Optic neuritis: findings on MRI, CSF examination and HLA class II typing in 60 patients and results of a short-term follow-up

The role of magnetic resonance imaging and visual evoked potential in management of optic neuritis

Introduction

To report our experience in management of patients with optic neuritis. The effects of brain magnetic resonance imaging and visual evoked potential on management were investigated

Methods

This is a four years clinical trial that included patients presenting with first attack of optic neuritis older than 16 years with visual acuity of less than 6/60 and presentation within first week of illness. Brain magnetic resonance imaging and visual evoked potentials were done for all patients. Patients were classified into three groups. First group received placebo, second received oral steroids and third received intravenous and oral steroids. Primary outcome measure was improvement in visual acuity.

Results

A total number of 150 patients were enrolled in the study. Ocular pain was seen 127 patients Relative afferent pupillary defect in 142 patients and color vision impairment in 131 patients. Abnormal MRI findings were seen in 84 patients. Pattern reversal VEP was abnormal in all patients. Using oral or intravenous steroid resulted in faster recovery but did not affect the final visual outcome. Recurrence rate was higher in patients with multiple MRI lesions and diminished VEP amplitude. Using intravenous steroids decreased recurrence rate in patients with three and more MRI lesions and non recordable VEP response.

Conclusion

MRI and pattern reversal VEP are recommended to be done in all patients presenting with optic neuritis. We advise to give intravenous methyl prednisolone in patients with multiple MRI white matter lesions and non recordable VEP at presentation.

Discovery and initial verification of differentially abundant proteins between multiple sclerosis patients and controls using iTRAQ and SID-SRM

In the present study, we aimed to discover cerebrospinal fluid (CSF) proteins with significant abundance difference between early multiple sclerosis patients and controls, and do an initial verification of these proteins using selected reaction monitoring (SRM). iTRAQ and Orbitrap MS were used to compare the CSF proteome of patients with clinically isolated syndrome (CIS) (n=5), patients with relapsing-remitting multiple sclerosis that had CIS at the time of lumbar puncture (n=5), and controls with other inflammatory neurological disease (n=5). Of more than 1200 identified proteins, five proteins were identified with significant abundance difference between the patients and controls. In the initial verification using SRM we analyzed a larger patient and control cohort (n=132) and also included proteins reported as differentially abundant in multiple sclerosis in the literature. We found significant abundance difference for 11 proteins after verification, of which the five proteins alpha-1-antichymotrypsin, contactin-1, apolipoprotein D, clusterin, and kallikrein-6 were significantly differentially abundant in several of the group comparisons. This initial study form the basis for further biomarker verification studies in even larger sample cohorts, to determine if these proteins have relevance as diagnostic or prognostic biomarkers for multiple sclerosis.

Oligoclonal bands predict multiple sclerosis after optic neuritis: a literature survey

BACKGROUND

Multiple sclerosis (MS) is an autoimmune disease resulting in inflammation and demyelination of neurones in the central nervous system (CNS). The first sign of MS is often monosymptomatic optic neuritis (MON). Cerebrospinal fluid from a patient with MS analysed by electrophoresis often shows a split to form so called oligoclonal bands (OCBs). OCBs consist of proteins from activated lymphocytes and plasma cell clones.

OBJECTIVES

The aim of this study was to review the published literature on OCBs in MON patients and perform a meta-analysis of the studies in order to assess the utility of OCB determination in patients with MON in the prediction of their risk of MS.

METHODS

Review and meta-analysis of the results of 10 published studies.

RESULTS

OCBs as a predictive test had a sensitivity of 73-100% (mean 88.5%), a specificity of 41-90% (mean 57%) and OR-values between 2.75 and 171 (mean 34.2). The areal under the summary receiver operator characteristic (ROC) curve was 0.89 (unweighted) and 0.82 (weighted). The studies showed large heterogeneity in the diagnostic accuracy.

CONCLUSION

This literature-based meta-analysis provides evidence that OCBs may have a high predictive value for the development of MS in patients with MON. Standardization of laboratory methods and diagnostic criteria would help bring out the full clinical potential of the test. To elucidate the predictive value of OCBs versus MRI, we recommend that a similar meta-analysis of studies of MRI in MON be performed.

