neurology, DKD Helios Klinik Wiesbaden, Wiesbaden, Germany
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165
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Lee H, Narayanan S, Brown RA, Chen JT, Atkins HL, Freedman MS, Arnold DL. Brain atrophy after bone marrow transplantation for treatment of multiple sclerosis. Mult Scler 2016; 23:420-431. [DOI: 10.1177/1352458516650992] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: A cohort of patients with poor-prognosis multiple sclerosis (MS) underwent chemotherapy-based immune ablation followed by immune reconstitution with an autologous hematopoietic stem cell transplant (IA/aHSCT). This eliminated new focal inflammatory activity, but resulted in early acceleration of brain atrophy. Objective: We modeled the time course of whole-brain volume in 19 patients to identify the baseline predictors of atrophy and to estimate the average rate of atrophy after IA/aHSCT. Methods: Percentage whole-brain volume changes were calculated between the baseline and follow-up magnetic resonance imaging (MRI; mean duration: 5 years). A mixed-effects model was applied using two predictors: total busulfan dose and baseline volume of T1-weighted white-matter lesions. Results: Treatment was followed by accelerated whole-brain volume loss averaging 3.3%. Both the busulfan dose and the baseline lesion volume were significant predictors. The atrophy slowed progressively over approximately 2.5 years. There was no evidence that resolution of edema contributed to volume loss. The mean rate of long-term atrophy was −0.23% per year, consistent with the rate expected from normal aging. Conclusion: Following IA/aHSCT, MS patients showed accelerated whole-brain atrophy that was likely associated with treatment-related toxicity and degeneration of “committed” tissues. Atrophy eventually slowed to that expected from normal aging, suggesting that stopping inflammatory activity in MS can reduce secondary degeneration and atrophy.
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Affiliation(s)
- Hyunwoo Lee
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Sridar Narayanan
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Robert A Brown
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Jacqueline T Chen
- Department of Neurosciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Harold L Atkins
- Ottawa Hospital Blood and Marrow Transplant Program, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Mark S Freedman
- University of Ottawa and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Douglas L Arnold
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, QC, Canada
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166
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Giovannoni G, Butzkueven H, Dhib-Jalbut S, Hobart J, Kobelt G, Pepper G, Sormani MP, Thalheim C, Traboulsee A, Vollmer T. Brain health: time matters in multiple sclerosis. Mult Scler Relat Disord 2016; 9 Suppl 1:S5-S48. [PMID: 27640924 DOI: 10.1016/j.msard.2016.07.003] [Citation(s) in RCA: 247] [Impact Index Per Article: 30.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 07/01/2016] [Indexed: 01/10/2023]
Abstract
INTRODUCTION We present international consensus recommendations for improving diagnosis, management and treatment access in multiple sclerosis (MS). Our vision is that these will be used widely among those committed to creating a better future for people with MS and their families. METHODS Structured discussions and literature searches conducted in 2015 examined the personal and economic impact of MS, current practice in diagnosis, treatment and management, definitions of disease activity and barriers to accessing disease-modifying therapies (DMTs). RESULTS Delays often occur before a person with symptoms suggestive of MS sees a neurologist. Campaigns to raise awareness of MS are needed, as are initiatives to improve access to MS healthcare professionals and services. We recommend a clear treatment goal: to maximize neurological reserve, cognitive function and physical function by reducing disease activity. Treatment should start early, with DMT and lifestyle measures. All parameters that predict relapses and disability progression should be included in the definition of disease activity and monitored regularly when practical. On suboptimal control of disease activity, switching to a DMT with a different mechanism of action should be considered. A shared decision-making process that embodies dialogue and considers all appropriate DMTs should be implemented. Monitoring data should be recorded formally in registries to generate real-world evidence. In many jurisdictions, access to DMTs is limited. To improve treatment access the relevant bodies should consider all costs to all parties when conducting economic evaluations and encourage the continuing investigation, development and use of cost-effective therapeutic strategies and alternative financing models. CONCLUSIONS The consensus findings of an international author group recommend a therapeutic strategy based on proactive monitoring and shared decision-making in MS. Early diagnosis and improved treatment access are also key components.
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Affiliation(s)
- Gavin Giovannoni
- Queen Mary University London, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK.
| | - Helmut Butzkueven
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia.
| | - Suhayl Dhib-Jalbut
- Department of Neurology, RUTGERS-Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
| | - Jeremy Hobart
- Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK.
| | | | | | | | | | - Anthony Traboulsee
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
| | - Timothy Vollmer
- Department of Neurology, University of Colorado Denver, Aurora, CO, USA.
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Zivadinov R, Jakimovski D, Gandhi S, Ahmed R, Dwyer MG, Horakova D, Weinstock-Guttman B, Benedict RRH, Vaneckova M, Barnett M, Bergsland N. Clinical relevance of brain atrophy assessment in multiple sclerosis. Implications for its use in a clinical routine. Expert Rev Neurother 2016; 16:777-93. [PMID: 27105209 DOI: 10.1080/14737175.2016.1181543] [Citation(s) in RCA: 112] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Brain atrophy measurement in multiple sclerosis (MS) has become an important outcome for determining patients at risk for developing physical and cognitive disability. AREAS COVERED In this article, we discuss the methodological issues related to using this MRI metric routinely, in a clinical setting. Understanding trajectories of annualized whole brain, gray and white matter, thalamic volume loss, and enlargement of ventricular space in specific MS phenotypes is becoming increasingly important. Evidence is mounting that disease-modifying treatments exert a positive effect on slowing brain atrophy progression in MS. Expert Commentary: While there is a need to translate measurement of brain atrophy to clinical routine at the individual patient level, there are still a number of challenges to be met before this can actually happen, including how to account for biological confounding factors and pseudoatrophy, standardize acquisition and analyses parameters, which can influence the accuracy of the assessments.
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Affiliation(s)
- Robert Zivadinov
- a Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences , University at Buffalo, State University of New York , Buffalo , NY , USA.,b MR Imaging Clinical Translational Research Center, Jacobs School of Medicine and Biomedical Sciences , University at Buffalo, State University of New York , Buffalo , NY , USA
| | - Dejan Jakimovski
- a Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences , University at Buffalo, State University of New York , Buffalo , NY , USA
| | - Sirin Gandhi
- a Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences , University at Buffalo, State University of New York , Buffalo , NY , USA
| | - Rahil Ahmed
- a Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences , University at Buffalo, State University of New York , Buffalo , NY , USA
| | - Michael G Dwyer
- a Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences , University at Buffalo, State University of New York , Buffalo , NY , USA
| | - Dana Horakova
- c Department of Neurology and Center of Clinical Neuroscience , Charles University in Prague, First Faculty of Medicine and General University Hospital , Prague , Czech Republic
| | - Bianca Weinstock-Guttman
- d Jacobs Multiple Sclerosis Center, Department of Neurology, School of Medicine and Biomedical Sciences , University at Buffalo, State University of New York , Buffalo , NY , USA
| | - Ralph R H Benedict
- d Jacobs Multiple Sclerosis Center, Department of Neurology, School of Medicine and Biomedical Sciences , University at Buffalo, State University of New York , Buffalo , NY , USA
| | - Manuela Vaneckova
- e Department of Radiology, First Faculty of Medicine and General University Hospital , Charles University , Prague , Czech Republic
| | - Michael Barnett
- f Sydney Neuroimaging Analysis Centre; Brain & Mind Centre , University of Sydney , Sydney , Australia
| | - Niels Bergsland
- a Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences , University at Buffalo, State University of New York , Buffalo , NY , USA.,g IRCCS 'S.Maria Nascente' , Don Gnocchi Foundation , Milan , Italy
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Rovira A, Auger C. Spinal Cord in Multiple Sclerosis: Magnetic Resonance Imaging Features and Differential Diagnosis. Semin Ultrasound CT MR 2016; 37:396-410. [PMID: 27616313 DOI: 10.1053/j.sult.2016.05.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Multiple sclerosis (MS) is an idiopathic inflammatory disorder of the central nervous system that affects not only the brain but also the spinal cord. In the diagnostic and monitoring process of MS, spinal cord magnetic resonance imaging (MRI) is not performed as commonly as brain MRI, mainly because of certain technical difficulties and the increase in total acquisition time. Nonetheless, spinal cord MRI findings are important to establish a prompt accurate diagnosis of MS, impart prognostic information, and provide valuable data for monitoring the disease course in certain cases. In this article, we discuss the technical aspects of spinal cord MRI, the typical MRI features of the spinal cord in MS, the clinical indications for this examination, and the differential diagnosis with other disorders that may produce similar clinical or MRI findings.
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Affiliation(s)
- Alex Rovira
- Department of Radiology, Hospital Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain.
| | - Cristina Auger
- Department of Radiology, Hospital Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain
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The Effect of Disease-Modifying Drugs on Brain Atrophy in Relapsing-Remitting Multiple Sclerosis: A Meta-Analysis. PLoS One 2016; 11:e0149685. [PMID: 26983008 PMCID: PMC4794160 DOI: 10.1371/journal.pone.0149685] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 02/03/2016] [Indexed: 11/19/2022] Open
Abstract
Background The quantification of brain atrophy in relapsing-remitting multiple sclerosis (RRMS) may serve as a marker of disease progression and treatment response. We compared the association between first-line (FL) or second-line (SL) disease-modifying drugs (DMDs) and brain volume changes over time in RRMS. Materials and Methods We reviewed clinical trials in RRMS between January 1, 1995 and June 1, 2014 that assessed the effect of DMDs and reported data on brain atrophy in Medline, Embase, the Cochrane database and meeting abstracts. First, we designed a meta-analysis to directly compare the percentage brain volume change (PBVC) between FLDMDs and SLDMDs at 24 months. Second, we conducted an observational and longitudinal linear regression analysis of a 48-month follow-up period. Sensitivity analyses considering PBVC between 12 and 48 months were also performed. Results Among the 272 studies identified, 117 were analyzed and 35 (18,140 patients) were included in the analysis. Based on the meta-analysis, atrophy was greater for the use of an FLDMD than that of an SLDMD at 24 months (primary endpoint mean difference, -0.86; 95% confidence interval: -1.57–-0.15; P = 0.02). Based on the linear regression analysis, the annual PBVC significantly differed between SLDMDs and placebo (-0.27%/y and -0.50%/y, respectively, P = 0.046) but not between FLDMDs (-0.33%/y) and placebo (P = 0.11) or between FLDMDs and SLDMDs (P = 0.49). Based on sensitivity analysis, the annual PBVC was reduced for SLDMDs compared with placebo (-0.14%/y and -0.56%/y, respectively, P<0.001) and FLDMDs (-0.46%/y, P<0.005), but no difference was detected between FLDMDs and placebo (P = 0.12). Conclusions SLDMDs were associated with reduced PBVC slope over time in RRMS, regardless of the period considered. These results provide new insights into the mechanisms underlying atrophy progression in RRMS.
