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Hemond CC, Gaitán MI, Absinta M, Reich DS. New Imaging Markers in Multiple Sclerosis and Related Disorders: Smoldering Inflammation and the Central Vein Sign. Neuroimaging Clin N Am 2024; 34:359-373. [PMID: 38942521 PMCID: PMC11213979 DOI: 10.1016/j.nic.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2024]
Abstract
Concepts of multiple sclerosis (MS) biology continue to evolve, with observations such as "progression independent of disease activity" challenging traditional phenotypic categorization. Iron-sensitive, susceptibility-based imaging techniques are emerging as highly translatable MR imaging sequences that allow for visualization of at least 2 clinically useful biomarkers: the central vein sign and the paramagnetic rim lesion (PRL). Both biomarkers demonstrate high specificity in the discrimination of MS from other mimics and can be seen at 1.5 T and 3 T field strengths. Additionally, PRLs represent a subset of chronic active lesions engaged in "smoldering" compartmentalized inflammation behind an intact blood-brain barrier.
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Affiliation(s)
- Christopher C Hemond
- Department of Neurology, University of Massachusetts Memorial Medical Center and University of Massachusetts Chan Medical School, Worcester, MA, USA; National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA.
| | - María I Gaitán
- Translational Neuroradiology Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Martina Absinta
- Translational Neuropathology Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Daniel S Reich
- Translational Neuroradiology Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
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Shi Z, Ma Y, Ding S, Yan Z, Zhu Q, Xiong H, Li C, Xu Y, Tan Z, Yin F, Chen S, Li Y. Radiomics derived from T2-FLAIR: the value of 2- and 3-classification tasks for different lesions in multiple sclerosis. Quant Imaging Med Surg 2024; 14:2049-2059. [PMID: 38415132 PMCID: PMC10895122 DOI: 10.21037/qims-23-1287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 01/02/2024] [Indexed: 02/29/2024]
Abstract
Background White matter (WM) lesions can be classified into contrast enhancement lesions (CELs), iron rim lesions (IRLs), and non-iron rim lesions (NIRLs) based on different pathological mechanism in relapsing-remitting multiple sclerosis (RRMS). The application of radiomics established by T2-FLAIR to classify WM lesions in RRMS is limited, especially for 3-class classification among CELs, IRLs, and NIRLs. Methods A total of 875 WM lesions (92 CELs, 367 IRLs, 416 NIRLs) were included in this study. The 2-class classification was only performed between IRLs and NIRLs. For the 2- and 3-class classification tasks, all the lesions were randomly divided into training and testing sets with a ratio of 8:2. We used least absolute shrinkage and selection operator (LASSO), reliefF algorithm, and mutual information (MI) for feature selection, then eXtreme gradient boosting (XGBoost), random forest (RF), and support vector machine (SVM) were used to establish discrimination models. Finally, the area under the curve (AUC), accuracy, sensitivity, specificity, and precision were used to evaluate the performance of the models. Results For the 2-class classification model, LASSO classifier with RF model showed the best discrimination performance with the AUC of 0.893 (95% CI: 0.838-0.942), accuracy of 0.813, sensitivity of 0.833, specificity of 0.781, and precision of 0.851. However, the 3-class classification model of LASSO with XGBoost displayed the highest performance with the AUC of 0.920 (95% CI: 0.887-0.950), accuracy of 0.796, sensitivity of 0.839, specificity of 0.881, and precision of 0.846. Conclusions Radiomics models based on T2-FLAIR images have the potential for discriminating among CELs, IRLs, and NIRLs in RRMS.