Stellenwert der Uveitis im Rahmen demyelinisierender Erkrankungen des Zentralnervensystems

An involvement of the visual system can be found in many neurologic diseases. Especially demyelinating processes of the central nervous system (CNS) and multiple sclerosis (MS) in particular present with a variety of ophthalmological abnormalities. While optic neuritis (ON) is known to be a positive predictor for the development of MS and can be considered a symptom of the disease, the high frequency of uveitis observed in MS patients seems to occur rather in the context of a general predisposition for autoimmune disorders. However, MS-associated uveitis can precede the onset of neurological symptoms by many years and shows response to treatment with steroids and interferons, suggesting the presence of similar underlying pathogenic mechanisms. Therefore, further studies are warranted in order to reveal whether administration of early immunomodulatory therapy can delay or even prevent the clinical manifestation of MS in a distinct subgroup of patients presenting with uveitis.

The effect of interferon-beta1a on relapses and progression of disability in patients with clinically isolated syndromes (CIS) suggestive of multiple sclerosis

OBJECTIVES

In 85% of young adults with multiple sclerosis (MS), onset is a subacute clinically isolated syndrome (CIS) of the optic nerves, brain stem or spinal cord. The advent of disease-modifying treatments for MS has increased attention on early stages of the disease. Therefore, the aim of this study was to evaluate the effect of interferon on relapses and progression of disability in patients with a CIS.

PATIENTS AND METHODS

This randomized, clinical trial was conducted in 25 patients who presented with a CIS indicative of MS. They were evaluated in two groups: 11 patients who were receiving interferon-beta(1a) (Rebif, Serono) subcutaneous injections three times a week (group A), and 14 patients who were not receiving disease-modifying treatment (group B). The progression of disability was determined using the Kurtzke Expanded Disability Status Scale (EDSS) and the numbers of new relapses were recorded during 21 months of follow-up.

RESULTS

The mean numbers of new relapses and changes in EDSS at the end of study period were 0.68 (standard deviation [S.D.]=0.80) and -1.09 (S.D.=0.49), and 1.79 (S.D.=1.05) and -0.64 (S.D.=0.49) in groups A and B, respectively. Statistical analysis showed that disease-modifying treatment with interferon-beta(1a) may reduce relapses (P=0.007) and prevent progressive disability (P=0.034).

CONCLUSION

Interferon-beta(1a) significantly delayed progression to disability and incidence of new relapses.

HLA‐DRB1*1501, ‐DQB1*0301, ‐DQB1*0302, ‐DQB1*0602, and ‐DQB1*0603 Alleles are Associated With More Severe Disease Outcome on Mri in Patients With Multiple Sclerosis

The most important confirmed genetic factor of susceptibility to multiple sclerosis (MS) has been identified in the HLA class II region. The hypothesis that several genes, including HLA class II, may influence the prognosis of patients with MS has been proposed. In a recent study, using low intermediate resolution typing, we found that some HLA alleles may predict disease severity as assessed by magnetic resonance imaging (MRI) measures. The aim of this study was to examine the relationship between high-resolution typing of HLA alleles and disease severity as measured by brain MRI quantitative markers of demyelinating and destructive pathology in patients with MS. In 41 MS patients (27 relapsing-remitting, 7 secondary progressive, and 7 primary progressive), we performed high-resolution typing of alleles HLA-DRB1*04, -DQB1*03, -DRB1*15, -DQB1*06, and of haplotypes -DRB1*04-DQB1*03 and -DRB1*15-DQB1*06. These alleles and haplotypes were associated with higher susceptibility to MS in a recently published case-control study conducted in the Friuli-Venezia-Giulia region, Italy. Of 41 included patients, 13 were men and 28 were women. Mean age was 43.3 (SD 11.4) years, mean disease duration 10.3 (SD 7.8) years, and mean EDSS 2.3. DNA extraction and genomic typing were obtained with the sequence-specific primers method using primer pairs that amplified the HLA alleles. All patients underwent a 1.5-T MRI examination of the brain. Disease severity was assessed by clinical measures [Expanded Disability Status Scale (EDSS)] and MRI measures. T2- and T1-lesion volumes (LVs) and brain atrophy measures [fractions of brain parenchyma (BPF), gray matter (GMF), and white matter (WMF)] were calculated. We used general linear model analysis (GML), controlled for age, disease duration, and treatment status, to compare the MRI measures according to allele and haplotype status. The following significant results were found: HLA-DRB1*1501 positive patients had significantly lower GMF (0.493 vs 0.526, p < 0.001), lower BPF (0.784 vs 0.815, p = 0.018), and higher T1-LV (2.8 vs 0.7ml, p = 0.036); -DQB1*0301 positive patients had significantly higher T2-LV (34.1 vs 0.7 ml, p = 0.041), and showed a trend for lower BPF (0.790 vs 0.846, p = 0.064); -DQB1*0302 positive patients had significantly lower T1-LV (2.4 vs 0.9 ml, p = 0.016); and -DQB1*0602 positive patients had significantly lower GMF (0.492 vs 0.521, p = 0.007) and lower BPF (0.781 vs 0.811, p = 0.023). No differences were found in the indices of MRI disease severity according to HLA haplotype associations. Both in correlation and in regression analyses, we observed significant associations between HLA-DRB1*1501 and lower GMF and BPF and higher T1-LV, between -DQB1*0301 and higher T2-LV and disease duration, between -DQB1*0302 and lower GMF and higher T1- and T2-LV, between -DQB1*0602 and lower GMF and BPF, and between -DQB1*0603 and higher T1-LV and EDSS. High-resolution HLA genotyping analysis revealed a robust relationship between alleles HLA-DRB1*1501, -DQB1*0301, -DQB1*0302, -DQB1*0602, and -DQB1*0603, and more severe damage on inflammatory and neurodegenerative MRI measures.

