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Nabizadeh F, Pirahesh K, Azami M, Moradkhani A, Sardaripour A, Ramezannezhad E. T1 and T2 weighted lesions and cognition in multiple Sclerosis: A systematic review and meta-analysis. J Clin Neurosci 2024; 119:1-7. [PMID: 37952373 DOI: 10.1016/j.jocn.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 11/01/2023] [Accepted: 11/07/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Considering the different results regarding the correlation between Magnetic Resonance Imaging (MRI) structural measures and cognitive dysfunction in patients with MS, we aimed to perform a systematic review and meta-analysis study to investigate the correlation between T1 and T2 weighted lesions and cognitive scores to find the most robust MRI markers for cognitive function in MS population. METHODS The literature of this paper was identified through a comprehensive search of electronic datasets including PubMed, Scopus, Web of Science, and Embase in February 2022. Studies that reported the correlation between cognitive status and T1 and T2 weighted lesions in MS patients were selected. RESULTS 21 studies with a total of 3771 MS patients with mean ages ranging from 30 to 57 years were entered into our study. Our analysis revealed that the volume of T1 lesions was significantly correlated with Symbol Digit Modality test (SDMT) (r: -0.30, 95 %CI: -0.59, -0.01) and Paced Auditory Serial-Addition Task (PASAT) scores (r: -0.23, 95 %CI: -0.36, -0.10). We investigated the correlation between T2 lesions and cognitive scores. The pooled estimates of z scores were significant for SDMT (r: -0.27, 95 %CI: -0.51, -0.03) and PASAT (r: -0.27, 95 %CI: -0.41, -0.13). CONCLUSION In conclusion, our systematic review and meta-analysis study provides strong evidence of the correlation between T1 and T2 lesions and cognitive function in MS patients. Further research is needed to explore the potential mechanisms underlying this relationship and to develop targeted interventions to improve cognitive outcomes in MS patients.
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Affiliation(s)
- Fardin Nabizadeh
- School of Medicine, Iran University of Medical Sciences, Tehran, Iran; School of Medicine, Tehran University of Medical Science, Tehran, Iran.
| | - Kasra Pirahesh
- Student Research Committee, School of Medicine, Kurdistan University of Medical Science, Sanandaj, Iran
| | - Mobin Azami
- Student Research Committee, School of Medicine, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Asra Moradkhani
- Student Research Committee, School of Medicine, Shahid Beheshti University of Medical Science, Tehran, Iran
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2
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Harsini S, Rezaei N. Autoimmune diseases. Clin Immunol 2023. [DOI: 10.1016/b978-0-12-818006-8.00001-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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3
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Chitnis T, Vandercappellen J, King M, Brichetto G. Symptom Interconnectivity in Multiple Sclerosis: A Narrative Review of Potential Underlying Biological Disease Processes. Neurol Ther 2022; 11:1043-1070. [PMID: 35680693 PMCID: PMC9338216 DOI: 10.1007/s40120-022-00368-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/16/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction Fatigue, cognitive impairment, depression, and pain are highly prevalent symptoms in multiple sclerosis (MS). These often co-occur and may be explained by a common etiology. By reviewing existing literature, we aimed to identify potential underlying biological processes implicated in the interconnectivity between these symptoms. Methods A literature search was conducted to identify articles reporting research into the biological mechanisms responsible for the manifestation of fatigue, cognitive impairment, depression, and pain in MS. PubMed was used to search for articles published from July 2011 to July 2021. We reviewed and assessed findings from the literature to identify biological processes common to the symptoms of interest. Results Of 693 articles identified from the search, 252 were selected following screening of titles and abstracts and assessing reference lists of review articles. Four biological processes linked with two or more of the symptoms of interest were frequently identified from the literature: (1) direct neuroanatomical changes to brain regions linked with symptoms of interest (e.g., thalamic injury associated with cognitive impairment, fatigue, and depression), (2) pro-inflammatory cytokines associated with so-called ‘sickness behavior,’ including manifestation of fatigue, transient cognitive impairment, depression, and pain, (3) dysregulation of monoaminergic pathways leading to depressive symptoms and fatigue, and (4) hyperactivity of the hypothalamic–pituitary-adrenal (HPA) axis as a result of pro-inflammatory cytokines promoting the release of brain noradrenaline, serotonin, and tryptophan, which is associated with symptoms of depression and cognitive impairment. Conclusion The co-occurrence of fatigue, cognitive impairment, depression, and pain in MS appears to be associated with a common set of etiological factors, namely neuroanatomical changes, pro-inflammatory cytokines, dysregulation of monoaminergic pathways, and a hyperactive HPA axis. This association of symptoms and biological processes has important implications for disease management strategies and, eventually, could help find a common therapeutic pathway that will impact both inflammation and neuroprotection. Supplementary Information The online version contains supplementary material available at 10.1007/s40120-022-00368-2.
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Affiliation(s)
- Tanuja Chitnis
- Department of Neurology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
| | | | - Miriam King
- Novartis Pharma AG, Fabrikstrasse 12-2, 4056, Basel, Switzerland
| | - Giampaolo Brichetto
- Associazione Italiana Sclerosi Multipla Rehabilitation Center, Via Operai, 30, 16149, Genoa, GE, Italy
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4
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Petracca M, Pontillo G, Moccia M, Carotenuto A, Cocozza S, Lanzillo R, Brunetti A, Brescia Morra V. Neuroimaging Correlates of Cognitive Dysfunction in Adults with Multiple Sclerosis. Brain Sci 2021; 11:346. [PMID: 33803287 PMCID: PMC8000635 DOI: 10.3390/brainsci11030346] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 03/02/2021] [Accepted: 03/04/2021] [Indexed: 02/06/2023] Open
Abstract
Cognitive impairment is a frequent and meaningful symptom in multiple sclerosis (MS), caused by the accrual of brain structural damage only partially counteracted by effective functional reorganization. As both these aspects can be successfully investigated through the application of advanced neuroimaging, here, we offer an up-to-date overview of the latest findings on structural, functional and metabolic correlates of cognitive impairment in adults with MS, focusing on the mechanisms sustaining damage accrual and on the identification of useful imaging markers of cognitive decline.
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Affiliation(s)
- Maria Petracca
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples “Federico II”, 80131 Naples, Italy; (M.P.); (M.M.); (A.C.); (V.B.M.)
| | - Giuseppe Pontillo
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy; (G.P.); (S.C.); (A.B.)
- Department of Electrical Engineering and Information Technology, University of Naples “Federico II”, 80125 Naples, Italy
| | - Marcello Moccia
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples “Federico II”, 80131 Naples, Italy; (M.P.); (M.M.); (A.C.); (V.B.M.)
| | - Antonio Carotenuto
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples “Federico II”, 80131 Naples, Italy; (M.P.); (M.M.); (A.C.); (V.B.M.)
| | - Sirio Cocozza
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy; (G.P.); (S.C.); (A.B.)
| | - Roberta Lanzillo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples “Federico II”, 80131 Naples, Italy; (M.P.); (M.M.); (A.C.); (V.B.M.)
| | - Arturo Brunetti
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy; (G.P.); (S.C.); (A.B.)
| | - Vincenzo Brescia Morra
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples “Federico II”, 80131 Naples, Italy; (M.P.); (M.M.); (A.C.); (V.B.M.)
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5
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Ontaneda D, Tallantyre EC, Raza PC, Planchon SM, Nakamura K, Miller D, Hersh C, Craner M, Bale C, Chaudhry B, Gunzler DD, Love TE, Gerry S, Coles A, Cohen JA, Evangelou N. Determining the effectiveness of early intensive versus escalation approaches for the treatment of relapsing-remitting multiple sclerosis: The DELIVER-MS study protocol. Contemp Clin Trials 2020; 95:106009. [DOI: 10.1016/j.cct.2020.106009] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 04/08/2020] [Accepted: 04/14/2020] [Indexed: 12/29/2022]
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6
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Ruano L, Branco M, Severo M, Sousa A, Castelo J, Araújo I, Pais J, Cerqueira J, Amato MP, Lunet N, Cruz VT. Tracking cognitive impairment in multiple sclerosis using the Brain on Track test: a validation study. Neurol Sci 2019; 41:183-191. [PMID: 31631230 DOI: 10.1007/s10072-019-04088-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 09/24/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND The accurate and regular monitoring cognitive performance in multiple sclerosis (MS) patients is critical to develop new prevention and management strategies for cognitive impairment (CI). The Brain on Track (BoT) test is a self-administered web-based tool developed for cognitive screening and monitoring. The objective of this study was to validate the use of the BoT in MS, by assessing its ability to distinguish between MS patients and matched controls, as well as detect CI among MS patients, by analysing its correlation with standard cognitive tests and its reliability and learning effects in repeatable use. METHODS The BoT was applied in 30 patients with MS consecutively selected and 30 age- and education-matched controls, first in a hospital clinic, under supervision, and then 1 week later from home. After these first two trials, MS patients repeated the test from home every 4 weeks for 3 months. A standard neuropsychological battery was also applied to MS patients at baseline. RESULTS The Cronbach's alpha was 0.89. Test scores were significantly different between MS patients and controls (Cohen's d = 0.87; p < 0.01). Among MS patients, scores were significantly lower in those with CI documented in the standard neuropsychological battery than in their cognitively preserved counterparts (Cohen's d = 2.0; p < 0.001). The BoT scores presented a good correlation with standard neuropsychological tests, particularly for information processing speed. Regarding test-retest reliability, 10/11 subtests presented two-way mixed single intraclass consistency correlation coefficients > 0.70. CONCLUSION The BoT showed good neuropsychological parameters in MS patients, endorsing the use of self-administered computerized tests in this setting.