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170
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Khatri BO. Fingolimod in the treatment of relapsing-remitting multiple sclerosis: long-term experience and an update on the clinical evidence. Ther Adv Neurol Disord 2016; 9:130-47. [PMID: 27006700 PMCID: PMC4784254 DOI: 10.1177/1756285616628766] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Since the approval in 2010 of fingolimod 0.5 mg (Gilenya; Novartis Pharma AG, Basel, Switzerland) in the USA as an oral therapy for relapsing forms of multiple sclerosis, long-term clinical experience with this therapy has been increasing. This review provides a summary of the cumulative dataset from clinical trials and their extensions, plus postmarketing studies that contribute to characterizing the efficacy and safety profile of fingolimod in patients with relapsing forms of multiple sclerosis. Data from the controlled, phase III, pivotal studies [FREEDOMS (FTY720 Research Evaluating Effects of Daily Oral therapy in Multiple Sclerosis), FREEDOMS II and TRANSFORMS (Trial Assessing Injectable Interferon versus FTY720 Oral in Relapsing-Remitting Multiple Sclerosis)] in relapsing-remitting multiple sclerosis have shown that fingolimod has a robust effect on clinical and magnetic resonance imaging outcomes. The respective study extensions show that effects on annualized relapse rates are sustained with continued fingolimod treatment. Consistent, significant reductions in magnetic resonance imaging lesion counts and brain volume loss have also been sustained with long-term treatment. The safety profile of fingolimod is also examined, particularly in light of its long-term use. A summary of the adverse events of interest that are associated with fingolimod treatment and associated label guidelines are also considered, which include cardiac effects following first-dose administration, infections, lymphopenia, macular edema and pregnancy. Historic hurdles to the prescription of fingolimod and how these challenges are being met are also discussed.
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Affiliation(s)
- Bhupendra O. Khatri
- The Regional MS Center, Center for Neurological Disorders, Wheaton Franciscan Health Care, 3237 S.16th Street, Milwaukee, WI 53215, USA
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171
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Zivadinov R, Uher T, Hagemeier J, Vaneckova M, Ramasamy DP, Tyblova M, Bergsland N, Seidl Z, Dwyer MG, Krasensky J, Havrdova E, Horakova D. A serial 10-year follow-up study of brain atrophy and disability progression in RRMS patients. Mult Scler 2016; 22:1709-1718. [PMID: 26883943 DOI: 10.1177/1352458516629769] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 01/07/2016] [Indexed: 01/22/2023]
Abstract
BACKGROUND We explored the evolution of brain atrophy in relation to development of confirmed disability progression (CDP) on serial 1.5T magnetic resonance imaging (MRI) scans over a 10-year period in 181 patients with early relapsing-remitting multiple sclerosis (RRMS). METHODS At 10-year follow-up, they were divided into those with (100) or without (76) CDP (confirmed after 48 weeks). Changes in whole brain (WB), cortical, gray matter (GM), white matter, and ventricular cerebrospinal fluid (vCSF) volumes were calculated on three-dimensional T1-weighted (3D-T1) scans between all available time points. RESULTS In multiple sclerosis (MS) patients with CDP compared to those without, the greatest effect size percentage volume change from baseline to follow-up was detected for WB (d = 0.55, -7.5% vs -5.2%, p < 0.001), followed by vCSF (d = 0.51, +41.1% vs +25.7%, p < 0.001), cortical (d = 0.49, -7.7% vs -6.2%, p = 0.001), and GM (d = 0.40, -7.1% vs -5.8%, p = 0.006) volumes. Mixed-effects model analysis, adjusted for age, sex, and treatment change, showed significant interactions between CDP status and percentage changes for WB and vCSF (p < 0.001), cortical (p = 0.02), and GM (p = 0.04) volumes. CONCLUSIONS WB and cortical atrophy, and enlargement of vCSF spaces are associated with development of CDP on serial yearly MRI assessments over a period of 10 years.
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Affiliation(s)
- Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA/MR Imaging Clinical Translational Research Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | - Tomas Uher
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA/Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine and General University Hospital, Charles University in Prague, Prague, Czech Republic
| | - Jesper Hagemeier
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | - Manuela Vaneckova
- Department of Radiology, First Faculty of Medicine and General University Hospital, Charles University in Prague, Prague, Czech Republic
| | - Deepa P Ramasamy
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | - Michaela Tyblova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine and General University Hospital, Charles University in Prague, Prague, Czech Republic
| | - Niels Bergsland
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA/IRCCS "S. Maria Nascente," Don Carlo Gnocchi Foundation, Milan, Italy
| | - Zdenek Seidl
- Department of Radiology, First Faculty of Medicine and General University Hospital, Charles University in Prague, Prague, Czech Republic
| | - Michael G Dwyer
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | - Jan Krasensky
- Department of Radiology, First Faculty of Medicine and General University Hospital, Charles University in Prague, Prague, Czech Republic
| | - Eva Havrdova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine and General University Hospital, Charles University in Prague, Prague, Czech Republic
| | - Dana Horakova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine and General University Hospital, Charles University in Prague, Prague, Czech Republic
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172
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Roy S, Carass A, Pacheco J, Bilgel M, Resnick SM, Prince JL, Pham DL. Temporal filtering of longitudinal brain magnetic resonance images for consistent segmentation. Neuroimage Clin 2016; 11:264-275. [PMID: 26958465 PMCID: PMC4773508 DOI: 10.1016/j.nicl.2016.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 01/13/2016] [Accepted: 02/12/2016] [Indexed: 01/13/2023]
Abstract
Longitudinal analysis of magnetic resonance images of the human brain provides knowledge of brain changes during both normal aging as well as the progression of many diseases. Previous longitudinal segmentation methods have either ignored temporal information or have incorporated temporal consistency constraints within the algorithm. In this work, we assume that some anatomical brain changes can be explained by temporal transitions in image intensities. Once the images are aligned in the same space, the intensities of each scan at the same voxel constitute a temporal (or 4D) intensity trend at that voxel. Temporal intensity variations due to noise or other artifacts are corrected by a 4D intensity-based filter that smooths the intensity values where appropriate, while preserving real anatomical changes such as atrophy. Here smoothing refers to removal of sudden changes or discontinuities in intensities. Images processed with the 4D filter can be used as a pre-processing step to any segmentation method. We show that such a longitudinal pre-processing step produces robust and consistent longitudinal segmentation results, even when applying 3D segmentation algorithms. We compare with state-of-the-art 4D segmentation algorithms. Specifically, we experimented on three longitudinal datasets containing 4-12 time-points, and showed that the 4D temporal filter is more robust and has more power in distinguishing between healthy subjects and those with dementia, mild cognitive impairment, as well as different phenotypes of multiple sclerosis.
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Affiliation(s)
- Snehashis Roy
- Center for Neuroscience and Regenerative Medicine, Henry M. Jackson Foundation for the Advancement of Military Medicine, United States,Corresponding author.
| | - Aaron Carass
- Image Analysis and Communications Laboratory, Department of Electrical and Computer Engineering, Johns Hopkins University, United States,Department of Computer Science, Johns Hopkins University, United States
| | - Jennifer Pacheco
- Laboratory of Behavioral Neuroscience, National Institute on Aging, United States
| | - Murat Bilgel
- Image Analysis and Communications Laboratory, Department of Electrical and Computer Engineering, Johns Hopkins University, United States,Laboratory of Behavioral Neuroscience, National Institute on Aging, United States
| | - Susan M. Resnick
- Laboratory of Behavioral Neuroscience, National Institute on Aging, United States
| | - Jerry L. Prince
- Image Analysis and Communications Laboratory, Department of Electrical and Computer Engineering, Johns Hopkins University, United States
| | - Dzung L. Pham
- Center for Neuroscience and Regenerative Medicine, Henry M. Jackson Foundation for the Advancement of Military Medicine, United States
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173
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Hunter SF, Bowen JD, Reder AT. The Direct Effects of Fingolimod in the Central Nervous System: Implications for Relapsing Multiple Sclerosis. CNS Drugs 2016; 30:135-47. [PMID: 26715391 PMCID: PMC4781895 DOI: 10.1007/s40263-015-0297-0] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Fingolimod, a structural analog of sphingosine derived from fungal metabolites, is a functional antagonist of the G-protein-coupled sphingosine 1-phosphate (S1P) receptors S1P(1,3,4,5). In the treatment of relapsing forms of multiple sclerosis (RMS), fingolimod acts by reversibly retaining central memory T cells and naïve T cells in lymph nodes, thereby reducing the recirculation of autoreactive lymphocytes to the central nervous system (CNS). Fingolimod also has differential effects on the trafficking and function of B-cell subtypes and natural killer (NK) cells in peripheral blood and the CNS. Fingolimod also crosses the blood-brain barrier (BBB) and accumulates in the CNS. Experimental evidence increasingly supports a direct action of fingolimod within the CNS on brain cells, providing protection against the neurodegenerative component of RMS. We review the direct influence of this compound on CNS pathogenesis in RMS, including the central effects of fingolimod in animal models of MS and on neural cell types that express S1P receptors, such as astrocytes, BBB endothelial cells, microglia, neurones, and oligodendrocytes, which are all involved in RMS pathology.