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Affiliation(s)
- Zhuowei Shi
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yuqi Ma
- College of Computer and Information Science, Southwest University, Chongqing, China
| | - Shuang Ding
- Department of Radiology, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Zichun Yan
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qiyuan Zhu
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hailing Xiong
- College of Electronic and Information Engineering, Southwest University, Chongqing, China
| | - Chuan Li
- College of Computer and Information Science, Southwest University, Chongqing, China
- Big Data and Intelligence Engineering School, Chongqing College of International Business and Economics, Chongqing, China
| | - Yuhui Xu
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zeyun Tan
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Feiyue Yin
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Shanxiong Chen
- College of Computer and Information Science, Southwest University, Chongqing, China
| | - Yongmei Li
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Clarke MA, Cheek R, Kazimuddin HF, Hernandez B, Clarke R, McKnight CD, Derwenskus J, Eaton J, Irlmeier R, Ye F, O’Grady KP, Rogers B, Smith SA, Bagnato F. Paramagnetic rim lesions and the central vein sign: Characterizing multiple sclerosis imaging markers. J Neuroimaging 2024; 34:86-94. [PMID: 38018353 PMCID: PMC10842224 DOI: 10.1111/jon.13173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 11/09/2023] [Accepted: 11/14/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND AND PURPOSE Paramagnetic rims and the central vein sign (CVS) are proposed imaging markers of multiple sclerosis (MS) lesions. Using 7 tesla magnetic resonance imaging, we aimed to: (1) characterize the appearance of paramagnetic rim lesions (PRLs); (2) assess whether PRLs and the CVS are associated with higher levels of MS pathology; and (3) compare the characteristics between subjects with and without PRLs in early MS. METHODS Prospective study of 32 treatment-naïve subjects around the time of diagnosis who were assessed for the presence of PRLs and the CVS. Comparisons of lesion volume and macromolecular pool size ratio (PSR) index, a proxy of myelin integrity, between PRLs and non-PRLs, and CVS-positive and CVS-negative lesions were carried out. Differences in clinical/demographic characteristics between patients with PRLs and those without were tested. RESULTS Fifteen subjects had ≥1 PRL for a total of 36 PRLs, of which two-thirds had a full rim. PRLs predicted a larger lesion size and decreased PSR signal. Lesion volume and presence of cervical spine lesions were significantly different between subjects with PRLs and those without, although neither remained significant after adjusting for multiple comparisons. One hundred and eighty-one lesions with CVS were identified with no differences between CVS-positive and CVS-negative lesions in volume (p = .27) and PSR values (p = .62). CONCLUSIONS PRLs, but not CVS-positive lesions, are larger and have lower myelin integrity. Our findings indicate that PRLs are associated with higher levels of lesion-specific pathology prior to the start of disease-modifying therapy.
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Affiliation(s)
- Margareta A. Clarke
- Neuroimaging Unit, Neuro-immunology Division, Department of Neurology, Vanderbilt University Medical Center
| | - Rachael Cheek
- Neuroimaging Unit, Neuro-immunology Division, Department of Neurology, Vanderbilt University Medical Center
- Meharry Medical College
| | - Habeeb F. Kazimuddin
- Neuroimaging Unit, Neuro-immunology Division, Department of Neurology, Vanderbilt University Medical Center
| | - Bryan Hernandez
- Neuroimaging Unit, Neuro-immunology Division, Department of Neurology, Vanderbilt University Medical Center
- Vanderbilt Medical Scientist Training Program, Vanderbilt University
| | - Reece Clarke
- Neuroimaging Unit, Neuro-immunology Division, Department of Neurology, Vanderbilt University Medical Center
| | - Colin D. McKnight
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center
| | - Joy Derwenskus
- Neuro-immunology Division, Department of Neurology, Vanderbilt University Medical Center
| | - James Eaton
- Neuro-immunology Division, Department of Neurology, Vanderbilt University Medical Center
| | - Rebecca Irlmeier
- Department of Biostatistics, Vanderbilt University Medica Center
| | - Fei Ye
- Department of Biostatistics, Vanderbilt University Medica Center
| | - Kristin P. O’Grady
- Vanderbilt Medical Scientist Training Program, Vanderbilt University
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medica Center
| | - Baxter Rogers
- Vanderbilt Medical Scientist Training Program, Vanderbilt University
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medica Center
| | - Seth A. Smith
- Vanderbilt Medical Scientist Training Program, Vanderbilt University
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medica Center
| | - Francesca Bagnato
- Neuroimaging Unit, Neuro-immunology Division, Department of Neurology, Vanderbilt University Medical Center
- Department of Neurology, VA Hospital, TN Valley Healthcare Center, Nashville, TN
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Hofmann A, Krajnc N, Dal-Bianco A, Riedl CJ, Zrzavy T, Lerma-Martin C, Kasprian G, Weber CE, Pezzini F, Leutmezer F, Rommer P, Bsteh G, Platten M, Gass A, Berger T, Eisele P, Magliozzi R, Schirmer L, Hametner S. Myeloid cell iron uptake pathways and paramagnetic rim formation in multiple sclerosis. Acta Neuropathol 2023; 146:707-724. [PMID: 37715818 PMCID: PMC10564819 DOI: 10.1007/s00401-023-02627-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 08/01/2023] [Accepted: 08/23/2023] [Indexed: 09/18/2023]
Abstract