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Affiliation(s)
- Luis Ruano
- Neurology Department, Centro Hospitalar de Entre Douro e Vouga, Santa Maria da Feira, Portugal. .,Departamento de Ciências da Saúde Pública e Forenses e Educação Médica Faculdade de Medicina da Universidade do Porto, Porto, Portugal. .,EPIUnit, Institute of Public Health, University of Porto, Rua das Taipas 135-139, 4050-600, Porto, Portugal.
| | - Mariana Branco
- Neurology Department, Centro Hospitalar de Entre Douro e Vouga, Santa Maria da Feira, Portugal.,Departamento de Ciências da Saúde Pública e Forenses e Educação Médica Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Milton Severo
- Departamento de Ciências da Saúde Pública e Forenses e Educação Médica Faculdade de Medicina da Universidade do Porto, Porto, Portugal.,EPIUnit, Institute of Public Health, University of Porto, Rua das Taipas 135-139, 4050-600, Porto, Portugal
| | - Andreia Sousa
- Neurology Department, Centro Hospitalar de Entre Douro e Vouga, Santa Maria da Feira, Portugal
| | - Juliana Castelo
- Neurology Department, Centro Hospitalar de Entre Douro e Vouga, Santa Maria da Feira, Portugal
| | - Isabel Araújo
- Neurology Department, Centro Hospitalar de Entre Douro e Vouga, Santa Maria da Feira, Portugal
| | - Joana Pais
- EPIUnit, Institute of Public Health, University of Porto, Rua das Taipas 135-139, 4050-600, Porto, Portugal
| | - João Cerqueira
- 2CA Braga, Braga, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal.,ICVS/3B's - PT Government Associate Laboratory, Braga, Guimarães, Portugal
| | - Maria Pia Amato
- Department NEUROFARBA, Section Neurosciences, University of Florence, Florence, Italy
| | - Nuno Lunet
- Departamento de Ciências da Saúde Pública e Forenses e Educação Médica Faculdade de Medicina da Universidade do Porto, Porto, Portugal.,EPIUnit, Institute of Public Health, University of Porto, Rua das Taipas 135-139, 4050-600, Porto, Portugal
| | - Vítor Tedim Cruz
- Neurology Department, Centro Hospitalar de Entre Douro e Vouga, Santa Maria da Feira, Portugal.,IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy.,Neurology Department, Hospital Pedro Hispano, Unidade Local de Saúde de Matosinhos, Sra. da Hora, Portugal
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7
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Raimo S, Spitaleri D, Trojano L, Santangelo G. Apathy as a herald of cognitive changes in multiple sclerosis: A 2-year follow-up study. Mult Scler 2019; 26:363-371. [DOI: 10.1177/1352458519828296] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Behavioral symptoms, such as apathy and depression, are common in multiple sclerosis (MS) but their relationship with cognitive and clinical characteristics often remains underinvestigated and not monitored over time. Objective: The aim of this study was to assess the evolution of cognitive profile of patients affected by MS in relation to apathy and depression using a 2-year follow-up study. Methods: Two years after the first assessment, 100 of 125 MS patients were re-evaluated on a comprehensive neuropsychological battery, and on specific scales for assessment of apathy (Apathy Evaluation Scale—Self-reported) and depression (Hamilton Depression Rating Scale). Results: After 2 years (T1), we found a relatively consistent prevalence of apathy (about 40%) and a reduction in prevalence of depression (from 44% to 30%). Higher level of apathy at baseline predicted the progressive cognitive changes at follow-up; and patients with apathy without depression (“pure” apathy) than patients without apathy had poorer performance on the interference task of the Stroop test assessing inhibitory control. Conclusion: The present results suggested that apathy in MS was associated with more severe executive dysfunctions (in particular cognitive control). Apathy rather than depression predicted cognitive impairment in MS over time.
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Affiliation(s)
- Simona Raimo
- Department of Medical and Surgical Sciences, University “Magna Graecia” of Catanzaro, Catanzaro, Italy/ Department of Psychology, University of Campania “Luigi Vanvitelli,” Caserta, Italy
| | - Daniele Spitaleri
- Neurology Unit “San Giuseppe Moscati,” Hospital Avellino, Avellino, Italy
| | - Luigi Trojano
- Department of Psychology, University of Campania “Luigi Vanvitelli,” Caserta, Italy/ Salvatore Maugeri Foundation, Scientific Institute of Telese Terme, Telese Terme, Italy
| | - Gabriella Santangelo
- Department of Psychology, University of Campania “Luigi Vanvitelli,” Caserta, Italy
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8
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Lammers F, Borchers F, Feinkohl I, Hendrikse J, Kant IMJ, Kozma P, Pischon T, Slooter AJC, Spies C, van Montfort SJT, Zacharias N, Zaborszky L, Winterer G. Basal forebrain cholinergic system volume is associated with general cognitive ability in the elderly. Neuropsychologia 2018; 119:145-156. [PMID: 30096414 PMCID: PMC6338214 DOI: 10.1016/j.neuropsychologia.2018.08.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 08/02/2018] [Accepted: 08/06/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVE At the present, it is unclear whether association of basal forebrain cholinergic system (BFCS) volume with cognitive performance exists in healthy as well as in cognitively impaired elderly subjects. Whereas one small study reported an association of BFCS volume with general cognitive ability 'g' in healthy ageing, effects on specific cognitive domains have only been found in subjects with cognitive decline. Here we aim to clarify whether an association of BFCS volume and 'g' is present in a larger sample of elderly subjects without obvious symptoms of dementia and whether similar associations can also be observed in specific cognitive domains. METHODS 282 pre-surgical patients from the BioCog study (aged 72.7 ± 4.9 years with a range of 65-87 years, 110 women) with a median MMSE score of 29 points (range 24-30) were investigated. BFCS and brain volume as well as brain parenchymal fraction were assessed in T1-weighted MR images using SPM12 and a probabilistic map of the BFCS. Neuropsychological assessment comprised the CANTAB cognitive battery and paper-and-pencil based tests. For data analysis, generalised linear models and quantile regression were applied. RESULTS Significant associations of BFCS volume with 'g' and several cognitive domains were found, with the strongest association found for 'g'. BFCS volume explained less variance in cognitive performance than brain volume. The association was not confounded by brain parenchymal fraction. Furthermore, the association of BFCS volume and 'g' was similar in high- and low-performers. CONCLUSION Our results extend previous study findings on BFCS volume associations with cognition in elderly subjects. Despite the observed associations of BFCS volume and cognitive performance, this association seems to reflect a more general association of brain volume and cognition. Accordingly, a specific association of BFCS volume and cognition in non-demented elderly subjects is questionable.
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Affiliation(s)
- Florian Lammers
- Department of Anaesthesiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany; Pharmaimage Biomarker Solutions GmbH, Robert-Rössle-Straße 10, 13125 Berlin, Germany.
| | - Friedrich Borchers
- Department of Anaesthesiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Insa Feinkohl
- Max-Delbrück-Center for Molecular Medicine in the Helmholtz Association (MDC), Robert-Rössle-Straße 10, 13125 Berlin, Germany
| | - Jeroen Hendrikse
- Department of Radiology and Brain Center Rudolf Magnus, University Medical Centre Utrecht, Utrecht University Heidelberglaan 100, 3584 CX Utrecht, Netherlands
| | - Ilse M J Kant
- Department of Intensive Care Medicine and Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University Heidelberglaan 100, 3584 CX Utrecht, Netherlands
| | - Petra Kozma
- Department of Anaesthesiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Tobias Pischon
- Max-Delbrück-Center for Molecular Medicine in the Helmholtz Association (MDC), Robert-Rössle-Straße 10, 13125 Berlin, Germany; Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Germany; MDC/BIH Biobank, Max-Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), and Berlin Institute of Health (BIH), Berlin, Germany
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University Heidelberglaan 100, 3584 CX Utrecht, Netherlands
| | - Claudia Spies
- Department of Anaesthesiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Simone J T van Montfort
- Department of Intensive Care Medicine and Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University Heidelberglaan 100, 3584 CX Utrecht, Netherlands
| | - Norman Zacharias
- Department of Anaesthesiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany; Pharmaimage Biomarker Solutions GmbH, Robert-Rössle-Straße 10, 13125 Berlin, Germany
| | - Laszlo Zaborszky
- Center for Molecular and Behavioral Neuroscience, Rutgers The State University of New Jersey, 197 University Avenue, Newark, NJ 07102, USA
| | - Georg Winterer
- Department of Anaesthesiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany; Pharmaimage Biomarker Solutions GmbH, Robert-Rössle-Straße 10, 13125 Berlin, Germany
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9
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Wybrecht D, Reuter F, Pariollaud F, Zaaraoui W, Le Troter A, Rico A, Confort-Gouny S, Soulier E, Guye M, Maarouf A, Ranjeva JP, Pelletier J, Audoin B. New brain lesions with no impact on physical disability can impact cognition in early multiple sclerosis: A ten-year longitudinal study. PLoS One 2017; 12:e0184650. [PMID: 29149177 PMCID: PMC5693435 DOI: 10.1371/journal.pone.0184650] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 08/28/2017] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE In early multiple sclerosis, although brain T2 lesions accrual are hallmark of the disease, only weak correlations were found between T2 lesions accrual and EDSS progression, the disability scale commonly used in multiple sclerosis studies. This may be related to the very poor sensitivity of EDSS to cognitive dysfunctions that may occur and progress from the first stage of the disease. In the present study, we aimed to demonstrate that cognitive deficits progress during the first ten years of MS and are significantly impacted by new T2 lesions. METHODS EDSS and extensive neuropsychological battery (22 measures) exploring memory, attention/speed of information processing and executive functions were assessed at baseline, Year 1 and Year 10 in 26 patients enrolled after their first clinical attack. To limit the bias of test-retest effect, only measures obtained at Year 1 and Year 10 were reported in the analysis. Raw scores of patients were transformed into z-scores using published normative data when available or scores of matched controls. Lesion probability mapping was used to assess the potential relationships between T2 lesions accumulation, cognitive decline and EDSS progression (P<0.05, FWE-corrected). RESULTS At Year 1, 27% of patients showed attention/speed of information processing deficits, 11.5% executive dysfunction and 11.5% memory impairment. During the follow-up, frequency and severity of executive dysfunction increased (from 11.5% of patients at Year 1 to 42% at Year 10, p<0.01) while no significant changes were evidenced for the other cognitive domains. Median EDSS increased from 0.5 [range: 0-3] at Year 1 to 2.5 [range: 0-6.5] at Year 10 (p<0.001). During the ten-year follow-up, lesions accumulation in the left cerebellum and semi-ovale centers was associated with EDSS progression. In contrast, most lesions accumulation in the frontal, parietal and temporal lobes were associated with cognitive decline but had no effect on EDSS progression. CONCLUSION The present study provides strong evidence that clinically silent T2 lesions impact cognition in early MS. In daily practice, early prevention of T2 lesions accrual may be useful to limit cognitive decline.