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Affiliation(s)
- Samuel F Hunter
- Advanced Neurosciences Institute, 101 Forrest Crossing Blvd, Suite 103, Franklin, TN, 37064-5430, USA.
| | - James D Bowen
- Multiple Sclerosis Center, Swedish Neuroscience Institute, Seattle, WA, USA.
| | - Anthony T Reder
- Department of Neurology, University of Chicago, Chicago, IL, USA.
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174
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Brown JWL, Chard DT. The role of MRI in the evaluation of secondary progressive multiple sclerosis. Expert Rev Neurother 2016; 16:157-71. [PMID: 26692498 DOI: 10.1586/14737175.2016.1134323] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Magnetic resonance imaging already has an established role in the diagnosis of multiple sclerosis, but it also has the potential to provide prognostic information, and to monitor [corrected] disease progression in clinical trials and practice. Magnetic resonance imaging measures are increasingly being used as the primary outcome in early phase clinical trials of immunomodulatory therapies (for example brain white matter lesion counts or volumes, and gadolinium contrast enhancing lesions) and putatively neuroprotective agents (for example measures of whole brain atrophy), and trials of agents that promote remyelination are also likely to follow suit. In this review we consider the use of magnetic resonance imaging measures as predictors and markers of disease progression in multiple sclerosis, and explore possible future directions in this rapidly developing field.
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Affiliation(s)
- J William L Brown
- a Department of Clinical Neurosciences , University of Cambridge , Cambridge , UK.,b NMR Research Unit, Queen Square Multiple Sclerosis Centre, Institute of Neurology , University College London (UCL) , London , UK
| | - Declan T Chard
- b NMR Research Unit, Queen Square Multiple Sclerosis Centre, Institute of Neurology , University College London (UCL) , London , UK.,c Biomedical Research Centre, National Institute for Health Research (NIHR) , University College London Hospitals (UCLH) , London , UK
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175
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Jeffery DR, Rammohan KW, Hawker K, Fox E. Fingolimod: a review of its mode of action in the context of its efficacy and safety profile in relapsing forms of multiple sclerosis. Expert Rev Neurother 2016; 16:31-44. [DOI: 10.1586/14737175.2016.1123094] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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176
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Brain structural changes in women and men during midlife. Neurosci Lett 2016; 615:107-12. [PMID: 26777626 PMCID: PMC4762229 DOI: 10.1016/j.neulet.2016.01.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 01/04/2016] [Accepted: 01/05/2016] [Indexed: 01/12/2023]
Abstract
Brain development during childhood and adolescence differs between boys and girls. Structural changes continue during adulthood and old age, particularly in terms of brain volume reductions that accelerate beyond age 35 years. We investigated whether brain structural change in mid-life differs between men and women. 43 men and 28 women from the Northern Finland 1966 Birth Cohort underwent MRI brain scans at age 33-35 (SD=0.67) and then again at age 42-44 (SD=0.41). We examined sex differences in total percentage brain volume change (PBVC) and regional brain change with FSL SIENA software. Women showed significant PBVC reduction compared with men between the ages of 33-35 and 42-44 years (Mean=-3.21% in men, Mean=-4.03% in women, F (1, 68)=6.37, p<0.05). In regional analyses, women exhibited greater brain reduction than men in widespread areas. After controlling for total percent brain volume change, men show greater relative regional brain reduction than women in bilateral precentral gyri, bilateral paracingulate gyri, and bilateral supplementary motor cortices. The results indicate sex differences in brain changes in mid-life. Women have more total brain reduction, and more reduction on the outer brain surface than men, whereas men exhibit more brain reduction on the mid-line surface than women after co-varying for total brain volume loss. These changes could contribute to sex differences in midlife behaviour and health.
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177
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Abstract
Due to its sensitivity to the different multiple sclerosis (MS)-related abnormalities, magnetic resonance imaging (MRI) has become an established tool to diagnose MS and to monitor its evolution. MRI has been included in the diagnostic workup of patients with clinically isolated syndromes suggestive of MS, and ad hoc criteria have been proposed and are regularly updated. In patients with definite MS, the ability of conventional MRI techniques to explain patients' clinical status and progression of disability is still suboptimal. Several advanced MRI-based technologies have been applied to estimate overall MS burden in the different phases of the disease. Their use has allowed the heterogeneity of MS pathology in focal lesions, normal-appearing white matter and gray matter to be graded in vivo. Recently, additional features of MS pathology, including macrophage infiltration and abnormal iron deposition, have become quantifiable. All of this, combined with functional imaging techniques, is improving our understanding of the mechanisms associated with MS evolution. In the near future, the use of ultrahigh-field systems is likely to provide additional insight into disease pathophysiology. However, the utility of advanced MRI techniques in clinical trial monitoring and in assessing individual patients' response to treatment still needs to be assessed.
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Affiliation(s)
- Massimo Filippi
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy.
| | - Paolo Preziosa
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Maria A Rocca
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
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178
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De Stefano N, Stromillo ML, Giorgio A, Bartolozzi ML, Battaglini M, Baldini M, Portaccio E, Amato MP, Sormani MP. Establishing pathological cut-offs of brain atrophy rates in multiple sclerosis. J Neurol Neurosurg Psychiatry 2016; 87:93-9. [PMID: 25904813 PMCID: PMC4717444 DOI: 10.1136/jnnp-2014-309903] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 01/11/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess whether it is feasible to establish specific cut-off values able to discriminate 'physiological' or 'pathological' brain volume rates in patients with multiple sclerosis (MS). METHODS The study was based on the analysis of longitudinal MRI data sets of patients with MS (n=206, 87% relapsing-remitting, 7% secondary progressive and 6% primary progressive) and healthy controls (HC; n=35). Brain atrophy rates were computed over a mean follow-up of 7.5 years (range 1-12) for patients with MS and 6.3 years (range 1-12.5) for HC with the SIENA software and expressed as annualised per cent brain volume change (PBVC/y). A weighted (on the follow-up length) receiver operating characteristic analysis and the area under the curve (AUC) were used for statistics. RESULTS The weighted PBVC/y was -0.51±0.27% in patients with MS and -0.27±0.15% in HC (p<0.0001). There was a significant age-related difference in PBVC/y between HC older and younger than 35 years of age (p=0.02), but not in patients with MS (p=0.8). The cut-off of PBVC/y, as measured by SIENA that could maximise the accuracy in discriminating patients with MS from HC, was -0.37%, with 67% sensitivity and 80% specificity. According to the observed distribution, values of PBVC/y as measured by SIENA that could define a pathological range were above -0.52% with 95% specificity, above -0.46% with 90% specificity and above -0.40% with 80% specificity. CONCLUSIONS Our evidence-based criteria provide values able to discriminate the presence or absence of 'pathological' brain volume loss in MS with high specificity. Such results could be of great value in a clinical setting, particularly in assessing treatment efficacy in MS.
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Affiliation(s)
- Nicola De Stefano
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | | | - Antonio Giorgio
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | | | - Marco Battaglini
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | | | - Emilio Portaccio
- Department of Neurology, University of Florence, Florence, Italy
| | - Maria Pia Amato
- Department of Neurology, University of Florence, Florence, Italy
| | - Maria Pia Sormani
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
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179
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Ziemssen T, Derfuss T, de Stefano N, Giovannoni G, Palavra F, Tomic D, Vollmer T, Schippling S. Optimizing treatment success in multiple sclerosis. J Neurol 2015; 263:1053-65. [PMID: 26705122 PMCID: PMC4893374 DOI: 10.1007/s00415-015-7986-y] [Citation(s) in RCA: 129] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Accepted: 11/25/2015] [Indexed: 01/01/2023]
Abstract
Despite important advances in the treatment of multiple sclerosis (MS) over recent years, the introduction of several disease-modifying therapies (DMTs), the burden of progressive disability and premature mortality associated with the condition remains substantial. This burden, together with the high healthcare and societal costs associated with MS, creates a compelling case for early treatment optimization with highly efficacious therapies. Often, patients receive several first-line therapies, while more recent and in part more effective treatments are still being introduced only after these have failed. However, with the availability of highly efficacious therapies, a novel treatment strategy has emerged, where the aim is to achieve no evidence of disease activity (NEDA). Achieving NEDA necessitates regular monitoring of relapses, disability and functionality. However, there is only a poor correlation between conventional magnetic resonance imaging measures like T2 hyperintense lesion burden and the level of clinical disability. Hence, MRI-based measures of brain atrophy have emerged in recent years potentially reflecting the magnitude of MS-related neuroaxonal damage. Currently available DMTs differ markedly in their effects on brain atrophy: some, such as fingolimod, have been shown to significantly slow brain volume loss, compared to placebo, whereas others have shown either no, inconsistent, or delayed effects. In addition to regular monitoring, treatment optimization also requires early intervention with efficacious therapies, because accumulating evidence shows that effective intervention during a limited period early in the course of MS is critical for maintaining neurological function and preventing subsequent disability. Together, the advent of new MS therapies and evolving management strategies offer exciting new opportunities to optimize treatment outcomes.