In multiple sclerosis (MS), sustained inflammatory activity can be visualized by iron-sensitive magnetic resonance imaging (MRI) at the edges of chronic lesions. These paramagnetic rim lesions (PRLs) are associated with clinical worsening, although the cell type-specific and molecular pathways of iron uptake and metabolism are not well known. We studied two postmortem cohorts: an exploratory formalin-fixed paraffin-embedded (FFPE) tissue cohort of 18 controls and 24 MS cases and a confirmatory snap-frozen cohort of 6 controls and 14 MS cases. Besides myelin and non-heme iron imaging, the haptoglobin-hemoglobin scavenger receptor CD163, the iron-metabolizing markers HMOX1 and HAMP as well as immune-related markers P2RY12, CD68, C1QA and IL10 were visualized in myeloid cell (MC) subtypes at RNA and protein levels across different MS lesion areas. In addition, we studied PRLs in vivo in a cohort of 98 people with MS (pwMS) via iron-sensitive 3 T MRI and haptoglobin genotyping by PCR. CSF samples were available from 38 pwMS for soluble CD163 (sCD163) protein level measurements by ELISA. In postmortem tissues, we observed that iron uptake was linked to rim-associated C1QA-expressing MC subtypes, characterized by upregulation of CD163, HMOX1, HAMP and, conversely, downregulation of P2RY12. We found that pwMS with [Formula: see text] 4 PRLs had higher sCD163 levels in the CSF than pwMS with [Formula: see text] 3 PRLs with sCD163 correlating with the number of PRLs. The number of PRLs was associated with clinical worsening but not with age, sex or haptoglobin genotype of pwMS. However, pwMS with Hp2-1/Hp2-2 haplotypes had higher clinical disability scores than pwMS with Hp1-1. In summary, we observed upregulation of the CD163-HMOX1-HAMP axis in MC subtypes at chronic active lesion rims, suggesting haptoglobin-bound hemoglobin but not transferrin-bound iron as a critical source for MC-associated iron uptake in MS. The correlation of CSF-associated sCD163 with PRL counts in MS highlights the relevance of CD163-mediated iron uptake via haptoglobin-bound hemoglobin. Also, while Hp haplotypes had no noticeable influence on PRL counts, pwMS carriers of a Hp2 allele might have a higher risk to experience clinical worsening.
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Affiliation(s)
- Annika Hofmann
- Department of Neurology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Nik Krajnc
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Assunta Dal-Bianco
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Christian J Riedl
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | - Tobias Zrzavy
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Celia Lerma-Martin
- Department of Neurology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Gregor Kasprian
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Claudia E Weber
- Department of Neurology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Francesco Pezzini
- Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Fritz Leutmezer
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Paulus Rommer
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Gabriel Bsteh
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Michael Platten
- Department of Neurology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Mannheim Center for Translational Neuroscience, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Mannheim Institute for Innate Immunity, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Interdisciplinary Center for Neurosciences, Heidelberg University, Heidelberg, Germany
- DKTK Clinical Cooperation Unit Neuroimmunology and Brain Tumor Immunology, German Cancer Research Center, INF 280, Heidelberg, Germany
| | - Achim Gass
- Department of Neurology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Mannheim Center for Translational Neuroscience, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Thomas Berger
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Philipp Eisele
- Department of Neurology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Mannheim Center for Translational Neuroscience, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Roberta Magliozzi
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Lucas Schirmer
- Department of Neurology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
- Mannheim Center for Translational Neuroscience, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
- Mannheim Institute for Innate Immunity, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
- Interdisciplinary Center for Neurosciences, Heidelberg University, Heidelberg, Germany.
| | - Simon Hametner
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria.
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria.
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Zierfuss B, Wang Z, Jackson AN, Moezzi D, Yong VW. Iron in multiple sclerosis - Neuropathology, immunology, and real-world considerations. Mult Scler Relat Disord 2023; 78:104934. [PMID: 37579645 DOI: 10.1016/j.msard.2023.104934] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 07/30/2023] [Accepted: 08/08/2023] [Indexed: 08/16/2023]
Abstract
Iron is an essential element involved in a multitude of bodily processes. It is tightly regulated, as elevated deposition in tissues is associated with diseases such as multiple sclerosis (MS). Iron accumulation in the central nervous system (CNS) of MS patients is linked to neurotoxicity through mechanisms including oxidative stress, glutamate excitotoxicity, misfolding of proteins, and ferroptosis. In the past decade, the combination of MRI and histopathology has enhanced our understanding of iron deposition in MS pathophysiology, including in the pro-inflammatory and neurotoxicity of iron-laden rims of chronic active lesions. In this regard, iron accumulation may not only have an impact on different CNS-resident cells but may also promote the innate and adaptive immune dysfunctions in MS. Although there are discordant results, most studies indicate lower levels of iron but higher amounts of the iron storage molecule ferritin in the circulation of people with MS. Considering the importance of iron, there is a need for evidence-guided recommendation for dietary intake in people living with MS. Potential novel therapeutic approaches include the regulation of iron levels using next generation iron chelators, as well as therapies to interfere with toxic consequences of iron overload including antioxidants in MS.