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Affiliation(s)
- D. Wybrecht
- Aix-Marseille Université, CNRS, CRMBM UMR 7339, Marseille, France
- Hôpital d’Instruction des Armées Sainte Anne, Toulon, France
- * E-mail:
| | - F. Reuter
- Aix-Marseille Université, CNRS, CRMBM UMR 7339, Marseille, France
- APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France
| | - F. Pariollaud
- Aix-Marseille Université, CNRS, CRMBM UMR 7339, Marseille, France
- APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France
| | - W. Zaaraoui
- Aix-Marseille Université, CNRS, CRMBM UMR 7339, Marseille, France
| | - A. Le Troter
- Aix-Marseille Université, CNRS, CRMBM UMR 7339, Marseille, France
| | - A. Rico
- Aix-Marseille Université, CNRS, CRMBM UMR 7339, Marseille, France
- APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France
| | - S. Confort-Gouny
- Aix-Marseille Université, CNRS, CRMBM UMR 7339, Marseille, France
| | - E. Soulier
- Aix-Marseille Université, CNRS, CRMBM UMR 7339, Marseille, France
| | - M. Guye
- Aix-Marseille Université, CNRS, CRMBM UMR 7339, Marseille, France
- APHM, Hôpital de la Timone, Pôle d’Imagerie Médicale, CEMEREM, Marseille, France
| | - A. Maarouf
- Aix-Marseille Université, CNRS, CRMBM UMR 7339, Marseille, France
- APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France
| | - J-P. Ranjeva
- Aix-Marseille Université, CNRS, CRMBM UMR 7339, Marseille, France
| | - J. Pelletier
- Aix-Marseille Université, CNRS, CRMBM UMR 7339, Marseille, France
- APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France
| | - B. Audoin
- Aix-Marseille Université, CNRS, CRMBM UMR 7339, Marseille, France
- APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France
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10
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Mollison D, Sellar R, Bastin M, Mollison D, Chandran S, Wardlaw J, Connick P. The clinico-radiological paradox of cognitive function and MRI burden of white matter lesions in people with multiple sclerosis: A systematic review and meta-analysis. PLoS One 2017; 12:e0177727. [PMID: 28505177 PMCID: PMC5432109 DOI: 10.1371/journal.pone.0177727] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 05/02/2017] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Moderate correlation exists between the imaging quantification of brain white matter lesions and cognitive performance in people with multiple sclerosis (MS). This may reflect the greater importance of other features, including subvisible pathology, or methodological limitations of the primary literature. OBJECTIVES To summarise the cognitive clinico-radiological paradox and explore the potential methodological factors that could influence the assessment of this relationship. METHODS Systematic review and meta-analysis of primary research relating cognitive function to white matter lesion burden. RESULTS Fifty papers met eligibility criteria for review, and meta-analysis of overall results was possible in thirty-two (2050 participants). Aggregate correlation between cognition and T2 lesion burden was r = -0.30 (95% confidence interval: -0.34, -0.26). Wide methodological variability was seen, particularly related to key factors in the cognitive data capture and image analysis techniques. CONCLUSIONS Resolving the persistent clinico-radiological paradox will likely require simultaneous evaluation of multiple components of the complex pathology using optimum measurement techniques for both cognitive and MRI feature quantification. We recommend a consensus initiative to support common standards for image analysis in MS, enabling benchmarking while also supporting ongoing innovation.
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Affiliation(s)
- Daisy Mollison
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Robin Sellar
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Mark Bastin
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Denis Mollison
- Department of Actuarial Mathematics and Statistics, Heriot-Watt University, Edinburgh, United Kingdom
| | - Siddharthan Chandran
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Joanna Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Peter Connick
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
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11
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Koçer B, Tezcan ME, Batur HZ, Haznedaroğlu Ş, Göker B, İrkeç C, Çetinkaya R. Cognition, depression, fatigue, and quality of life in primary Sjögren's syndrome: correlations. Brain Behav 2016; 6:e00586. [PMID: 28032007 PMCID: PMC5167008 DOI: 10.1002/brb3.586] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 08/12/2016] [Accepted: 08/23/2016] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE The aim of the present study was to investigate the prevalence and pattern of cognitive dysfunction observed in primary Sjögren's syndrome (PSS) and to examine the relationships between cognitive abilities, depression, fatigue, and quality of life. MATERIALS AND METHODS Thirty-two subjects with PSS were compared with 19 healthy controls on comprehensive neuropsychological, depression, fatigue, health state, and daily-life activities tests. RESULTS There was low performance in Clock Drawing, COWAT, Paced Auditory Serial Addition Test (PASAT), Colorless Word Reading (Stroop1) and Recognizing Colors (Stroop2) Patterns of STROOP test, SDLT, Auditory-Verbal Learning Test (AVLT), immediate and long-term verbal memory, Benton Judgment of Line Orientation Test (BJLOT), and in all the patterns of RCFT in PSS patients compared to the healthy control group (p < .05). It was observed an increased depression frequency and fatigue severity, impairment in health condition, and a decreased quality of life in PSS cases compared to the healthy controls (p < .05). All the depression, fatigue severity, and quality of life tests showed a significant positive correlation with each other (p < .05). A significant negative correlation between Clock Drawing and SF-36-BP (p = .031, r = -.382) and SF-36-GH (p = .027, r = -.392) was observed. CONCLUSIONS Clock Drawing, PASAT, and AVLT are very useful tests to determine the subclinical and clinical cognitive dysfunction to evaluate attention, information processing speed, executive functions, and short-term and long-term verbal memory in PSS patients. Depression and fatigue may not affect the neuropsychological tests performance.
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Affiliation(s)
- Belgin Koçer
- Department of Neurology Gazi University School of Medicine Ankara Turkey
| | | | - Hale Zeynep Batur
- Department of Neurology Gazi University School of Medicine Ankara Turkey
| | | | - Berna Göker
- Department of Rheumatology Gazi University School of Medicine Ankara Turkey
| | - Ceyla İrkeç
- Department of Neurology Gazi University School of Medicine Ankara Turkey
| | - Rümeysa Çetinkaya
- Department of Neurology Gazi University School of Medicine Ankara Turkey
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12
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Uher T, Vaneckova M, Sormani MP, Krasensky J, Sobisek L, Dusankova JB, Seidl Z, Havrdova E, Kalincik T, Benedict RHB, Horakova D. Identification of multiple sclerosis patients at highest risk of cognitive impairment using an integrated brain magnetic resonance imaging assessment approach. Eur J Neurol 2016; 24:292-301. [PMID: 27873386 DOI: 10.1111/ene.13200] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 09/25/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE While impaired cognitive performance is common in multiple sclerosis (MS), it has been largely underdiagnosed. Here a magnetic resonance imaging (MRI) screening algorithm is proposed to identify patients at highest risk of cognitive impairment. The objective was to examine whether assessment of lesion burden together with whole brain atrophy on MRI improves our ability to identify cognitively impaired MS patients. METHODS Of the 1253 patients enrolled in the study, 1052 patients with all cognitive, volumetric MRI and clinical data available were included in the analysis. Brain MRI and neuropsychological assessment with the Brief International Cognitive Assessment for Multiple Sclerosis were performed. Multivariable logistic regression and individual prediction analysis were used to investigate the associations between MRI markers and cognitive impairment. The results of the primary analysis were validated at two subsequent time points (months 12 and 24). RESULTS The prevalence of cognitive impairment was greater in patients with low brain parenchymal fraction (BPF) (<0.85) and high T2 lesion volume (T2-LV) (>3.5 ml) than in patients with high BPF (>0.85) and low T2-LV (<3.5 ml), with an odds ratio (OR) of 6.5 (95% CI 4.4-9.5). Low BPF together with high T2-LV identified in 270 (25.7%) patients predicted cognitive impairment with 83% specificity, 82% negative predictive value, 51% sensitivity and 75% overall accuracy. The risk of confirmed cognitive decline over the follow-up was greater in patients with high T2-LV (OR 2.1; 95% CI 1.1-3.8) and low BPF (OR 2.6; 95% CI 1.4-4.7). CONCLUSIONS The integrated MRI assessment of lesion burden and brain atrophy may improve the stratification of MS patients who may benefit from cognitive assessment.
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Affiliation(s)
- T Uher
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - M Vaneckova
- Department of Radiology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - M P Sormani
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - J Krasensky
- Department of Radiology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - L Sobisek
- Department of Statistics and Probability, University of Economics in Prague, Prague, Czech Republic
| | - J Blahova Dusankova
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Z Seidl
- Department of Radiology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - E Havrdova
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - T Kalincik
- Department of Medicine, University of Melbourne, Melbourne, Vic., Australia.,Department of Neurology, Royal Melbourne Hospital, Melbourne, Vic., Australia
| | - R H B Benedict
- Department of Neurology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - D Horakova
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
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13
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Kinner M, Hoepner R, Klotz P, Prehn C, Faissner S, Salmen A, Linker RA, Gold R, Chan A. Immunotherapy Improves Cognitive Function in Secondary Progressive Multiple Sclerosis. CNS Neurosci Ther 2016; 22:1019-1022. [PMID: 27739247 DOI: 10.1111/cns.12652] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 09/21/2016] [Accepted: 09/22/2016] [Indexed: 12/01/2022] Open
Affiliation(s)
- Markus Kinner
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Robert Hoepner
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Peter Klotz
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Christian Prehn
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Simon Faissner
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Anke Salmen
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany.,Department of Neurology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ralf A Linker
- Department of Neurology, University of Erlangen, Erlangen, Germany
| | - Ralf Gold
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Andrew Chan
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany.,Department of Neurology, Bern University Hospital, University of Bern, Bern, Switzerland
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14
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Paul F. Pathology and MRI: exploring cognitive impairment in MS. Acta Neurol Scand 2016; 134 Suppl 200:24-33. [PMID: 27580903 DOI: 10.1111/ane.12649] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2016] [Indexed: 01/24/2023]
Abstract
Cognitive impairment is a frequent symptom in people with multiple sclerosis, affecting up to 70% of patients. This article reviews the published association of cognitive dysfunction with neuroimaging findings. Cognitive impairment has been related to focal T2 hyperintense lesions, diffuse white matter damage and corical and deep gray matter atrophy. Focal lesions cannot sufficiently explain cognitive dysfunction in MS; microstructural tissue damage detectable by diffusion tensor imaging and gray matter atrophy are probably at least as relevant. Resting state functional magnetic resonance imaging is increasingly used to investigate the contribution of functional connectivity changes to cognitive function in MS. The fact that at least one third of MS patients are not overtly cognitively impaired despite significant radiographic tissue damage argues for protective factors (brain reserve, cognitive reserve) that require further clarification. It is concluded that the reported correlations between imaging findings and cognitive function do not imply causality. Well conceived and sufficiently powered longitudinal studies are lacking. Such studies would help unravel protective mechanisms against cogniitve decline and identify suitable imaging techniques to monitor cognitive function in individual patients with MS.