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Affiliation(s)
- Tjalf Ziemssen
- MS Center Dresden, Center of Clinical Neuroscience, Neurological Clinic, University Hospital Carl Gustav Carus, Dresden University of Technology, Fetscherstrasse 74, 01307, Dresden, Germany.
| | - Tobias Derfuss
- MS Center Dresden, Center of Clinical Neuroscience, Neurological Clinic, University Hospital Carl Gustav Carus, Dresden University of Technology, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Nicola de Stefano
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Gavin Giovannoni
- Queen Mary University London, Barts and The London School of Medicine and Dentistry, London, UK
| | - Filipe Palavra
- Neurology-Neuroimmunology Department, Multiple Sclerosis Centre of Catalonia (Cemcat), Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - Tim Vollmer
- University of Colorado Health Sciences Center, Aurora, CO, USA
| | - Sven Schippling
- Department of Neurology, Neuroimmunology and Multiple Sclerosis Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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180
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Tsivgoulis G, Katsanos AH, Grigoriadis N, Hadjigeorgiou GM, Heliopoulos I, Papathanasopoulos P, Dardiotis E, Kilidireas C, Voumvourakis K. The effect of disease-modifying therapies on brain atrophy in patients with clinically isolated syndrome: a systematic review and meta-analysis. Ther Adv Neurol Disord 2015; 8:193-202. [PMID: 26557896 DOI: 10.1177/1756285615600381] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES Brain atrophy is associated with cognitive deficits in patients with clinically isolated syndrome (CIS) and can predict conversion to clinical definite multiple sclerosis. The aim of the present meta-analysis was to evaluate the effect of disease-modifying drugs (DMDs) on brain atrophy in patients with CIS. METHODS Eligible placebo-control randomized clinical trials of patients with CIS that had reported changes in brain volume during the study period were identified by searching the MEDLINE, SCOPUS, and Cochrane Central Register of Controlled Trials (CENTRAL) databases. This meta-analysis adopted the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for systematic reviews and meta-analyses. RESULTS Three eligible studies were identified, comprising 1362 patients. The mean percentage change in brain volume was found to be significantly lower in DMD-treated patients versus placebo-treated subgroups (standardized mean difference [SMD]: = -0.13, 95% confidence interval [CI]: -0.25, 0.01; p = 0.04). In the subgroup analysis of the two studies that provided data on brain-volume changes for the first (0-12 months) and second (13-24 months) year of treatment, DMD attenuated brain-volume loss in comparison with placebo during the second year (SMD = -0.25; 95% CI: -0.43, -0.07; p < 0.001), but not during the first year of treatment (SMD = -0.01; 95% CI: -0.27, 0.24; p = 0.93). No evidence of heterogeneity was found between estimates, while funnel-plot inspection revealed no evidence of publication bias. CONCLUSIONS DMDs appear to attenuate brain atrophy over time in patients with CIS. The effect of DMDs on brain-volume loss is evident after the first year of treatment.
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Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, School of Medicine, University of Athens, Iras 39, Gerakas Attikis, Athens, 15344, Greece
| | - Aristeidis H Katsanos
- Second Department of Neurology, 'Attikon' Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Nikolaos Grigoriadis
- Second Department of Neurology, 'AHEPA' University Hospital, Aristotelion University of Thessaloniki, Thessaloniki, Greece
| | - Georgios M Hadjigeorgiou
- Department of Neurology, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - Ioannis Heliopoulos
- Department of Neurology, Alexandroupolis University Hospital, Democritus University of Thrace, Alexandroupolis, Greece
| | | | - Efthimios Dardiotis
- Department of Neurology, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - Constantinos Kilidireas
- First Department of Neurology, 'Eginition' Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Konstantinos Voumvourakis
- Second Department of Neurology, 'Attikon' Hospital, School of Medicine, University of Athens, Athens, Greece
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181
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Enzinger C, Barkhof F, Ciccarelli O, Filippi M, Kappos L, Rocca MA, Ropele S, Rovira À, Schneider T, de Stefano N, Vrenken H, Wheeler-Kingshott C, Wuerfel J, Fazekas F. Nonconventional MRI and microstructural cerebral changes in multiple sclerosis. Nat Rev Neurol 2015; 11:676-86. [PMID: 26526531 DOI: 10.1038/nrneurol.2015.194] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
MRI has become the most important paraclinical tool for diagnosing and monitoring patients with multiple sclerosis (MS). However, conventional MRI sequences are largely nonspecific in the pathology they reveal, and only provide a limited view of the complex morphological changes associated with MS. Nonconventional MRI techniques, such as magnetization transfer imaging (MTI), diffusion-weighted imaging (DWI) and susceptibility-weighted imaging (SWI) promise to complement existing techniques by revealing more-specific information on microstructural tissue changes. Past years have witnessed dramatic advances in the acquisition and analysis of such imaging data, and numerous studies have used these tools to probe tissue alterations associated with MS. Other MRI-based techniques-such as myelin-water imaging, (23)Na imaging, magnetic resonance elastography and magnetic resonance perfusion imaging-might also shed new light on disease-associated changes. This Review summarizes the rapid technical progress in the use of MRI in patients with MS, with a focus on nonconventional structural MRI. We critically discuss the present utility of nonconventional MRI in MS, and provide an outlook on future applications, including clinical practice. This information should allow appropriate selection of advanced MRI techniques, and facilitate their use in future studies of this disease.
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Affiliation(s)
- Christian Enzinger
- Division of Neuroradiology, Medical University of Graz, Auenbruggerplatz 22, 8036 Graz, Austria.,Department of Neurology, Medical University of Graz, Auenbruggerplatz 22, 8036 Graz, Austria
| | - Frederik Barkhof
- VU University MS Center Amsterdam, Department of Radiology and Nuclear Medicine and Department of Physics &Medical Technology, VU University Medical Center, Netherlands
| | - Olga Ciccarelli
- NMR Research Unit, Queen Square MS Centre, University College London Institute of Neurology, UK
| | - Massimo Filippi
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Italy
| | - Ludwig Kappos
- Department of Neurology, University of Basel, Switzerland
| | - Maria A Rocca
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Italy
| | - Stefan Ropele
- Department of Neurology, Medical University of Graz, Auenbruggerplatz 22, 8036 Graz, Austria
| | - Àlex Rovira
- Magnetic Resonance Unit, Cemcat, Hospital Vall d'Hebron, Autonomous University of Barcelona, Spain
| | - Torben Schneider
- NMR Research Unit, Queen Square MS Centre, University College London Institute of Neurology, UK
| | - Nicola de Stefano
- Department of Neurological and Behavioural Sciences, University of Siena, Italy
| | - Hugo Vrenken
- VU University MS Center Amsterdam, Department of Radiology and Nuclear Medicine and Department of Physics &Medical Technology, VU University Medical Center, Netherlands
| | | | - Jens Wuerfel
- Medical Image Analysis Center, University Hospital Basel, Switzerland
| | - Franz Fazekas
- Department of Neurology, Medical University of Graz, Auenbruggerplatz 22, 8036 Graz, Austria
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182
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Hutchinson M. Neurodegeneration in multiple sclerosis is a process separate from inflammation: No. Mult Scler 2015; 21:1628-31. [DOI: 10.1177/1352458515612244] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Michael Hutchinson
- St Vincent’s University Hospital, Dublin; School of Medicine and Medical Sciences, University College Dublin, Ireland
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183
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Lanzillo R, Quarantelli M, Pozzilli C, Trojano M, Amato MP, Marrosu MG, Francia A, Florio C, Orefice G, Tedeschi G, Bellantonio P, Annunziata P, Grimaldi LM, Comerci M, Brunetti A, Bonavita V, Alfano B, Marini S, Brescia Morra V. No evidence for an effect on brain atrophy rate of atorvastatin add-on to interferon β1b therapy in relapsing-remitting multiple sclerosis (the ARIANNA study). Mult Scler 2015; 22:1163-73. [PMID: 26466947 DOI: 10.1177/1352458515611222] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 09/17/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND A previous phase 2 trial has suggested that statins might delay brain atrophy in secondary progressive multiple sclerosis. OBJECTIVES The objective of this study was to evaluate the effect of atorvastatin add-on therapy on cerebral atrophy in relapsing-remitting multiple sclerosis. METHODS This randomised, placebo-controlled study compared atorvastatin 40 mg or placebo add-on therapy to interferon β1b for 24 months. Brain magnetic resonance imaging, multiple sclerosis functional composite score, Rao neuropsychological battery and expanded disability status scale were evaluated over 24 months. RESULTS A total of 154 patients were randomly assigned, 75 in the atorvastatin and 79 in the placebo arms, with a comparable drop-out rate (overall 23.4%). Brain atrophy over 2 years was not different in the two arms (-0.38% and -0.32% for the atorvastatin and placebo groups, respectively). Relapse rate, expanded disability status scale, multiple sclerosis functional composite score or cognitive changes were not different in the two arms. Patients withdrawing from the study had a higher number of relapses in the previous 2 years (P=0.04) and a greater probability of relapsing within 12 months. CONCLUSIONS Our results suggest that the combination of atorvastatin and interferon β1b is not justified in early relapsing-remitting multiple sclerosis and adds to the body of evidence indicating an absence of significant radiological and clinical benefit of statins in relapsing-remitting multiple sclerosis.