Evolving management of optic neuritis and multiple sclerosis

PURPOSE

To review the relation of optic neuritis to multiple sclerosis (MS) and the indications, modalities, and results of therapy for optic neuritis, for both visual and general neurologic function.

DESIGN

Literature review and author's experience.

METHODS

Analysis of both laboratory and clinical evidence supporting the use of corticosteroids, immunomodulation agents, and other modalities in the treatment of optic neuritis and MS.

RESULTS

Although treatment of optic neuritis with corticosteroids may hasten visual recovery to a minor degree, it has no long-term beneficial effect on visual outcome. Optic neuritis is frequently the initial manifestation of multiple sclerosis. The risk of later development of clinically definite MS (CDMS) correlates with white matter demyelinative lesions on magnetic resonance imaging (MRI). The role of corticosteroid therapy alone in reducing the risk of subsequent MS is unclear, but recent studies suggest that the combination of immunomodulation agents (IMAs) and corticosteroids significantly reduces the later development of MS. Current research indicates that, contrary to previous doctrine, axonal damage is an early finding in MS.

CONCLUSIONS

The risk of MS after optic neuritis may be predicted. The use of corticosteroids and IMAs, particularly in those at substantial risk, reduces the frequency and severity of developing CDMS. Earlier, more aggressive therapy in optic neuritis may be proven to reduce permanent axonal injury and progressive disability in MS.

Predicting multiple sclerosis at optic neuritis onset

Using multivariate analyses, individual risk of clinically definite multiple sclerosis (CDMS) after monosymptomatic optic neuritis (MON) was quantified in a prospective study with clinical MON onset during 1990-95 in Stockholm, Sweden. During a mean follow-up time of 3.8 years, the presence of MS-like brain magnetic resonance imaging (MRI) lesions and oligoclonal immunoglobulin (Ig) G bands in cerebrospinal fluid (CSF) were strong prognostic markers of CDMS, with relative hazard ratios of 4.68 [95% confidence interval (CI) 2.21-9.91] and 5.39 (95% CI 1.56-18.61), respectively. Age and season of clinical onset were also significant predictors, with relative hazard ratios of 1.76 (95% CI 1.02-3.04) and 2.21 (95% CI 1.13-3.98), respectively. Based on the above two strong predictors, individual probability of CDMS development after MON was calculated in a three-quarter sample drawn from a cohort, with completion of follow-up at three years. The highest probability, 0.66 (95% CI 0.48-0.80), was obtained for individuals presenting with three or more brain MRI lesions and oligoclonal bands in the CSF, and the lowest, 0.09 (95% CI 0.02-0.32), for those not presenting with these traits. Medium values, 0.29 (95% CI 0.13-0.53) and 0.32 (95% CI 0.07-0.73), were obtained for individuals discordant for the presence of brain MRI lesions and oligoclonal bands in the CSF. These predictions were validated in an external one-quarter sample.

Intrathecal IgG synthesis and autoantibody-secreting cells in multiple sclerosis

We studied intrathecal IgG synthesis and autoantibody-secreting cells in 148 patients with possible onset symptoms of MS (POSMS) or clinically definite MS (CDMS). In POSMS intrathecal synthesis of IgG oligoclonal bands and abnormalities on T2-weighted magnetic resonance imaging were associated but the former were more prevalent. The cerebrospinal fluid (CSF) leukocyte count and the number of anti-protelipid protein antibody-secreting cells in cerebrospinal fluid (CSF) correlated with disease activity in POSMS. Intrathecal IgG synthesis levels and the number of anti-myelin basic protein antibody-secreting cells in CSF correlated with disease activity in CDMS. Our results support recent reports of pathogenetic heterogeneity and a pathogenetic role of the antibody response in MS.