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Affiliation(s)
- F. Paul
- NeuroCure Clinical Research Center and Clinical and Experimental Multiple Sclerosis Research Center; Department of Neurology; Charité - Universitaetsmedizin Berlin; Berlin Germany
- Experimental and Clinical Research Center; Max Delbrueck Center for Molecular Medicine and Charité - Universitaetsmedizin Berlin; Berlin Germany
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15
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Fox RJ, Coffey CS, Cudkowicz ME, Gleason T, Goodman A, Klawiter EC, Matsuda K, McGovern M, Conwit R, Naismith R, Ashokkumar A, Bermel R, Ecklund D, Koepp M, Long J, Natarajan S, Ramachandran S, Skaramagas T, Thornell B, Yankey J, Agius M, Bashir K, Cohen B, Coyle P, Delgado S, Dewitt D, Flores A, Giesser B, Goldman M, Jubelt B, Lava N, Lynch S, Miravalle A, Moses H, Ontaneda D, Perumal J, Racke M, Repovic P, Riley C, Severson C, Shinnar S, Suski V, Weinstock-Gutman B, Yadav V, Zabeti A. Design, rationale, and baseline characteristics of the randomized double-blind phase II clinical trial of ibudilast in progressive multiple sclerosis. Contemp Clin Trials 2016; 50:166-77. [PMID: 27521810 DOI: 10.1016/j.cct.2016.08.009] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 08/02/2016] [Accepted: 08/09/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Primary and secondary progressive multiple sclerosis (MS), collectively called progressive multiple sclerosis (PMS), is characterized by gradual progression of disability. The current anti-inflammatory treatments for MS have little or no efficacy in PMS in the absence of obvious active inflammation. Optimal biomarkers for phase II PMS trials is unknown. Ibudilast is an inhibitor of macrophage migration inhibitor factor and phosphodiesterases-4 and -10 and exhibits possible neuroprotective properties. The goals of SPRINT-MS study are to evaluate the safety and efficacy of ibudilast in PMS and to directly compare several imaging metrics for utility in PMS trials. METHODS SPRINT-MS is a randomized, placebo-controlled, phase II trial of ibudilast in patients with PMS. Eligible subjects were randomized 1:1 to receive either ibudilast (100mg/day) or placebo for 96weeks. Imaging is conducted every 24weeks for whole brain atrophy, magnetization transfer ratio, diffusion tensor imaging, cortical brain atrophy, and retinal nerve fiber layer thickness. Clinical outcomes include neurologic disability and patient reported quality of life. Safety assessments include laboratory testing, electrocardiography, and suicidality screening. RESULTS A total of 331 subjects were enrolled, of which 255 were randomized onto active study treatment. Randomized subjects were 53.7% female and mean age 55.7 (SD 7.3) years. The last subject is projected to complete the study in May 2017. CONCLUSION SPRINT-MS is designed to evaluate the safety and efficacy of ibudilast as a treatment for PMS while simultaneously validating five different imaging biomarkers as outcome metrics for use in future phase II proof-of-concept PMS trials.
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Affiliation(s)
- Robert J Fox
- Cleveland Clinic, Neurological Institute, Cleveland, OH, United States.
| | - Christopher S Coffey
- Data Coordinating Center, NeuroNEXT, University of Iowa, Iowa City, IA, United States
| | - Merit E Cudkowicz
- Clinical Coordinating Center, NeuroNEXT, Harvard Partners, Boston, MA, United States
| | | | - Andrew Goodman
- University of Rochester Medical Center, Rochester, NY, United States
| | | | | | - Michelle McGovern
- Clinical Coordinating Center, NeuroNEXT, Harvard Partners, Boston, MA, United States
| | - Robin Conwit
- National Institutes of Neurological Disease and Stroke, Bethesda, MD, United States
| | - Robert Naismith
- Washington University School of Medicine, St. Louis, MO, United States
| | - Akshata Ashokkumar
- Data Coordinating Center, NeuroNEXT, University of Iowa, Iowa City, IA, United States
| | - Robert Bermel
- Cleveland Clinic, Neurological Institute, Cleveland, OH, United States
| | - Dixie Ecklund
- Data Coordinating Center, NeuroNEXT, University of Iowa, Iowa City, IA, United States
| | - Maxine Koepp
- Data Coordinating Center, NeuroNEXT, University of Iowa, Iowa City, IA, United States
| | - Jeffrey Long
- Data Coordinating Center, NeuroNEXT, University of Iowa, Iowa City, IA, United States
| | - Sneha Natarajan
- Cleveland Clinic, Neurological Institute, Cleveland, OH, United States
| | | | - Thomai Skaramagas
- Cleveland Clinic, Neurological Institute, Cleveland, OH, United States
| | - Brenda Thornell
- Clinical Coordinating Center, NeuroNEXT, Harvard Partners, Boston, MA, United States
| | - Jon Yankey
- Data Coordinating Center, NeuroNEXT, University of Iowa, Iowa City, IA, United States
| | - Mark Agius
- University of California at Davis, Sacramento, CA; currently at Barrows Neurological Institute, Phoenix, AZ, United States
| | - Khurram Bashir
- University of Alabama at Birmingham, Birmingham, AL, United States
| | - Bruce Cohen
- Northwestern University, Chicago, IL, United States
| | - Patricia Coyle
- State University of New York, Stony Brook, NY, United States
| | - Silvia Delgado
- University of Miami School of Medicine, Miami, FL, United States
| | - Dana Dewitt
- University of Utah, Salt Lake City, UT, United States
| | - Angela Flores
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Barbara Giesser
- University of California at Los Angeles, Los Angeles, CA, United States
| | - Myla Goldman
- University of Virginia at Charlottesville, Charlottesville, VA, United States
| | - Burk Jubelt
- State University of New York Upstate Medical University, Syracuse, NY, United States
| | - Neil Lava
- Emory University, Atlanta, GA, United States
| | - Sharon Lynch
- University of Kansas Medical Center, Kansas City, KS, United States
| | | | - Harold Moses
- Vanderbilt University, Nashville, TN, United States
| | - Daniel Ontaneda
- Cleveland Clinic, Neurological Institute, Cleveland, OH, United States
| | - Jai Perumal
- Weill Cornell Medical College, New York, NY, United States
| | - Michael Racke
- The Ohio State University, Columbus, OH, United States
| | - Pavle Repovic
- Swedish Medical Center at Seattle, Seattle, WA, United States
| | - Claire Riley
- Columbia University Medical Center, New York, NY, United States
| | | | | | - Valerie Suski
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | | | - Vijayshree Yadav
- Oregon Health and Science University, Portland, OR, United States
| | - Aram Zabeti
- University of Cincinnati, Cincinnati, OH, United States
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16
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Tezcan ME, Kocer EB, Haznedaroglu S, Sonmez C, Mercan R, Yucel AA, Irkec C, Bitik B, Goker B. Primary Sjögren's syndrome is associated with significant cognitive dysfunction. Int J Rheum Dis 2016; 19:981-988. [PMID: 27455357 DOI: 10.1111/1756-185x.12912] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
AIM Cognitive dysfunction is a neurologic manifestation in primary Sjögren syndrome (PSS). On the other hand, several antibodies are related to cognitive dysfunction. The aim of this study is to assess the cognitive dysfunction of PSS patients via detailed neurologic tests. Moreover, its associations with antibodies were also evaluated. METHOD Twenty-eight female patients with PSS and 17 healthy controls comprised the study groups. Short-term memory, long-term memory, verbal learning, visual memory, visual spatial perception, attention, verbal frequency function, executive functions and information processing speed were evaluated with neurologic tests in both of the study groups. Furthermore, anti-N-methyl-D-aspartate (NMDA) type anti-glutamate-receptor antibody, anti-ribosomal-p and antiganglioside antibodies were assessed in the study groups. RESULTS The attention, data processing speed, verbal learning, short-term verbal memory and visuo-spatial perception performances were lower in the patients with PSS when compared to the healthy controls. The difference reached statistical significance in Paced Auditory Serial Addition Test (P < 0.01), Serial Digit Learning Test (P < 0.01), clock drawing (P = 0.03), Auditory Verbal Learning Test immediate verbal memory (P = 0.01) and Benton Judgement of Line Orientation Test (P = 0.03). Even if antiganglioside antibodies were more likely to be present in the PSS group when compared to the healthy controls, no relationship was found between its positivity and cognitive dysfunction. CONCLUSION Results of this study suggest that cognitive dysfunction is quite prevalent in PSS patients without being associated with studied antibodies.