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Affiliation(s)
- Roberta Lanzillo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Federico II University of Naples, Italy
| | - Mario Quarantelli
- National Research Council (CNR) Biostructure and Bioimaging Institute (IBB), Naples Multiple Sclerosis Centre, Italy
| | - Carlo Pozzilli
- Department of Neurology and Psychiatry, Sapienza University, Italy
| | - Maria Trojano
- Department of Neurosciences and Organs of Senses, University of Bari, Italy
| | | | - Maria G Marrosu
- Department of Public Health and Clinical and Molecular Medicine, University of Cagliari, Italy
| | - Ada Francia
- Department of Neurology and Psychiatry, Sapienza University, Italy
| | - Ciro Florio
- Multiple Sclerosis Regional Center, Azienda Ospedaliera "Antonio Cardarelli", Italy
| | - Giuseppe Orefice
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Federico II University of Naples, Italy
| | - Gioacchino Tedeschi
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, Second University of Naples, Italy
| | | | - Pasquale Annunziata
- Department of Neurological, Neurosurgical and Behavioural Sciences, University of Siena, Italy
| | - Luigi M Grimaldi
- Neurology Unit, Fondazione Istituto San Raffaele "G. Giglio", Italy
| | - Marco Comerci
- National Research Council (CNR) Biostructure and Bioimaging Institute (IBB), Naples Multiple Sclerosis Centre, Italy
| | - Arturo Brunetti
- Department of Biomedical Advanced Sciences, Federico II University, Italy
| | | | - Bruno Alfano
- National Research Council (CNR) Biostructure and Bioimaging Institute (IBB), Naples Multiple Sclerosis Centre, Italy
| | | | - Vincenzo Brescia Morra
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Federico II University of Naples, Italy
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184
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Kolind S, Seddigh A, Combes A, Russell-Schulz B, Tam R, Yogendrakumar V, Deoni S, Sibtain NA, Traboulsee A, Williams SCR, Barker GJ, Brex PA. Brain and cord myelin water imaging: a progressive multiple sclerosis biomarker. NEUROIMAGE-CLINICAL 2015; 9:574-80. [PMID: 26594633 PMCID: PMC4625204 DOI: 10.1016/j.nicl.2015.10.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 09/09/2015] [Accepted: 10/01/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Conventional magnetic resonance imaging (MRI) is used to diagnose and monitor inflammatory disease in relapsing remitting (RR) multiple sclerosis (MS). In the less common primary progressive (PP) form of MS, in which focal inflammation is less evident, biomarkers are still needed to enable evaluation of novel therapies in clinical trials. Our objective was to characterize the association - across the brain and cervical spinal cord - between clinical disability measures in PPMS and two potential biomarkers (one for myelin, and one for atrophy, both resulting from the same imaging technique). METHODS Multi-component driven equilibrium single pulse observation of T1 and T2 (mcDESPOT) MRI of the brain and cervical spinal cord were obtained for 15 PPMS patients and 11 matched controls. Data were analysed to estimate the signal related to myelin water (VFM), as well as volume measurements. MS disability was assessed using the Multiple Sclerosis Functional Composite score, which includes measures of cognitive processing (Paced Auditory Serial Addition Test), manual dexterity (9-Hole Peg Test) and ambulatory function (Timed 25-Foot Walk); and the Expanded Disability Status Scale. RESULTS Brain and spinal cord volumes were different in PPMS compared to controls, particularly ventricular (+ 46%, p = 0.0006) and cervical spinal cord volume (- 16%, p = 0.0001). Brain and spinal cord myelin (VFM) were also reduced in PPMS (brain: - 11%, p = 0.01; spine: - 19%, p = 0.000004). Cognitive processing correlated with brain ventricular volume (p = 0.009). Manual dexterity correlated with brain ventricular volume (p = 0.007), and both brain and spinal cord VFM (p = 0.01 and 0.06, respectively). Ambulation correlated with spinal cord volume (p = 0.04) and spinal cord VFM (p = 0.04). INTERPRETATION In this study we demonstrated that mcDESPOT can be used to measure myelin and atrophy in the brain and spinal cord. Results correlate well with clinical disability scores in PPMS representing cognitive, fine motor and ambulatory disability.
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Key Words
- 9HPT, 9-Hole Peg Test
- Atrophy
- CCV, cervical cord volume
- CSF, cerebrospinal fluid
- EDSS, Expanded Disability Status Scale
- FOV, field of view
- MR, magnetic resonance
- MRI, magnetic resonance imaging
- MS, multiple sclerosis
- MSFC, Multiple Sclerosis Functional Composite
- Myelin
- Myelin water imaging
- PASAT, Paced Auditory Serial Addition Test
- PP, primary progressive
- Primary progressive multiple sclerosis
- RR, relapsing remitting
- SPGR, spoiled gradient echo
- SSFP, steady state free precession
- Spinal cord
- T25FW, Timed 25-Foot Walk
- TE, echo time
- TR, repetition time
- VFM, myelin water volume fraction
- mcDESPOT, Multi-component driven equilibrium single pulse observation of T1 & T2
- vCSF, ventricular cerebrospinal fluid
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Affiliation(s)
- Shannon Kolind
- Department of Medicine (Division of Neurology), University of BC, Vancouver, Canada
| | - Arshia Seddigh
- King's College Hospital NHS Foundation Trust, London, UK
| | - Anna Combes
- Department of Neuroimaging, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | | | - Roger Tam
- Department of Radiology, University of BC, Vancouver, Canada
| | - Vignan Yogendrakumar
- Department of Medicine (Division of Neurology), University of BC, Vancouver, Canada
| | - Sean Deoni
- Department of Pediatric Radiology, Children's Hospital Colorado, Denver, CO, USA ; Department of Radiology, University of Colorado School of Medicine, Denver, CO, USA
| | | | - Anthony Traboulsee
- Department of Medicine (Division of Neurology), University of BC, Vancouver, Canada
| | - Steven C R Williams
- Department of Neuroimaging, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Gareth J Barker
- Department of Neuroimaging, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Peter A Brex
- King's College Hospital NHS Foundation Trust, London, UK
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185
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Ratzer R, Iversen P, Börnsen L, Dyrby TB, Romme Christensen J, Ammitzbøll C, Madsen CG, Garde E, Lyksborg M, Andersen B, Hyldstrup L, Sørensen PS, Siebner HR, Sellebjerg F. Monthly oral methylprednisolone pulse treatment in progressive multiple sclerosis. Mult Scler 2015; 22:926-34. [PMID: 26432857 DOI: 10.1177/1352458515605908] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 08/23/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is a large unmet need for treatments for patients with progressive multiple sclerosis (MS). Phase 2 studies with cerebrospinal fluid (CSF) biomarker outcomes may be well suited for the initial evaluation of efficacious treatments. OBJECTIVE To evaluate the effect of monthly oral methylprednisolone pulse treatment on intrathecal inflammation in progressive MS. METHODS In this open-label phase 2A study, 15 primary progressive and 15 secondary progressive MS patients received oral methylprednisolone pulse treatment for 60 weeks. Primary outcome was changes in CSF concentrations of osteopontin. Secondary outcomes were other CSF biomarkers of inflammation, axonal damage and demyelination; clinical scores; magnetic resonance imaging measures of disease activity, magnetization transfer ratio (MTR) and diffusion tensor imaging (DTI); motor evoked potentials; and bone density scans. RESULTS We found no change in the CSF concentration of osteopontin, but we observed significant improvement in clinical scores, MTR, DTI and some secondary CSF outcome measures. Adverse events were well-known side effects to methylprednisolone. CONCLUSION Monthly methylprednisolone pulse treatment was safe, but had no effect on the primary outcome. However, improvements in secondary clinical and MRI outcome measures suggest that this treatment regimen may have a beneficial effect in progressive MS.
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Affiliation(s)
- Rikke Ratzer
- Danish Multiple Sclerosis Center, Department of Neurology, Rigshospitalet, University of Copenhagen, Denmark
| | - Pernille Iversen
- Danish Research Center for Magnetic Resonance, Centre for Functional and Diagnostic Imaging and Research, Hvidovre Hospital, University of Copenhagen, Denmark
| | - Lars Börnsen
- Danish Multiple Sclerosis Center, Department of Neurology, Rigshospitalet, University of Copenhagen, Denmark
| | - Tim B Dyrby
- Danish Research Center for Magnetic Resonance, Centre for Functional and Diagnostic Imaging and Research, Hvidovre Hospital, University of Copenhagen, Denmark
| | - Jeppe Romme Christensen
- Danish Multiple Sclerosis Center, Department of Neurology, Rigshospitalet, University of Copenhagen, Denmark
| | - Cecilie Ammitzbøll
- Danish Multiple Sclerosis Center, Department of Neurology, Rigshospitalet, University of Copenhagen, Denmark
| | - Camilla Gøbel Madsen
- Danish Research Center for Magnetic Resonance, Centre for Functional and Diagnostic Imaging and Research, Hvidovre Hospital, University of Copenhagen, Denmark
| | - Ellen Garde
- Danish Research Center for Magnetic Resonance, Centre for Functional and Diagnostic Imaging and Research, Hvidovre Hospital, University of Copenhagen, Denmark
| | - Mark Lyksborg
- Danish Research Center for Magnetic Resonance, Centre for Functional and Diagnostic Imaging and Research, Hvidovre Hospital, University of Copenhagen, Denmark
| | - Birgit Andersen
- Department of Clinical Neurophysiology, Rigshospitalet, University of Copenhagen, Denmark
| | - Lars Hyldstrup
- Department of Endocrinology, Hvidovre Hospital, University of Copenhagen, Denmark
| | - Per Soelberg Sørensen
- Danish Multiple Sclerosis Center, Department of Neurology, Rigshospitalet, University of Copenhagen, Denmark
| | - Hartwig R Siebner
- Danish Research Center for Magnetic Resonance, Centre for Functional and Diagnostic Imaging and Research, Hvidovre Hospital, University of Copenhagen, Denmark
| | - Finn Sellebjerg
- Danish Multiple Sclerosis Center, Department of Neurology, Rigshospitalet, University of Copenhagen, Denmark
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186
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The natural history of brain volume loss among patients with multiple sclerosis: A systematic literature review and meta-analysis. J Neurol Sci 2015; 357:8-18. [DOI: 10.1016/j.jns.2015.07.014] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 06/15/2015] [Accepted: 07/09/2015] [Indexed: 11/21/2022]
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187
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Matthews L, Kolind S, Brazier A, Leite MI, Brooks J, Traboulsee A, Jenkinson M, Johansen-Berg H, Palace J. Imaging Surrogates of Disease Activity in Neuromyelitis Optica Allow Distinction from Multiple Sclerosis. PLoS One 2015; 10:e0137715. [PMID: 26381510 PMCID: PMC4575169 DOI: 10.1371/journal.pone.0137715] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 08/21/2015] [Indexed: 11/19/2022] Open
Abstract
Inflammatory demyelinating lesions of the central nervous system are a common feature of both neuromyelitis optica and multiple sclerosis. Despite this similarity, it is evident clinically that the accumulation of disability in patients with neuromyelitis optica is relapse related and that a progressive phase is very uncommon. This poses the question whether there is any pathological evidence of disease activity or neurodegeneration in neuromyelitis optica between relapses. To investigate this we conducted a longitudinal advanced MRI study of the brain and spinal cord in neuromyelitis optica patients, comparing to patients with multiple sclerosis and controls. We found both cross-sectional and longitudinal evidence of diffusely distributed neurodegenerative surrogates in the multiple sclerosis group (including thalamic atrophy, cervical cord atrophy and progressive widespread diffusion and myelin water imaging abnormalities in the normal appearing white matter) but not in those with neuromyelitis optica, where localised abnormalities in the optic radiations of those with severe visual impairment were noted. In addition, between relapses, there were no new silent brain lesions in the neuromyelitis optica group. These findings indicate that global central nervous system neurodegeneration is not a feature of neuromyelitis optica. The work also questions the theory that neurodegeneration in multiple sclerosis is a chronic sequela to prior inflammatory and demyelinating pathology, as this has not been found to be the case in neuromyelitis optica where the lesions are often more destructive.