Ophthalmology update for primary practitioners. Part I. Update on optic neuritis

Optic neuritis is a common cause of acute visual loss. It is typified by sudden onset of visual impairment and pain with eye movements, followed by spontaneous recovery of vision over several months. Pathologically, optic neuritis is an acute demyelinating event affecting the optic nerve. Objective physical findings are typically few, including an afferent pupillary defect or Marcus-Gunn pupil, whereas subjective psychophysical findings abound (ie, diminished central visual acuity, color vision, decreased contrast sensitivity, and visual field abnormalities). These characteristics have made the diagnosis of optic neuritis based solely on clinical grounds disquieting to practitioner and patient alike. In addition, the fact that optic neuritis is often associated with multiple sclerosis as the first clinical manifestation of disease gives further reason for both patient and physician anxiety. The serious nature of visual loss and the consequences of making the diagnosis of optic neuritis has given rise to extensive testing and expensive treatments. This review is intended to explore our current state of knowledge with regard to (1) clinical presentation, (2) ancillary testing, (3) therapeutic intervention, and (4) associated disease, specifically the risk for multiple sclerosis in the patient who presents with an acute optic neuritis. Finally, a suggestion guide for informing the patient and addressing his or her concerns will be presented.

HLA DRB1*1501 and intrathecal inflammation in multiple sclerosis

CD4 T cells are considered to be pivotal in the pathogenesis of multiple sclerosis (MS), and the human leukocyte antigen (HLA) haplotype associated with DRB1*1501 confers susceptibility to MS in patients of Northern European descent. Some previous studies have suggested an association of DRB1*1501 with T- and B-cell reactivity to specific myelin protein peptides, other studies suggested an association with enhanced cytokine production or intrathecal immunoglobulin (Ig) synthesis. In order to further assess the role of DRB1*1501 in the pathogenesis of MS, we studied intrathecal inflammation and T-cell phenotypes in patients with possible onset symptoms or clinically definite MS. Presence of DRB1*1501 was associated with higher levels of cerebrospinal fluid (CSF) inflammation as assessed by IgG synthesis levels and higher levels of matrix metalloproteinase-9 activity. DRB1*1501-positive patients also had a lower percentage of T cells in CSF expressing HLA-DR without co-expressing CD25. These findings suggest that enhanced intrathecal inflammation and an altered T-cell activation status may be of importance in conferring the DRB1*1501-associated susceptibility to MS.

Nuclear magnetic resonance monitoring of treatment and prediction of outcome in multiple sclerosis

Magnetic resonance (MR) techniques provide an objective, sensitive and quantitative assessment of the evolving pathology in multiple sclerosis. There is an increasing definition of the pathological specificity of newer techniques, and more robust correlations with clinical evolution are emerging. As the pathophysiological basis of in vivo nuclear MR signal abnormalities is further elucidated, it is likely that the importance of MR as a tool to monitor new therapies will increase.

Progression of optic neuritis to multiple sclerosis: an 8-year follow-up study

OBJECTIVE

The relationship between acute monosymptomatic optic neuritis (AON) and subsequent multiple sclerosis (MS) is still doubtful. We investigated the risk of developing MS in patients from North Bavaria, who were suffering from AON.

PATIENTS/METHODS

Twenty-nine patients with clinical evidence of AON were included in the study. Initial evaluation included brain resonance imaging (MRI) and a clinical neurological examination. Follow-up examinations were performed after 72-108 months (mean: 96 months) in 26 patients (three patients were lost to follow-up) and consisted of a second complete neurological examination. Diagnosis of MS was established according to the criteria of Poser CM, Paty DW, Scheinberg L. New diagnostic criteria for multiple sclerosis: guidelines for research protocols. Ann Neurol 1983:13:227-231.

RESULTS

At follow-up, 14 of 26 patients (54%) had converted to clinically definite MS. Nine patients (64%) had developed MS within 2 years after the onset of AON.

CONCLUSION

We observed the development of MS in 54% of the 26 investigated AON patients. The exceptional feature of the present study was the relatively long follow-up period of 8 years.