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Affiliation(s)
- Mehmet Engin Tezcan
- Department of Rheumatology, Lutfi Kirdar Kartal Education and Training Hospital, Ankara, Turkey.
| | - Emine Belgin Kocer
- Department of Neurology, Gazi University School of Medicine, Ankara, Turkey
| | | | - Cemile Sonmez
- Public Health Institution of Turkey, Gazi University School of Medicine, Ankara, Turkey
| | - Ridvan Mercan
- Department of Rheumatology, Gazi University School of Medicine, Ankara, Turkey
| | - Aysegul Atak Yucel
- Department of Immunology, Gazi University School of Medicine, Ankara, Turkey
| | - Ceyla Irkec
- Department of Neurology, Gazi University School of Medicine, Ankara, Turkey
| | - Berivan Bitik
- Department of Rheumatology, Gazi University School of Medicine, Ankara, Turkey
| | - Berna Goker
- Department of Rheumatology, Gazi University School of Medicine, Ankara, Turkey
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17
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Lazeron RHC, de Sonneville LMJ, Scheltens P, Polman CH, Barkhof F. Cognitive slowing in multiple sclerosis is strongly associated with brain volume reduction. Mult Scler 2016; 12:760-8. [PMID: 17263004 DOI: 10.1177/1352458506070924] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction In this study, we investigated the influence of in vivo disease pathology (measured as magnetic resonance imaging (MRI) lesion load and brain volume reduction) on cognitive functioning, especially the speed of processing, in multiple sclerosis (MS) patients. Since MS is characterized by cognitive slowing rather than impaired accuracy, we used the Amsterdam Neuropsychological Tasks (ANT) program, a computerized test proven to be very sensitive to cognitive slowing in MS patients. Methods Thirty-two patients performed the ANT and underwent MRI scanning. Using the ANT computerized tests, we investigated focused, divided, sustained attention, executive function and psychomotor function, and examined associations of speed, speed fluctuation and accuracy of performance of these tests with MRI lesion load and brain volume parameters. Results A decrease in the speed of processing and response speed stability, and a decrease in psychomotor accuracy and stability were clearly associated with less brain volume, and with higher lesion loads, in particular at frontal and occipital areas. Correlations with brain volume reduction were found for all domains, except for visuo-spatial processing. In particular, speed and speed fluctuation scores correlated with brain volume reduction, while accuracy of performance, in general, did not correlate. Only some test speed scores and speed fluctuation scores correlated with lesion load measurements. Conclusion This study shows that, in MS patients, accuracy of processing is not compromised unless high working memory demands are involved. Problems in neurocognitive functioning in MS are mainly modulated by speed and stability of speed processing, in particular when attention-demanding controlled information processing is required. Abnormalities in these domains are most strongly associated with brain volume loss, confirming that pathology beyond focal lesions is important in MS.
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Affiliation(s)
- R H C Lazeron
- Department of Neurology, Vrije Universiteit Medical Center, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands.
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18
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Brass SD, Benedict RHB, Weinstock-Guttman B, Munschauer F, Bakshi R. Cognitive impairment is associated with subcortical magnetic resonance imaging grey matter T2 hypointensity in multiple sclerosis. Mult Scler 2016; 12:437-44. [PMID: 16900757 DOI: 10.1191/135248506ms1301oa] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Grey matter hypointensity on T2-weighted magnetic resonance imaging (MRI) scans, suggesting iron deposition, has been described in multiple sclerosis (MS) and is related to physical disability, disease course and brain atrophy. We tested the hypothesis that subcortical grey matter T2 hypointensity is related to cognitive impairment after adjusting for the effect of MRI lesion and atrophy measures. We studied 33 patients with MS and 14 healthy controls. Normalized T2 signal intensity in the caudate, putamen, globus pallidus and thalamus, total brain T1-hypointense lesion volume (T1LV), fluid-attenuated inversion-recovery-hyperintense lesion volume (FLLV) and brain parenchymal fraction (BPF) were obtained quantitatively. A neuropsychological composite score (NCS) encompassed new learning, attention, working memory, spatial processing and executive function. In each of the regions of interest, the normalized T2 intensity was lower in the MS versus control group (all P <0.001). Regression modelling tested the relative association between all MRI variables and NCS. Globus pallidus T2 hypointensity was the only variable selected in the final model ( R2 = 0.301, P = 0.007). Pearson correlations between MRI and NCS were T1LV: r = -0.319; FLLV: r = -0.347; BPF: r = 0.374; T2 hypointensity of the caudate: r = 0.305; globus pallidus: r = 0.395; putamen: r = 0.321; and thalamus: r = 0.265. Basal ganglia T2 hypointensity and BPF demonstrated the strongest associations with cognitive impairment on individual cognitive subtests. Subcortical grey matter T2 hypointensity is related to cognitive impairment in MS, supporting the clinical relevance of T2 hypointensity as a biological marker of MS tissue damage. These data implicate a role for basal ganglia iron deposition in neuropsychological dysfunction.
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Affiliation(s)
- S D Brass
- Department of Neurology, Center for Neurological Imaging, Partners Multiple Sclerosis Center, Brigham & Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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19
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Lynch SG, Parmenter BA, Denney DR. The association between cognitive impairment and physical disability in multiple sclerosis. Mult Scler 2016; 11:469-76. [PMID: 16042232 DOI: 10.1191/1352458505ms1182oa] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Background: The association between cognitive impairment and physical disability was examined in a larger, more representative sample of patients with multiple sclerosis (MS) than in previous studies. Method: Two hundred and fifty-three patients attending an MS clinic were assessed with respect to physical disability using the Expanded Disability Status Scale and cognitive impairment using a battery of neuropsychological tests. Results: Physical disability correlated with duration of disease; cognitive impairment did not. Virtually all measures derived from the cognitive battery were significantly correlated with physical disability. Three measures of speeded information processing and one involving delayed recall of verbal material were unique predictors of disability status. The relationship between cognitive impairment and physical disability was equivalent for patients with shorter (<3 years) versus longer (>10 years) disease duration. Cognitive impairment correlated with the rate of disability progression as reflected by the progression index. Conclusion: Cognitive impairment is more closely associated with physical disability than most previous studies indicate. This relationship appears to be stable throughout the duration of MS, although this conclusion is qualified by the cross-sectional design of the study. Further attention should be paid to cognitive impairment as a possible predictor of the rate of patients’ physical decline.
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Affiliation(s)
- Sharon G Lynch
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS 66160, USA
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20
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Gerstenecker A, Martin R, Marson DC, Bashir K, Triebel KL. Introducing demographic corrections for the 10/36 Spatial Recall Test. Int J Geriatr Psychiatry 2016; 31:406-11. [PMID: 26270773 PMCID: PMC4752917 DOI: 10.1002/gps.4346] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 06/09/2015] [Accepted: 07/21/2015] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The 10/36 Spatial Recall Test is a measure of visuospatial memory and has been recommended for inclusion when administering a brief cognitive assessment to patients with multiple sclerosis by multiple groups. However, a notable limitation of the measure includes a lack of normative data with demographic corrections. Thus, the primary objective of the current study was to examine demographic influences on the 10/36 Spatial Recall Test and to introduce demographically corrected normative data for the instrument. METHODS Data were collected from 116 participants over the age of 50 years. All study participants were free of any neurologic disease or disorder and classified as cognitively intact by a consensus conference team that was comprised of neurologists and neuropsychologists. All study participants were administered a neuropsychological evaluation that included the 10/36 Spatial Recall Test Version A at the baseline visit. RESULTS 10/36 Spatial Recall Test scores were affected by age, education, and race. Gender effects were not observed. Given these effects, regression equations were used to correct for the effects of demographic variables. The z-scores obtained from these corrections were not significantly influenced by demographical variables. CONCLUSION The demographic corrections introduced in this paper offer the possibility to enhance the clinical utility of the 10/36 Spatial Recall Test.
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Affiliation(s)
- Adam Gerstenecker
- Department of Neurology, Division of Neuropsychology, University of Alabama at Birmingham, USA
| | - Roy Martin
- Department of Neurology, Division of Neuropsychology, University of Alabama at Birmingham, USA
| | - Daniel C. Marson
- Department of Neurology, Division of Neuropsychology, University of Alabama at Birmingham, USA
| | - Khurram Bashir
- Department of Neurology, Division of Neuroimmunology and Multiple Sclerosis, University of Alabama at Birmingham, USA
| | - Kristen L. Triebel
- Department of Neurology, Division of Neuropsychology, University of Alabama at Birmingham, USA
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21
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Roman CAF, Arnett PA. Structural brain indices and executive functioning in multiple sclerosis: A review. J Clin Exp Neuropsychol 2016; 38:261-74. [DOI: 10.1080/13803395.2015.1105199] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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22
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Longitudinal associations between MRI and cognitive changes in very early MS. Mult Scler Relat Disord 2016; 5:47-52. [DOI: 10.1016/j.msard.2015.10.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 09/17/2015] [Accepted: 10/26/2015] [Indexed: 11/18/2022]
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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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Rocca MA, Amato MP, De Stefano N, Enzinger C, Geurts JJ, Penner IK, Rovira A, Sumowski JF, Valsasina P, Filippi M. Clinical and imaging assessment of cognitive dysfunction in multiple sclerosis. Lancet Neurol 2015; 14:302-17. [PMID: 25662900 DOI: 10.1016/s1474-4422(14)70250-9] [Citation(s) in RCA: 363] [Impact Index Per Article: 40.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
In patients with multiple sclerosis (MS), grey matter damage is widespread and might underlie many of the clinical symptoms, especially cognitive impairment. This relation between grey matter damage and cognitive impairment has been lent support by findings from clinical and MRI studies. However, many aspects of cognitive impairment in patients with MS still need to be characterised. Standardised neuropsychological tests that are easy to administer and sensitive to disease-related abnormalities are needed to gain a better understanding of the factors affecting cognitive performance in patients with MS than exists at present. Imaging measures of the grey matter are necessary, but not sufficient to fully characterise cognitive decline in MS. Imaging measures of both lesioned and normal-appearing white matter lend support to the hypothesis of the existence of an underlying disconnection syndrome that causes clinical symptoms to trigger. Findings on cortical reorganisation support the contribution of brain plasticity and cognitive reserve in limiting cognitive deficits. The development of clinical and imaging biomarkers that can monitor disease development and treatment response is crucial to allow early identification of patients with MS who are at risk of cognitive impairment.