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Affiliation(s)
- Lucy Matthews
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
- Neurology Department, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Shannon Kolind
- Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Alix Brazier
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Maria Isabel Leite
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
- Neurology Department, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Jonathan Brooks
- Clinical Research and Imaging Centre (CRiCBristol), University of Bristol, Bristol, United Kingdom
| | - Anthony Traboulsee
- Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Mark Jenkinson
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Heidi Johansen-Berg
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Jacqueline Palace
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
- Neurology Department, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
- * E-mail:
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188
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Wattjes MP, Rovira À, Miller D, Yousry TA, Sormani MP, de Stefano MP, Tintoré M, Auger C, Tur C, Filippi M, Rocca MA, Fazekas F, Kappos L, Polman C, Frederik Barkhof, Xavier Montalban. Evidence-based guidelines: MAGNIMS consensus guidelines on the use of MRI in multiple sclerosis--establishing disease prognosis and monitoring patients. Nat Rev Neurol 2015; 11:597-606. [PMID: 26369511 DOI: 10.1038/nrneurol.2015.157] [Citation(s) in RCA: 348] [Impact Index Per Article: 38.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The role of MRI in the assessment of multiple sclerosis (MS) goes far beyond the diagnostic process. MRI techniques can be used as regular monitoring to help stage patients with MS and measure disease progression. MRI can also be used to measure lesion burden, thus providing useful information for the prediction of long-term disability. With the introduction of a new generation of immunomodulatory and/or immunosuppressive drugs for the treatment of MS, MRI also makes an important contribution to the monitoring of treatment, and can be used to determine baseline tissue damage and detect subsequent repair. This use of MRI can help predict treatment response and assess the efficacy and safety of new therapies. In the second part of the MAGNIMS (Magnetic Resonance Imaging in MS) network's guidelines on the use of MRI in MS, we focus on the implementation of this technique in prognostic and monitoring tasks. We present recommendations on how and when to use MRI for disease monitoring, and discuss some promising MRI approaches that may be introduced into clinical practice in the near future.
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189
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Ziemssen T, De Stefano N, Sormani MP, Van Wijmeersch B, Wiendl H, Kieseier BC. Optimizing therapy early in multiple sclerosis: An evidence-based view. Mult Scler Relat Disord 2015; 4:460-469. [DOI: 10.1016/j.msard.2015.07.007] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 06/01/2015] [Accepted: 07/15/2015] [Indexed: 01/26/2023]
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190
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Pichler A, Khalil M, Langkammer C, Pinter D, Bachmaier G, Ropele S, Fuchs S, Enzinger C, Fazekas F. Combined analysis of global and compartmental brain volume changes in early multiple sclerosis in clinical practice. Mult Scler 2015; 22:340-6. [DOI: 10.1177/1352458515593405] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 05/31/2015] [Indexed: 11/16/2022]
Abstract
Background: The extent and clinical significance of brain volume changes in different phases of multiple sclerosis (MS) is still under discussion. Objective: To determine the rate of global and compartmental brain volume changes in patients with a clinically-isolated syndrome (CIS) compared to patients with definite MS, by long-term follow-up and as a predictor of conversion to MS in a routine clinical setting. Methods: We investigated 120 patients (63 CIS and 57 MS) at baseline and after a mean follow-up period of 43 months, including detailed clinical examination and 3-Tesla magnetic resonance imaging (MRI). Our imaging analyses comprised the normalized brain volume (NBV), cortical grey matter (cGMV) and white matter (WMV) volumes using SIENA/X, the percentage of brain volume change (PBVC) using SIENA and the change in the volume of the thalami (TV) and basal ganglia (BGV). We also determined the amount and change of T2-lesion load (T2-LL). Results: At baseline, all the brain volume metrics, except cGMV, were significantly lower; and the T2-LL was significantly higher, in patients with MS rather than CIS. During the follow-up, only the PBVC was higher in MS ( p = 0.008) and this difference was driven by converters from CIS to MS. Quartiles of PBVC did not allow us to predict conversion to MS, but were associated with the degree of disability. Conclusions: PBVC is the most sensitive marker of progressing atrophy and a higher PBVC was generally associated with more active disease; however, it did not serve to predict the course of MS on an individual basis, in this study.
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Affiliation(s)
| | - M Khalil
- Medical University of Graz, Austria
| | | | - D Pinter
- Medical University of Graz, Austria
| | | | - S Ropele
- Medical University of Graz, Austria
| | - S Fuchs
- Medical University of Graz, Austria
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191
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Varosanec M, Uher T, Horakova D, Hagemeier J, Bergsland N, Tyblova M, Seidl Z, Vaneckova M, Krasensky J, Dwyer MG, Havrdova E, Zivadinov R. Longitudinal Mixed-Effect Model Analysis of the Association between Global and Tissue-Specific Brain Atrophy and Lesion Accumulation in Patients with Clinically Isolated Syndrome. AJNR Am J Neuroradiol 2015; 36:1457-64. [PMID: 26113068 DOI: 10.3174/ajnr.a4330] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 12/26/2014] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND PURPOSE The relationship between lesion formation and brain atrophy development in the early phase of multiple sclerosis is unclear. We investigated the association between new lesion accumulation and brain atrophy progression in patients with clinically isolated syndrome over 48 months. MATERIALS AND METHODS Patients with clinically isolated syndrome (n = 210) were evaluated with 1.5T MR imaging at baseline and at 6, 12, 24, 36, and 48 months as part of a multicenter observational study of early administration of intramuscular interferon β-1a. Mixed-effect model analyses, adjusted for age, sex, and treatment status, investigated the association between accumulation of contrast-enhancing and T2 lesions and brain-volume percent changes in a 48-month period. RESULTS In patients with clinically isolated syndrome, the average whole-brain volume decreased 2.5%, the mean lateral ventricle volume increased 16.9%, and a mean of 7.7 new/enlarging T2 lesions accumulated over the follow-up period. Patients with clinically isolated syndrome who showed greater percentages of change in whole-brain, white and gray matter, cortical, and lateral ventricle volumes over the follow-up period had more severe lesion outcomes at baseline (all P < .007). There were significant associations between decreased individual brain-volume measures at baseline and greater percentages of change during follow-up (P < .05). We found a significant association between the total cumulative number of new/enlarging T2 lesions and the evolution of whole-brain (P < .001), lateral ventricle (P = .007), gray matter and thalamic (P = .013), subcortical deep gray matter (P = .015), and cortical (P = .036) volumes over the follow-up period. CONCLUSIONS Lesion accumulation and brain-volume changes occur simultaneously in the early phase of clinically isolated syndrome. More severe lesion and brain-volume outcomes at baseline were associated with greater development of brain atrophy over the follow-up period in patients with clinically isolated syndrome.
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Affiliation(s)
- M Varosanec
- From the Buffalo Neuroimaging Analysis Center (M.V., T.U., J.H., N.B., M.G.D., R.Z.), Department of Neurology, University at Buffalo SUNY, Buffalo, New York
| | - T Uher
- From the Buffalo Neuroimaging Analysis Center (M.V., T.U., J.H., N.B., M.G.D., R.Z.), Department of Neurology, University at Buffalo SUNY, Buffalo, New York Department of Neurology and Center of Clinical Neuroscience (T.U., D.H., M.T., E.H.)
| | - D Horakova
- Department of Neurology and Center of Clinical Neuroscience (T.U., D.H., M.T., E.H.)
| | - J Hagemeier
- From the Buffalo Neuroimaging Analysis Center (M.V., T.U., J.H., N.B., M.G.D., R.Z.), Department of Neurology, University at Buffalo SUNY, Buffalo, New York
| | - N Bergsland
- From the Buffalo Neuroimaging Analysis Center (M.V., T.U., J.H., N.B., M.G.D., R.Z.), Department of Neurology, University at Buffalo SUNY, Buffalo, New York IRCCS "Santa Maria Nascente" (N.B.), Don Gnocchi Foundation, Milan, Italy
| | - M Tyblova
- Department of Neurology and Center of Clinical Neuroscience (T.U., D.H., M.T., E.H.)
| | - Z Seidl
- Department of Radiology (Z.S., M.V., J.K.), Charles University in Prague, First Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | - M Vaneckova
- Department of Radiology (Z.S., M.V., J.K.), Charles University in Prague, First Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | - J Krasensky
- Department of Radiology (Z.S., M.V., J.K.), Charles University in Prague, First Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | - M G Dwyer
- From the Buffalo Neuroimaging Analysis Center (M.V., T.U., J.H., N.B., M.G.D., R.Z.), Department of Neurology, University at Buffalo SUNY, Buffalo, New York
| | - E Havrdova
- Department of Neurology and Center of Clinical Neuroscience (T.U., D.H., M.T., E.H.)
| | - R Zivadinov
- From the Buffalo Neuroimaging Analysis Center (M.V., T.U., J.H., N.B., M.G.D., R.Z.), Department of Neurology, University at Buffalo SUNY, Buffalo, New York
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192
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Abstract
Multiple sclerosis (MS) is an inflammatory disorder of the CNS that affects both the brain and the spinal cord. MRI studies in MS focus more often on the brain than on the spinal cord, owing to the technical challenges in imaging this smaller, mobile structure. However, spinal cord abnormalities at disease onset have important implications for diagnosis and prognosis. Furthermore, later in the disease course, in progressive MS, myelopathy becomes the primary characteristic of the clinical presentation, and extensive spinal cord pathology--including atrophy, diffuse abnormalities and numerous focal lesions--is common. Recent spinal cord imaging studies have employed increasingly sophisticated techniques to improve detection and quantification of spinal cord lesions, and to elucidate their relationship with physical disability. Quantitative MRI measures of cord size and tissue integrity could be more sensitive to the axonal loss and other pathological processes in the spinal cord than is conventional MRI, putting quantitative MRI in a key role to elucidate the association between disability and spinal cord abnormalities seen in people with MS. In this Review, we summarize the most recent MS spinal cord imaging studies and discuss the new insights they have provided into the mechanisms of neurological impairment. Finally, we suggest directions for further and future research.