Correlation of clinical, magnetic resonance imaging, and cerebrospinal fluid findings in optic neuritis

We found 42 of 74 patients (57%) with isolated monosymptomatic optic neuritis to have 1 to 20 brain lesions, by magnetic resonance imaging (MRI). All of the brain lesions were clinically silent and had characteristics consistent with multiple sclerosis (MS). None of the patients had ever experienced neurologic symptoms prior to the episode of optic neuritis. During 5.6 years of follow-up, 21 patients (28%) developed definite MS on clinical grounds. Sixteen of the 21 converting patients (76%) had abnormal MRIs; the other 5 (24%) had MRIs that were normal initially (when they had optic neuritis only) and when repeated after they had developed clinical MS in 4 of the 5. Of the 53 patients who have not developed clinically definite MS, 26 (49%) have abnormal MRIs and 27 (51%) have normal MRIs. The finding of an abnormal MRI at the time of optic neuritis was significantly related to the subsequent development of MS on clinical grounds, but interpretation of the strength of that relationship must be tempered by the fact that some of the converting patients had normal MRIs and approximately half of the patients who did not develop clinical MS had abnormal MRIs. We found that abnormal IgG levels in the cerebrospinal fluid correlated more strongly than abnormal MRIs with the subsequent development of clinically definite MS.

Isolated optic neuritis and its prognosis for multiple sclerosis: a clinical and paraclinical study with evoked potentials. CSF examination and brain MRI

Our study evaluated the frequency of developing multiple sclerosis (MS) after acute isolated optic neuritis (ON), the possible association with risk factors (gender, age), and the diagnostic and prognosis role of paraclinical tests. We studied 100 ON patients (mean age 28.9 years: SD 8.9): 85 patients were regularly followed up. Sixty-six patients underwent multimodality evoked potential (EP) test, examination and brain MRI within six months of the onset of ON. Over a mean follow-up of 5.2 years, MS occurred in 28/85 cases. The risk of developing MS after four years was 0.35 at life-table analysis, regardless of gender or age at the onset of ON. Visual EPs in unaffected eyes were abnormal in 25.4%, brainstem auditory EPs in 6.5% somatosensory EPs in 8.1%, upper limb motor EPs in 6.8% of the tested patients; intrathecal IgG synthesis was revealed in 51.7% and MRI lesions in 73.8%. Fifty-one of the patients who underwent paraclinical tests were followed up for more than one year, and MS occurred in 13 cases. All of these presented MRI lesions, nine intrathecal IgG synthesis, and two abnormal extraocular EPs. The risk of developing MS after four years was 0.33 in patients with MRI lesions; the simultaneous presence of intrathecal IgG synthesis increased the risk to 0.46.

Distribution of HLA-Dw2 in optic neuritis and multiple sclerosis indicates heterogeneity

The human leukocyte antigen (HLA) phenotype Dw2 is known to be increased in multiple sclerosis (MS), but only slightly in optic neuritis (ON).

MATERIAL AND METHODS

127 consecutive patients with unilateral monosymptomatic ON were typed genomically for HLA-DR and -DQ genes.

RESULTS

The frequency of HLA-Dw2 among ON patients (47%) was found to be significantly higher than among 250 controls (30%) but significantly lower than in a group of 245 MS patients (60%), all of the same ethnic origin. At the group level, these figures can be calculated to indicate that 53% of the ON patients belong to the group of "MS-type ON" (95% confidence limits 25-78%). A compilation of published data on the frequency of the HLA-DR17(3), DQ2 haplotype, prompted by a slight increase in this material, revealed a significant association with this haplotype in ON, after compensation for the increase of Dw2.

CONCLUSION

ON differs from both MS and controls regarding HLA-Dw2. Thus, a substantial number of patients with ON may suffer from conditions not immuno-genetically related to MS, which might be designated as non-MS type ON. This condition may be more common in men and in young patients of both sexes.

Tumor necrosis factor alpha-308 alleles in multiple sclerosis and optic neuritis

Tumor necrosis factor-alpha (TNF-alpha), a proinflammatory cytokine, is believed to play an important role in multiple sclerosis (MS) pathogenesis. A bi-allelic polymorphism in the TNF-alpha promoter region (TNF alpha-308), has been reported to influence levels of TNF-alpha production. In the present study, we investigated the TNF alpha-308 polymorphism in 93 patients with MS, 17 patients with optic neuritis (ON) and 95 healthy individuals using an allele-specific PCR technique. Allelic genotype was compared with TNF-alpha mRNA expression levels and HLA class II phenotypes. No significant difference regarding the TNF alpha-308 polymorphism was observed between MS patients and controls. Specifically, the less common allele, TNF2, which is associated with higher expression levels of TNF-alpha, was somewhat less frequent among MS patients. In fact, analysis of 19 patients homozygous for the MS associated HLA-DR-DQ haplotype HLA-Dw2 showed that this haplotype does not carry the TNF2 allele. In addition, in 47 patients, the TNF-alpha alleles did not correlate with expression levels measured as numbers of TNF-alpha expressing cells. Thus, we found no evidence for an important role of TNF alpha-308 polymorphism for genetic susceptibility to MS.