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Affiliation(s)
- Maria A Rocca
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Department of Neurology, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Maria P Amato
- Department of Neurofarba, Section of Neurosciences, University of Florence, Florence, Italy
| | - Nicola De Stefano
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | | | - Jeroen J Geurts
- Department of Anatomy and Neuroscience, Section of Clinical Neuroscience, VU University Medical Centre, VUmc Multiple Sclerosis Centre Amsterdam, Amsterdam, Netherlands
| | - Iris-K Penner
- University and University Children's Hospital Basel, Cognitive Psychology and Methodology and Division of Paediatric Neurology and Developmental Medicine, Basel, Switzerland
| | - Alex Rovira
- Magnetic Resonance Unit, Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - James F Sumowski
- Neuropsychology and Neuroscience, Kessler Foundation Research Center, West Orange, NJ, USA
| | - Paola Valsasina
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Filippi
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Department of Neurology, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy.
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25
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Cognitive dysfunction in patients with multiple sclerosis treated with different types of interferon beta: A randomized clinical trial. J Neurol Sci 2014; 342:16-20. [DOI: 10.1016/j.jns.2014.01.038] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2013] [Revised: 01/13/2014] [Accepted: 01/27/2014] [Indexed: 11/24/2022]
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26
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Gray V, Arnett P. Aging with multiple sclerosis: cognitive, emotional and neuropathological considerations. Neurodegener Dis Manag 2014; 4:187-94. [DOI: 10.2217/nmt.14.12] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Although individuals aging with multiple sclerosis (MS) can experience a compounding of their symptoms, in some circumstances they become more adept at coping with aging-related changes. Fortunately, individuals aging with MS often adjust well to aging, particularly if they have sufficient social support. They also do not appear to show accelerated rates of cognitive decline, and rates of some neuropathological changes have been shown to normalize compared with those seen in normal aging. Results are mixed as to whether older MS patients have higher rates of depression.
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Correlations between MRI and Information Processing Speed in MS: A Meta-Analysis. Mult Scler Int 2014; 2014:975803. [PMID: 24795824 PMCID: PMC3984845 DOI: 10.1155/2014/975803] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Revised: 01/25/2014] [Accepted: 02/09/2014] [Indexed: 12/03/2022] Open
Abstract
Objectives. To examine relationships between conventional MRI measures and the paced auditory serial addition test (PASAT) and symbol digit modalities test (SDMT). Methods. A systematic literature review was conducted. Included studies had ≥30 multiple sclerosis (MS) patients, administered the SDMT or PASAT, and measured T2LV or brain atrophy. Meta-analysis of MRI/information processing speed (IPS) correlations, analysis of MRI/IPS significance tests to account for reporting bias, and binomial testing to detect trends when comparing correlation strengths of SDMT versus PASAT and T2LV versus atrophy were conducted. Results. The 39 studies identified frequently reported only significant correlations, suggesting reporting bias. Direct meta-analysis was only feasible for correlations between SDMT and T2LV (r = −0.45, P < 0.001) and atrophy in patients with mixed-MS subtypes (r = −0.54, P < 0.001). Familywise Holm-Bonferroni testing found that selective reporting was not the source of at least half of significant results reported. Binomial tests (P = 0.006) favored SDMT over PASAT in strength of MRI correlations. Conclusions. A moderate-to-strong correlation exists between impaired IPS and MRI in mixed MS populations. Correlations with MRI were stronger for SDMT than for PASAT. Neither heterogeneity among populations nor reporting bias appeared to be responsible for these findings.
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Hankomäki E, Multanen J, Kinnunen E, Hämäläinen P. The progress of cognitive decline in newly diagnosed MS patients. Acta Neurol Scand 2014; 129:184-91. [PMID: 23773012 DOI: 10.1111/ane.12161] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Cognitive impairment occurs in multiple sclerosis already in the early stages of the disease. Less is known about the evolution of cognitive decline, especially in newly diagnosed MS patients. The results of existing studies are contradictory in that both cognitive preservation and progressive deterioration have been reported. The purpose of this study was to examine how cognitive impairment evolves over time in the early stages of MS. MATERIAL AND METHODS At baseline, the participants were 36 newly diagnosed MS patients and 37 controls. A group of 30 patients were followed longitudinally at a mean test-retest interval of 6.1 years. The test battery covered attention, information processing, memory and learning, verbal and motor functions and reasoning. RESULTS There was a significant decline in divided attention (dual task) and information-processing speed (SDMT) at follow-up, but no significant deterioration in overall cognitive performance. CONCLUSIONS Overall cognitive functioning remained quite stable during the 6-year follow-up, whereas divided attention and processing speed deteriorated. However, deterioration in performance on the SDMT and the dual task does not seem to indicate more extensive cognitive deterioration. Given the impact of cognitive impairment on patients' quality of life, early detection of its occurrence in MS is extremely important.
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Affiliation(s)
- E. Hankomäki
- Ludus-Neuropsychology; Helsinki Finland
- Department of Neurology; Hyvinkää hospital; Hyvinkää Finland
| | - J. Multanen
- Department of Neurology; Hyvinkää hospital; Hyvinkää Finland
| | - E. Kinnunen
- Department of Neurology; Hyvinkää hospital; Hyvinkää Finland
| | - P. Hämäläinen
- Masku Neurological Rehabilitation Centre; Masku Finland
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29
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Amato MP, Zipoli V. Cognitive dysfunction in multiple sclerosis: current approaches to clinical management. Expert Rev Neurother 2014; 2:731-42. [DOI: 10.1586/14737175.2.5.731] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Tekok-Kilic A, Benedict RHB, Zivadinov R. Update on the relationships between neuropsychological dysfunction and structural MRI in multiple sclerosis. Expert Rev Neurother 2014; 6:323-31. [PMID: 16533137 DOI: 10.1586/14737175.6.3.323] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Multiple sclerosis (MS) is a chronic inflammatory disease of the CNS, characterized by demyelination and neurodegeneration. Besides the sensory and motor deficits that are the hallmark of this disease, approximately 50% of MS patients are cognitively impaired. Over the years, structural neuroimaging has been used widely in MS patients for both diagnostic and research purposes. Various conventional and nonconventional magnetic resonance imaging (MRI) measures have provided important information about the degree and mechanisms of cerebral pathology, and these measures correlate with cognitive and affective disturbances. In this article, recent contributions to the literature regarding the correlation between MRI and neuropsychological function in MS are reviewed.
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Affiliation(s)
- Ayda Tekok-Kilic
- Department of Neurology, State University of New York, Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY, USA.
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31
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Toosy A, Ciccarelli O, Thompson A. Symptomatic treatment and management of multiple sclerosis. HANDBOOK OF CLINICAL NEUROLOGY 2014; 122:513-562. [PMID: 24507534 DOI: 10.1016/b978-0-444-52001-2.00023-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The range of symptoms which occur in multiple sclerosis (MS) can have disabling functional consequences for patients and lead to significant reductions in their quality of life. MS symptoms can also interact with each other, making their management challenging. Clinical trials aimed at identifying symptomatic therapies have generally been poorly designed and have tended to be underpowered. Therefore, the evidence base for the management of MS symptoms with pharmacologic therapies is not strong and tends to rely upon open-label studies, case reports, and clinical trials with small numbers of patients and poorly validated clinical outcome measures. Recently, there has been a growing interest in the management of MS symptoms with pharmacologic treatments, and better-designed, randomized, double-blind, controlled trials have been reported. This chapter will describe the evidence base predominantly behind the various pharmacologic approaches to the management of MS symptoms, which in most, if not all, cases, requires multidisciplinary input. Drugs routinely recommended for individual symptoms and new therapies, which are currently in the development pipeline, will be reviewed. More interventional therapies related to symptoms that are refractory to pharmacotherapy will also be discussed, where relevant.
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Affiliation(s)
- Ahmed Toosy
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London, UK
| | - Olga Ciccarelli
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London, UK
| | - Alan Thompson
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London, UK.
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Marin SE, Banwell BB, Till C. Cognitive trajectories in 4 patients with pediatric-onset multiple sclerosis: serial evaluation over a decade. J Child Neurol 2013; 28:1577-86. [PMID: 23143723 DOI: 10.1177/0883073812465010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cognitive dysfunction is common in pediatric-onset multiple sclerosis, but long-term data on cognitive maturation in these patients are sparse. We report the clinical features and cognitive trajectories in 4 pediatric-onset multiple sclerosis patients who were 10 years or younger at first attack and were followed between 1998 and 2010. Relapses in all 4 patients were frequent early in the disease and became infrequent or absent over time. Declines on neuropsychological testing were most pronounced on measures of processing speed, specifically visuomotor speed, and executive control requiring mental sequencing and set shifting, whereas global intellectual ability and phonemic fluency remained stable or improved over time. These case studies demonstrate a negative impact of multiple sclerosis on cognitive development in the long term and suggest that continued observation into adulthood is required to appreciate the vocational consequences of pediatric-onset multiple sclerosis.