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Freedman MS, Abdoli M. Evaluating response to disease-modifying therapy in relapsing multiple sclerosis. Expert Rev Neurother 2015; 15:407-23. [DOI: 10.1586/14737175.2015.1023711] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Tsivgoulis G, Katsanos AH, Grigoriadis N, Hadjigeorgiou GM, Heliopoulos I, Kilidireas C, Voumvourakis K. The effect of disease modifying therapies on brain atrophy in patients with relapsing-remitting multiple sclerosis: a systematic review and meta-analysis. PLoS One 2015; 10:e0116511. [PMID: 25756363 PMCID: PMC4355592 DOI: 10.1371/journal.pone.0116511] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 12/10/2014] [Indexed: 11/18/2022] Open
Abstract
Background The aim of the present meta-analysis was to evaluate the effect of disease-modifying drugs (DMD) on brain atrophy in patients with relapsing-remitting multiple sclerosis (RRMS) using available randomized-controlled trial (RCT) data. Methods We conducted a systematic review and meta-analysis according to PRISMA guidelines of all available RCTs of patients with RRMS that reported data on brain volume measurements during the study period. Results We identified 4 eligible studies, including a total of 1819 RRMS patients (71% women, mean age 36.5 years, mean baseline EDSS-score: 2.4). The mean percentage change in brain volume was found to be significantly lower in DMD versus placebo subgroup (standardized mean difference: -0.19; 95%CI: -0.27–-0.11; p<0.001). We detected no evidence of heterogeneity between estimates (I2 = 30%, p = 0.19) nor publication bias in the Funnel plots. Sensitivity analyses stratifying studies according to brain atrophy neuroimaging protocol disclosed no evidence of heterogeneity (p = 0.16). In meta-regression analyses, the percentage change in brain volume was found to be inversely related with duration of observation period in both DMD (meta-regression slope = -0.03; 95% CI: -0.04–-0.02; p<0.001) and placebo subgroups (meta-regression slope = -0.05; 95% CI: -0.06–-0.04; p<0.001). However, the rate of percentage brain volume loss over time was greater in placebo than in DMD subgroup (p = 0.017, ANCOVA). Conclusions DMD appear to be effective in attenuating brain atrophy in comparison to placebo and their benefit in delaying the rate of brain volume loss increases linearly with longer treatment duration.
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Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, “Attikon” Hospital, School of Medicine, University of Athens, Athens, Greece
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, Tennessee, United States of America
- International Clinical Research Center, Department of Neurology, St. Anne’s University Hospital in Brno, Brno, Czech Republic
- * E-mail:
| | - Aristeidis H. Katsanos
- Second Department of Neurology, “Attikon” Hospital, School of Medicine, University of Athens, Athens, Greece
- Department of Neurology, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Nikolaos Grigoriadis
- Second Department of Neurology, “AHEPA” University Hospital, Aristotelion University of Thessaloniki, Thessaloniki, Macedonia, Greece
| | | | - Ioannis Heliopoulos
- Department of Neurology, Alexandroupolis University Hospital, Democritus University of Thrace, Alexandroupolis, Greece
| | - Constantinos Kilidireas
- First Department of Neurology, “Eginition” Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Konstantinos Voumvourakis
- Second Department of Neurology, “Attikon” Hospital, School of Medicine, University of Athens, Athens, Greece
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Radue EW, Barkhof F, Kappos L, Sprenger T, Häring DA, de Vera A, von Rosenstiel P, Bright JR, Francis G, Cohen JA. Correlation between brain volume loss and clinical and MRI outcomes in multiple sclerosis. Neurology 2015; 84:784-93. [PMID: 25632085 PMCID: PMC4339126 DOI: 10.1212/wnl.0000000000001281] [Citation(s) in RCA: 110] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Accepted: 11/07/2014] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE We investigated the determinants and clinical correlations of MRI-detected brain volume loss (BVL) among patients with relapsing-remitting multiple sclerosis from the phase 3 trials of fingolimod: FREEDOMS, FREEDOMS II, and TRANSFORMS. METHODS Post hoc analyses were conducted in the intent-to-treat populations from each trial and in a combined dataset of 3,635 patients from the trials and their extensions. The relationship between brain volume changes and demographic, clinical, and MRI parameters was studied in pairwise correlations (Pearson) and in multiple regression models. The relative frequency of confirmed disability progression was evaluated in the combined dataset by strata of concurrent BVL at up to 4 years. RESULTS Increasing age, disease duration, T2 lesion volume, T1-hypointense lesion volume, and disability were associated with reduced brain volume (p < 0.001, all). The strongest individual baseline predictors of on-study BVL were T2 lesion volume, gadolinium-enhancing lesion count, and T1-hypointense lesion volume (p < 0.01, all). During each study, BVL correlated most strongly with cumulative gadolinium-enhancing lesion count, new/enlarged T2 lesion count (p < 0.001, both), and number of confirmed on-study relapses (p < 0.01). Over 4 years in the combined dataset (mean exposure to study drug, 2.4 years), confirmed disability progression was most frequent in patients with greatest BVL. CONCLUSIONS Rate of BVL in patients during the fingolimod trials correlated with disease severity at baseline and new disease activity on study, and was associated with worsening disability.
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Affiliation(s)
- Ernst-Wilhelm Radue
- From the Medical Image Analysis Centre (E.-W.R.), University Hospital, University of Basel, Switzerland; Image Analysis Center (F.B.), VU Medical Centre, Amsterdam, the Netherlands; Departments of Medicine and Clinical Research, Neurology (L.K., T.S.) and Radiology (T.S.), Division of Neuroradiology, University Hospital, Basel, Switzerland; Novartis Pharma AG (D.A.H., A.d.V., P.v.R.), Basel, Switzerland; Oxford PharmaGenesis Ltd. (J.R.B.), Tubney, Oxford, UK; Novartis Pharmaceuticals Corporation (G.F.), East Hanover, NJ; and Neurological Institute (J.A.C.), Cleveland Clinic, OH
| | - Frederik Barkhof
- From the Medical Image Analysis Centre (E.-W.R.), University Hospital, University of Basel, Switzerland; Image Analysis Center (F.B.), VU Medical Centre, Amsterdam, the Netherlands; Departments of Medicine and Clinical Research, Neurology (L.K., T.S.) and Radiology (T.S.), Division of Neuroradiology, University Hospital, Basel, Switzerland; Novartis Pharma AG (D.A.H., A.d.V., P.v.R.), Basel, Switzerland; Oxford PharmaGenesis Ltd. (J.R.B.), Tubney, Oxford, UK; Novartis Pharmaceuticals Corporation (G.F.), East Hanover, NJ; and Neurological Institute (J.A.C.), Cleveland Clinic, OH
| | - Ludwig Kappos
- From the Medical Image Analysis Centre (E.-W.R.), University Hospital, University of Basel, Switzerland; Image Analysis Center (F.B.), VU Medical Centre, Amsterdam, the Netherlands; Departments of Medicine and Clinical Research, Neurology (L.K., T.S.) and Radiology (T.S.), Division of Neuroradiology, University Hospital, Basel, Switzerland; Novartis Pharma AG (D.A.H., A.d.V., P.v.R.), Basel, Switzerland; Oxford PharmaGenesis Ltd. (J.R.B.), Tubney, Oxford, UK; Novartis Pharmaceuticals Corporation (G.F.), East Hanover, NJ; and Neurological Institute (J.A.C.), Cleveland Clinic, OH.