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Affiliation(s)
- Samantha E Marin
- 1Department of Pediatric Neurology, McMaster Children's Hospital, Hamilton, Ontario, Canada
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33
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Cognition, Cognitive Dysfunction, and Cognitive Rehabilitation in Multiple Sclerosis. Phys Med Rehabil Clin N Am 2013; 24:663-72. [DOI: 10.1016/j.pmr.2013.06.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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34
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Exploration of the relationships between regional grey matter atrophy and cognition in multiple sclerosis. Brain Imaging Behav 2012; 8:378-86. [DOI: 10.1007/s11682-012-9170-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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35
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Brissart H, Morele E, Baumann C, Debouverie M. Verbal episodic memory in 426 multiple sclerosis patients: impairment in encoding, retrieval or both? Neurol Sci 2012; 33:1117-23. [DOI: 10.1007/s10072-011-0915-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Accepted: 12/20/2011] [Indexed: 01/20/2023]
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36
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Benedict RHB, Zivadinov R. Risk factors for and management of cognitive dysfunction in multiple sclerosis. Nat Rev Neurol 2011; 7:332-42. [PMID: 21556031 DOI: 10.1038/nrneurol.2011.61] [Citation(s) in RCA: 251] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Cognitive impairment is common in multiple sclerosis (MS), especially when assessed by neuropsychological tests that emphasize mental processing speed, episodic memory, and some aspects of executive function. In this Review, we question why some MS patients develop severe impairment in cognitive abilities, while cognitive ability remains intact in others. We find that the heterogeneity in neuropsychological presentation among patients with MS reflects the influence of many factors, including genetics, sex, intelligence, disease course, comorbid neuropsychiatric illness, and health behaviors. Neuropsychological deficits are also robustly correlated with brain MRI metrics. Male patients with early evidence of cerebral gray matter atrophy are most prone to impairment, whereas high premorbid intelligence improves the neuropsychological prognosis. Routine evaluation of cognition is useful for helping patients to navigate problems related to activities of daily living and work disability and, if reliable methods are employed, cognitive decline can be detected and included among the many clinical signs of disease progression or treatment failure. Pharmacological treatments for neuropsychological impairment are on the horizon, although presently no firm medical indications exist for the condition.
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Affiliation(s)
- Ralph H B Benedict
- Department of Neurology, Suite D6, Buffalo General Hospital, State University of New York at Buffalo, 100 High Street, Buffalo, NY 14203, USA.
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37
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Horowski S, Zettl UK, Benecke R, Walter U. Sonographic basal ganglia alterations are related to non-motor symptoms in multiple sclerosis. J Neurol 2010; 258:195-202. [DOI: 10.1007/s00415-010-5707-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Accepted: 08/09/2010] [Indexed: 10/19/2022]
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38
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Amato MP, Portaccio E, Goretti B, Zipoli V, Iudice A, Della Pina D, Malentacchi G, Sabatini S, Annunziata P, Falcini M, Mazzoni M, Mortilla M, Fonda C, De Stefano N. Relevance of cognitive deterioration in early relapsing-remitting MS: a 3-year follow-up study. Mult Scler 2010; 16:1474-82. [PMID: 20729256 DOI: 10.1177/1352458510380089] [Citation(s) in RCA: 139] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To assess longitudinally cognitive functioning in relapsing-remitting multiple sclerosis (RRMS) patients and its relationship with clinical and MRI variables. METHODS Early RRMS patients and matched healthy controls were assessed in parallel in three testing sessions over 3 years, using the Rao's Brief Repeatable Battery of Neuropsychological Tests. Patients also underwent an MRI analysis of T2-weighted lesion volume (T2LV), number of gadolinium-enhanced lesions and whole brain atrophy. Forty-nine RRMS patients (mean age 36.9 ± 8.9 years; mean disease duration 2.9 ± 1.7 years, mean Expanded Disability Status Scale, 1.7 ± 0.7) and 56 healthy controls were recruited. RESULTS At baseline, cognitive impairment was detected in 15 patients (30.6%). After 3 years, cognitive functioning worsened in the 29.3% of patients, whereas Expanded Disability Status Scale progression was observed in only three patients. The most sensitive test to detect cognitive deterioration over time was the Symbol Digit Modalities Test (SDMT). Only the presence of moderate cognitive impairment at baseline predicted further cognitive deterioration (p = 0.03). Among MRI variables, T2LV showed a weak to moderate relationship with some cognitive tasks. CONCLUSIONS Over a 3-year period cognitive deterioration can be expected in approximately one-third of MS patients with relatively short disease duration. The SDMT is particularly suitable for longitudinal assessment of MS-related cognitive changes.
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Affiliation(s)
- Maria P Amato
- Department of Neurology, University of Florence, Italy.
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39
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Kargiotis O, Paschali A, Messinis L, Papathanasopoulos P. Quality of life in multiple sclerosis: effects of current treatment options. Int Rev Psychiatry 2010; 22:67-82. [PMID: 20233115 DOI: 10.3109/09540261003589521] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Multiple sclerosis is the most common non-traumatic neurodegenerative disease in adults. Most of the patients present with both physical and mental deficits which reflect the dissemination of the lesions in the central nervous system, produced by the inflammatory process. The incomplete recovery after relapses, the accumulation of new deficits and the progressive nature of the condition interfere with daily activities of individuals and have a negative impact on their well-being. Indeed, studies show that quality of life measurements are constantly lower in patients with multiple sclerosis. Estimation of health-related quality of life is being increasingly recognized as necessary when analysing the effectiveness of treatment modalities and for the follow up of patients with chronic diseases such as multiple sclerosis. Current immunomodulatory interventions that are shown to reduce the frequency of relapses and delay disease progression might also have a positive effect on quality of life measurements. Additive pharmacological agents that target cognitive impairments and common symptoms such as depression, fatigue and pain, along with life-style modifications and rehabilitation programmes are also important for the appropriate management that aims to improve quality of life.
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Affiliation(s)
- Odysseas Kargiotis
- Department of Neurology, Neuropsychology Section, University of Patras Medical School, Greece.
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40
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Deloire M, Ruet A, Hamel D, Bonnet M, Brochet B. Early cognitive impairment in multiple sclerosis predicts disability outcome several years later. Mult Scler 2010; 16:581-7. [DOI: 10.1177/1352458510362819] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cognition is frequently impaired in the early stages of multiple sclerosis (MS). The predictive value of cognitive impairment on disability is unknown. The objective of this study was to correlate cognitive impairment and the progression of disability over 7 years. Forty-five patients, recruited after MS diagnosis, were followed for 7 years by yearly Expanded Disability Status Scale (EDSS) and Multiple Sclerosis Functional Composite (MSFC) evaluations and were classified as cognitively impaired (CI) or unimpaired (CU) according to neuropsychological testing at baseline. At baseline, 47.8% of patients were CI, with deficits in mainly memory and information processing speed (IPS). The baseline EDSS correlated significantly with one IPS test. The EDSS, but not the MSFC, deteriorated significantly over the 7 years in the whole group and the CI group, but not the CU group. A multivariate analysis showed correlations between the EDSS change over 5 and 7 years and two baseline tests evaluating IPS and verbal memory. The deterioration of the EDSS after 7 years was significantly correlated with verbal memory testing at baseline after adjustment for age and baseline EDSS. In conclusion, in this sample of MS patients early in the disease, the baseline IPS and verbal memory impairments predict the EDSS score 5 and 7 years later.
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Affiliation(s)
- Mathilde Deloire
- EA 2966, Université de Bordeaux 2, Bordeaux, France, Services de Neurologie, CHU Bordeaux, France
| | | | | | | | - Bruno Brochet
- EA 2966, Université de Bordeaux 2, Bordeaux, France, , Services de Neurologie, CHU Bordeaux, France
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41
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Ukkonen M, Vahvelainen T, Hämäläinen P, Dastidar P, Elovaara I. Cognitive dysfunction in primary progressive multiple sclerosis: a neuropsychological and MRI study. Mult Scler 2009; 15:1055-61. [DOI: 10.1177/1352458509106231] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although cognitive dysfunction is known to occur in multiple sclerosis (MS), only few studies have reported cognitive performance in patients with primary progressive MS (PPMS). To find out the pattern of cognitive performance in PPMS, 28 PPMS patients underwent an extensive battery of neuropsychological tests. The results were compared to those of healthy controls ( n = 20) and patients with secondary progressive MS (SPMS, n = 28). Furthermore, the results of neuropsychological tests in PPMS were correlated to magnetic resonance imaging findings. Our study showed that the PPMS patients have deficits in several cognitive domains when compared to age-matched and education-matched controls, but the cognitive impairment in the PPMS and SPMS patients appeared to be similar. Cognitive deficits in PPMS patients correlated with diffuse brain lesion, T1- and T2-lesion load, but no correlations were found with atrophy.
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Affiliation(s)
- M Ukkonen
- Department of Neurology and Rehabilition, Tampere University Hospital, Tampere, Finland; Medical School, University of Tampere, Tampere, Finland; National Graduate School of Clinical Investigation, Finland
| | - T Vahvelainen
- Department of Neurology and Rehabilition, Tampere University Hospital, Tampere, Finland
| | - P Hämäläinen
- Masku Neurological Rehabilitation Centre. Masku, Finland
| | - P Dastidar
- Department of Diagnostic Imaging, Tampere University Hospital, Tampere, Finland
| | - I Elovaara
- Department of Neurology and Rehabilition, Tampere University Hospital, Tampere, Finland; National Graduate School of Clinical Investigation, Finland
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Reuter F, Audoin B, Rico A, Malikova I, Ranjeva JP, Pelletier J. [Cognitive impairment]. Rev Neurol (Paris) 2009; 165 Suppl 4:S113-22. [PMID: 19361675 DOI: 10.1016/s0035-3787(09)72122-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Cognitive impairment is common in multiple sclerosis (MS), occurring at all stages of the disease, even at the earliest, and can be a major source of disability, social impairment, and impoverished quality of life. Cognitive dysfunction is mainly focused on working memory, conceptual reasoning, verbal fluency, speed of information processing, attention and executive function. Measures of information-processing speed appear to be the most robust and sensitive markers of cognitive impairment in MS patients. Cognitive testing in MS patients is complex and cognitive screening tests are time- and cost-saving test instruments. A comprehensive and sensitive cognitive test procedure should be administered to detect cognitive dysfunction, and recent studies demonstrate that single, predominantly speed-related cognitive tests may be superior to extensive and time-consuming test batteries in screening cognitive decline. Additional clinical factors, including disease course, fatigue, and affective disturbance, can impact the degree of MS-related cognitive impairment. Despite weak correlation with disease duration and physical disability status, the degree of cognitive impairment in MS has been related to the extent of topographically specific neuronal tissue damage and loss. Numerous studies have applied conventional and quantitative magnetic resonance imaging (MRI) techniques to correlate the profile and degree of cognitive impairment with various MRI-detectable abnormalities. The burden of MRI-visible lesions does not fully account for the degree of MS-related cognitive impairment. Nonconventional MRI findings suggest the extent of subtle tissue damage in normal-appearing white and grey matter to correlate best with the severity of cognitive impairment in MS patients. Structural MRI approaches have recently been extended by functional MRI studies scrutinizing the brain's ability for adaptive functional reorganization in the presence of widespread tissue damage. Cognitive impairment in MS seems to be not simply the result of tissue destruction, but also a balance between tissue destruction, tissue repair, and adaptive functional reorganization. These findings highlight the need to screen for cognitive deficits in MS patients to conduct potential cognitive rehabilitation intervention.
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Affiliation(s)
- F Reuter
- Pôle de Neurosciences Cliniques, Service de Neurologie, CHU Timone, Rue Saint Pierre, 13385 Marseille cedex 5, France
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Sumowski JF, Chiaravalloti N, DeLuca J. Cognitive reserve protects against cognitive dysfunction in multiple sclerosis. J Clin Exp Neuropsychol 2009; 31:913-26. [PMID: 19330566 DOI: 10.1080/13803390902740643] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Cognitive reserve theory helps to explain the neuropsychological expression of neurologic disease (e.g., Alzheimer's disease; Stern, 2006). Multiple sclerosis (MS) is a neurologic disease characterized by information processing inefficiency and verbal learning and memory deficits. The current study is the first to investigate whether higher cognitive reserve moderates the relationship between MS and cognitive functioning. A word-reading proxy of premorbid intelligence was used to estimate cognitive reserve for 58 persons with MS and 43 healthy controls. Dependent measures of simple processing efficiency, complex information processing efficiency, and verbal learning and memory were administered. There were significant Group x Cognitive Reserve interactions for complex information processing efficiency and verbal learning and memory, such that persons with MS demonstrated deficits relative to controls at lower, but not higher, levels of reserve. No such interaction was found for simple processing efficiency. The protective influence of higher cognitive reserve against disease-related cognitive deficits is discussed.
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Affiliation(s)
- James F Sumowski
- Kessler Foundation Research Center, Neuropsychology and Neuroscience Laboratory, West Orange, NJ 07052, USA.
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44
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Abstract
Multiple sclerosis (MS) is a progressive disease of the CNS that is characterised by widespread lesions in the brain and spinal cord. MS results in motor, cognitive, and neuropsychiatric symptoms, all of which can occur independently of one another. The common cognitive symptoms include deficits in complex attention, efficiency of information processing, executive functioning, processing speed, and long-term memory. These deficits detrimentally affect many aspects of daily life, such as the ability to run a household, participate fully in society, and maintain employment--factors that can all affect the overall quality of life of the patient. The increased use of neuroimaging techniques in patients with MS has advanced our understanding of structural and functional changes in the brain that are characteristic of this disease, although much remains to be learned. Moreover, examination of efforts to treat the cognitive deficits in MS is still in the early stages.
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45
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Ryan KA, Rapport LJ, Telmet Harper K, Fuerst D, Bieliauskas L, Khan O, Lisak R. Fitness to drive in multiple sclerosis: Awareness of deficit moderates risk. J Clin Exp Neuropsychol 2008; 31:126-39. [DOI: 10.1080/13803390802119922] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
| | | | | | | | | | - Omar Khan
- c Multiple Sclerosis Center, Department of Neurology , Wayne State University School of Medicine , Detroit, MI, USA
| | - Robert Lisak
- c Multiple Sclerosis Center, Department of Neurology , Wayne State University School of Medicine , Detroit, MI, USA
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46
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Evaluating sub-clinical cognitive dysfunction and event-related potentials (P300) in clinically isolated syndrome. Neurol Sci 2008; 29:435-44. [PMID: 19002651 DOI: 10.1007/s10072-008-1020-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2008] [Accepted: 09/09/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE This study investigated the presence of sub-clinical cognitive dysfunction in patients with clinically isolated syndrome (CIS) and the abnormalities of cognitive event-related potentials (ERPs). METHODS Subclinical cognitive dysfunction was assessed in 20 patients with CIS and in 20 healthy controls. RESULTS Patients had impairments in verbal learning and long-term memory, evaluating attention, executive function and visuospatial skills, in decreasing order of frequency. SDLT and SIT were the most, and COWAT and BNT were the least affected tests. The N200 and P200 latencies were prolonged, and N100, N200 and P200 amplitudes were reduced in the patients relative to the controls, from the Fz, Cz and Pz electrode positions (p<0.05). CONCLUSION Detailed cognitive testing is valuable in determining subclinical cognitive dysfunction in CIS patients. ERP abnormalities as well as abnormalities in detailed cognitivetesting in patients with CIS are helpful in the diagnosis of sub-clinical cognitive dysfunction.
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Stroop performance in multiple sclerosis: information processing, selective attention, or executive functioning? J Int Neuropsychol Soc 2008; 14:805-14. [PMID: 18764975 DOI: 10.1017/s1355617708080946] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Cognitive impairments in information processing speed, attention and executive functioning are widely reported in patients with multiple sclerosis (MS). Several studies have identified impaired performance on the Stroop test in people with MS, yet uncertainty remains over the cause of this phenomenon. In this study, 25 patients with MS were assessed with a neuropsychological test battery including a computerized Stroop test and a computerized test of information processing speed, the Graded Conditional Discrimination Tasks (GCDT). The patient group was compared with an individually age, sex and estimated premorbid IQ-matched healthy control group. The patients' reaction times (RTs) were significantly longer than those of the controls on all Stroop test trials and there was a significantly enhanced absolute (RT(incongruent)-RT(neutral)) and relative (100 x [RT(incongruent)-RT(neutral)]/RT(neutral)) Stroop interference effect for the MS group. The linear function relating RT to stimulus complexity in the GCDT was significantly steeper in the patient group, indicating slowed information processing. The results are discussed with reference to the difference engine model, a theory of diversity in speeded cognition. It is concluded that, in the assessment of people with MS, great caution must be used in the interpretation of performance on neuropsychological tests which rely on RT as the primary measure.
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Brochet B, Deloire MSA, Bonnet M, Salort-Campana E, Ouallet JC, Petry KG, Dousset V. Should SDMT substitute for PASAT in MSFC? A 5-year longitudinal study. Mult Scler 2008; 14:1242-9. [PMID: 18653737 DOI: 10.1177/1352458508094398] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The multiple sclerosis functional composite (MSFC) includes the Paced Auditory Serial Addition test (PASAT) as a measure of cognition. OBJECTIVES AND METHODS We compared the MSFC incorporating the Symbol Digit Modalities test (SDMT) (MSFC [sdmt]) to the usually applied MSFC (MSFC [pasat]) in a sample of 46 ptients with relapsing-remitting MS who were followed over a five-year period. Magnetic resonance imaging was performed at baseline. RESULTS The Expanded Disability Status scale (EDSS) deteriorated significantly over 5 years (P < 0.01), but MSFC scores remained stable. MSFC [sdmt] correlated with EDSS at all time points of evaluation, but MSFC [pasat] correlated with EDSS only at baseline, 1, and 5 years. The 5-year EDSS correlated significantly with baseline MSFC [sdmt] and MSFC [pasat] but did not correlate after adjustment for baseline EDSS. No significant correlation was found at baseline between MSFC and imaging parameters (lesion load, brain parenchymal fraction [BPF], ventricular fraction, mean magnetization transfer ratio of lesions and normal-appearing brain tissue), but baseline BPF correlated significantly with changes of SDMT z score (P = 0.0003), MSFC [pasat] (P = 0.006), and MSFC [sdmt] (P = 0.0002) over 5 years. CONCLUSION We propose not to substitute PASAT by SDMT in the MSFC but to consider SDMT as a complementary useful approach to evaluate overall MS disease.
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Affiliation(s)
- B Brochet
- EA 2966, Université de Bordeaux, and Services de Neurologie et Neuroradiologie, CHU de Bordeaux, Bordeaux, France.
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Duan Y, Hildenbrand PG, Sampat MP, Tate DF, Csapo I, Moraal B, Bakshi R, Barkhof F, Meier DS, Guttmann CRG. Segmentation of subtraction images for the measurement of lesion change in multiple sclerosis. AJNR Am J Neuroradiol 2008; 29:340-6. [PMID: 18272569 DOI: 10.3174/ajnr.a0795] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Lesion volume change (LVC) assessment is essential in monitoring MS progression. LVC is usually measured by independently segmenting serial MR imaging examinations. Subtraction imaging has been proposed for improved visualization and characterization of lesion change. We compare segmentation of subtraction images (SSEG) with serial single time-point conventional segmentation (CSEG) by assessing the LVC relationship to brain atrophy and disease duration, as well as scan-rescan reproducibility and annual rates of lesion accrual. MATERIALS AND METHODS Pairs of scans were acquired 1.5 to 4.7 years apart in 21 patients with multiple sclerosis (MS). Scan-rescan MR images were acquired within 30 minutes in 10 patients with MS. LVC was measured with CSEG and SSEG after coregistration and normalization. Coefficient of variation (COV) and Bland-Altman analyses estimated method reproducibility. Spearman rank correlations probed associations between LVC and other measures. RESULTS Atrophy rate and net LVC were associated for SSEG (R = -0.446; P < .05) but not when using CSEG (R = -0.180; P = .421). Disease duration did not show an association with net lesion volume change per year measured by CSEG (R = -0.360; P = .11) but showed an inverse correlation with SSEG-derived measurements (R = -0.508; P < .05). Scan-rescan COV was lower for SSEG (0.98% +/- 1.55%) than for CSEG (8.64% +/- 9.91%). CONCLUSION SSEG unveiled a relationship between T2 LVC and concomitant brain atrophy and demonstrated significantly higher measurement reproducibility. SSEG, a promising tool providing detailed analysis of subtle alterations in lesion size and intensity, may provide critical outcome measures for clinical trials of novel treatments, and may provide further insight into progression patterns in MS.
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Affiliation(s)
- Y Duan
- Center for Neurological Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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A 3-year longitudinal study of cognitive impairment in patients with primary progressive multiple sclerosis: Speed matters. J Neurol Sci 2008; 267:129-36. [DOI: 10.1016/j.jns.2007.10.007] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2007] [Revised: 10/04/2007] [Accepted: 10/05/2007] [Indexed: 11/24/2022]
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