| | - Till Sprenger
- From the Medical Image Analysis Centre (E.-W.R.), University Hospital, University of Basel, Switzerland; Image Analysis Center (F.B.), VU Medical Centre, Amsterdam, the Netherlands; Departments of Medicine and Clinical Research, Neurology (L.K., T.S.) and Radiology (T.S.), Division of Neuroradiology, University Hospital, Basel, Switzerland; Novartis Pharma AG (D.A.H., A.d.V., P.v.R.), Basel, Switzerland; Oxford PharmaGenesis Ltd. (J.R.B.), Tubney, Oxford, UK; Novartis Pharmaceuticals Corporation (G.F.), East Hanover, NJ; and Neurological Institute (J.A.C.), Cleveland Clinic, OH
| | - Dieter A Häring
- From the Medical Image Analysis Centre (E.-W.R.), University Hospital, University of Basel, Switzerland; Image Analysis Center (F.B.), VU Medical Centre, Amsterdam, the Netherlands; Departments of Medicine and Clinical Research, Neurology (L.K., T.S.) and Radiology (T.S.), Division of Neuroradiology, University Hospital, Basel, Switzerland; Novartis Pharma AG (D.A.H., A.d.V., P.v.R.), Basel, Switzerland; Oxford PharmaGenesis Ltd. (J.R.B.), Tubney, Oxford, UK; Novartis Pharmaceuticals Corporation (G.F.), East Hanover, NJ; and Neurological Institute (J.A.C.), Cleveland Clinic, OH
| | - Ana de Vera
- From the Medical Image Analysis Centre (E.-W.R.), University Hospital, University of Basel, Switzerland; Image Analysis Center (F.B.), VU Medical Centre, Amsterdam, the Netherlands; Departments of Medicine and Clinical Research, Neurology (L.K., T.S.) and Radiology (T.S.), Division of Neuroradiology, University Hospital, Basel, Switzerland; Novartis Pharma AG (D.A.H., A.d.V., P.v.R.), Basel, Switzerland; Oxford PharmaGenesis Ltd. (J.R.B.), Tubney, Oxford, UK; Novartis Pharmaceuticals Corporation (G.F.), East Hanover, NJ; and Neurological Institute (J.A.C.), Cleveland Clinic, OH
| | - Philipp von Rosenstiel
- From the Medical Image Analysis Centre (E.-W.R.), University Hospital, University of Basel, Switzerland; Image Analysis Center (F.B.), VU Medical Centre, Amsterdam, the Netherlands; Departments of Medicine and Clinical Research, Neurology (L.K., T.S.) and Radiology (T.S.), Division of Neuroradiology, University Hospital, Basel, Switzerland; Novartis Pharma AG (D.A.H., A.d.V., P.v.R.), Basel, Switzerland; Oxford PharmaGenesis Ltd. (J.R.B.), Tubney, Oxford, UK; Novartis Pharmaceuticals Corporation (G.F.), East Hanover, NJ; and Neurological Institute (J.A.C.), Cleveland Clinic, OH
| | - Jeremy R Bright
- From the Medical Image Analysis Centre (E.-W.R.), University Hospital, University of Basel, Switzerland; Image Analysis Center (F.B.), VU Medical Centre, Amsterdam, the Netherlands; Departments of Medicine and Clinical Research, Neurology (L.K., T.S.) and Radiology (T.S.), Division of Neuroradiology, University Hospital, Basel, Switzerland; Novartis Pharma AG (D.A.H., A.d.V., P.v.R.), Basel, Switzerland; Oxford PharmaGenesis Ltd. (J.R.B.), Tubney, Oxford, UK; Novartis Pharmaceuticals Corporation (G.F.), East Hanover, NJ; and Neurological Institute (J.A.C.), Cleveland Clinic, OH
| | - Gordon Francis
- From the Medical Image Analysis Centre (E.-W.R.), University Hospital, University of Basel, Switzerland; Image Analysis Center (F.B.), VU Medical Centre, Amsterdam, the Netherlands; Departments of Medicine and Clinical Research, Neurology (L.K., T.S.) and Radiology (T.S.), Division of Neuroradiology, University Hospital, Basel, Switzerland; Novartis Pharma AG (D.A.H., A.d.V., P.v.R.), Basel, Switzerland; Oxford PharmaGenesis Ltd. (J.R.B.), Tubney, Oxford, UK; Novartis Pharmaceuticals Corporation (G.F.), East Hanover, NJ; and Neurological Institute (J.A.C.), Cleveland Clinic, OH
| | - Jeffrey A Cohen
- From the Medical Image Analysis Centre (E.-W.R.), University Hospital, University of Basel, Switzerland; Image Analysis Center (F.B.), VU Medical Centre, Amsterdam, the Netherlands; Departments of Medicine and Clinical Research, Neurology (L.K., T.S.) and Radiology (T.S.), Division of Neuroradiology, University Hospital, Basel, Switzerland; Novartis Pharma AG (D.A.H., A.d.V., P.v.R.), Basel, Switzerland; Oxford PharmaGenesis Ltd. (J.R.B.), Tubney, Oxford, UK; Novartis Pharmaceuticals Corporation (G.F.), East Hanover, NJ; and Neurological Institute (J.A.C.), Cleveland Clinic, OH
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Nakahara J. [Pathogenesis of cognitive impairment in multiple sclerosis]. Rinsho Shinkeigaku 2015; 54:1063-5. [PMID: 25672710 DOI: 10.5692/clinicalneurol.54.1063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Around a half of multiple sclerosis (MS) patients suffer from cognitive impairment such as attention deficit. A similar impairment is already observable in one third of patients with clinical isolated syndrome, suggesting that the symptom cannot be solely explained by the accumulation of demyelinated lesions. Recently, several studies indicated that demyelination and atrophy in specific regions of the brain are related to the cognitive impairment, although those patients with brain and cognitive reserves are resistant to the development of such symptom. Aging, male sex and smoking increases whereas certain disease-modifying therapy decreases the risk of cognitive impairment in MS. Together, the development of cognitive impairment in MS appears to be determined by the balance between specific aggravating and protective factors.
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Affiliation(s)
- Jin Nakahara
- Department of Neurology, Keio University School of Medicine
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198
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Sormani MP, De Stefano N, Francis G, Sprenger T, Chin P, Radue EW, Kappos L. Fingolimod effect on brain volume loss independently contributes to its effect on disability. Mult Scler 2015; 21:916-24. [DOI: 10.1177/1352458515569099] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 12/24/2014] [Indexed: 11/17/2022]
Abstract
Background: Brain volume loss occurs in patients with relapsing–remitting MS. Fingolimod reduced brain volume loss in three phase 3 studies. Objective: To evaluate whether the effect of fingolimod on disability progression was mediated by its effects on MRI lesions, relapses or brain volume loss, and the extent of this effect. Methods: Patients (992/1272; 78%) from the FTY720 Research Evaluating Effects of Daily Oral Therapy in Multiple Sclerosis (FREEDOMS) study were analyzed. Month-24 percentage brain volume change, month-12 MRI-active lesions and relapse were assessed. The Prentice criteria were used to test surrogate marker validity. The proportion of treatment effect on disability progression explained by each marker was calculated. Results: Two-year disability progression was associated with active T2 lesions (OR = 1.24; p = 0.001) and more relapses during year 1 (OR = 2.90; p < 0.001) and lower percentage brain volume change over two years (OR = 0.78; p < 0.001). Treatment effect on active T2 lesions, relapses and percentage brain volume change explained 46%, 60% and 23% of the fingolimod effect on disability. Multivariate analysis showed the number of relapses during year 1 (OR = 2.62; p < 0.001) and yearly percentage brain volume change over two years (OR = 0.85; p = 0.009) were independent predictors of disability progression, together explaining 73% of fingolimod effect on disability. Conclusions: The treatment effect on relapses and, to a lesser extent, brain volume loss were both predictors of treatment effect on disability; combining these predictors better explained the effect on disability than either factor alone.
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Affiliation(s)
- MP Sormani
- Biostatistics Unit, University of Genoa, Italy
| | - N De Stefano
- Department of Medicine Surgery and Neuroscience, University of Siena, Italy
| | - G Francis
- Novartis Pharmaceuticals Corporation, New Jersey, USA
| | - T Sprenger
- Department of Neurology, University Hospital Basel, Switzerland/Medical Image Analysis Center, University Hospital Basel, Switzerland
| | - P Chin
- Novartis Pharmaceuticals Corporation, New Jersey, USA
| | - EW Radue
- Medical Image Analysis Center, University Hospital Basel, Switzerland
| | - L Kappos
- Department of Neurology, University Hospital Basel, Switzerland
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Ontaneda D, Fox RJ, Chataway J. Clinical trials in progressive multiple sclerosis: lessons learned and future perspectives. Lancet Neurol 2015; 14:208-23. [PMID: 25772899 PMCID: PMC4361791 DOI: 10.1016/s1474-4422(14)70264-9] [Citation(s) in RCA: 159] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Progressive multiple sclerosis is characterised clinically by the gradual accrual of disability independent of relapses and can occur with disease onset (primary progressive) or can be preceded by a relapsing disease course (secondary progressive). An effective disease-modifying treatment for progressive multiple sclerosis has not yet been identified, and so far the results of clinical trials have generally been disappointing. Ongoing advances in the knowledge of pathogenesis, in the identification of novel targets for neuroprotection, and in improved outcome measures could lead to effective treatments for progressive multiple sclerosis. In this Series paper, we summarise the lessons learned from completed clinical trials and perspectives from trials in progress in progressive multiple sclerosis. We review promising clinical, imaging, and biological markers, along with novel designs, for clinical trials. The use of more refined outcomes and truly neuroprotective drugs, coupled with more efficient trial design, has the capacity to deliver a new era of therapeutic discovery in this challenging area.
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Affiliation(s)
- Daniel Ontaneda
- Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, Cleveland, OH, USA.
| | - Robert J Fox
- Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, Cleveland, OH, USA
| | - Jeremy Chataway
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Institute of Neurology, University College London, London, UK; National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
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Abstract
PURPOSE OF REVIEW We summarize MRI measures currently available to assess treatment efficacy and safety in multiple sclerosis (MS) clinical trials and discuss novel metrics that could enter the clinical arena in the near future. RECENT FINDINGS In relapsing remitting MS, MRI measures of disease activity (new T2 and gadolinium-enhancing lesions) provide a good surrogacy of treatment effect on relapse rate and disability progression; however, their value in progressive MS remains elusive. For the progressive disease forms, these measures need to be combined with quantities assessing the extent of irreversible tissue loss, which have already been introduced in some clinical trials (e.g., evolution of active lesions into permanent black holes and brain atrophy). Novel measures (e.g., quantification of gray matter and spinal cord atrophy) have demonstrated a great value in explaining patients' clinical outcome, but still need to be fully validated. Despite showing promise, evaluations of cortical lesions, of microscopic tissue abnormalities, and of functional cortical reorganization are still some way off for monitoring of treatment effects. SUMMARY Trial outcomes in MS should include measures of inflammation and neurodegeneration, which should be combined according to the disease clinical phenotype, phase of the study, and the supposed mechanism of action of the drug tested.
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