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Affiliation(s)
- Bettina Zierfuss
- The Research Center of the Centre Hospitalier de l'Université de Montréal (CRCHUM), Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal H2X 0A9, Québec, Canada
| | - Zitong Wang
- Department of Psychiatry, College of Health Sciences, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta T6G 2B7, Canada
| | - Alexandra N Jackson
- School of Rehabilitation Therapy, Faculty of Health Sciences, Queen's University, Kingston, Ontario K7L 3N6, Canada
| | - Dorsa Moezzi
- The Hotchkiss Brain Institute and the Department of Clinical Neurosciences, University of Calgary, 3330 Hospital Dr NW, Calgary, Alberta T2N 4N1, Canada
| | - V Wee Yong
- The Hotchkiss Brain Institute and the Department of Clinical Neurosciences, University of Calgary, 3330 Hospital Dr NW, Calgary, Alberta T2N 4N1, Canada.
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Kim S, Lee EK, Song CJ, Sohn E. Iron Rim Lesions as a Specific and Prognostic Biomarker of Multiple Sclerosis: 3T-Based Susceptibility-Weighted Imaging. Diagnostics (Basel) 2023; 13:diagnostics13111866. [PMID: 37296717 DOI: 10.3390/diagnostics13111866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 05/23/2023] [Accepted: 05/24/2023] [Indexed: 06/12/2023] Open
Abstract
This study aimed to identify the clinical significance of iron rim lesions (IRLs) in distinguishing multiple sclerosis (MS) from other central nervous system (CNS) demyelinating diseases, determine the relationship between IRLs and disease severity, and understand the long-term dynamic changes in IRLs in MS. We retrospectively evaluated 76 patients with CNS demyelinating diseases. CNS demyelinating diseases were classified into three groups: MS (n = 30), neuromyelitis optica spectrum disorder (n = 23), and other CNS demyelinating diseases (n = 23). MRI images were obtained using conventional 3T MRI including susceptibility-weighted imaging. Sixteen of 76 patients (21.1%) had IRLs. Of the 16 patients with IRLs, 14 were in the MS group (87.5%), indicating that IRLs were significantly specific for MS. In the MS group, patients with IRLs had a significantly higher number of total WMLs, experienced more frequent recurrence, and were treated more with second-line immunosuppressive agents than were patients without IRLs. In addition to IRLs, T1-blackhole lesions were observed more frequently in the MS group than in the other groups. IRLs are specific for MS and could represent a reliable imaging biomarker to improve the diagnosis of MS. Additionally, the presence of IRLs seems to reflect more severe disease progression in MS.
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Affiliation(s)
- Sooyoung Kim
- Department of Neurology, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon 35015, Republic of Korea
| | - Eun Kyoung Lee
- Department of Neurology, Chungnam National University Sejong Hospital, Chungnam National University College of Medicine, Daejeon 35015, Republic of Korea
| | - Chang June Song
- Department of Radiology, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon 35015, Republic of Korea
| | - Eunhee Sohn
- Department of Neurology, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon 35015, Republic of Korea
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Krajnc N, Dal-Bianco A, Leutmezer F, Kasprian G, Pemp B, Kornek B, Berger T, Rommer PS, Hametner S, Lassmann H, Bsteh G. Association of paramagnetic rim lesions and retinal layer thickness in patients with multiple sclerosis. Mult Scler 2023; 29:374-384. [PMID: 36537667 DOI: 10.1177/13524585221138486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
Abstract
BACKGROUND Paramagnetic rim lesions (PRLs) are chronic active lesions associated with a more severe disease course in multiple sclerosis (MS). Retinal layer thinning measured by optical coherence tomography (OCT) is a biomarker of neuroaxonal damage associated with disability progression in MS. OBJECTIVE We aimed to determine a potential association between OCT parameters (peripapillary retinal nerve fiber layer (pRNFL) ganglion cell-inner plexiform layer (GCIPL), inner nuclear layer (INL) thickness), and PRLs in patients with MS (pwMS). METHODS In this cross-sectional retrospective study, we included pwMS with both 3T brain MRI and an OCT scan. Regression models were calculated with OCT parameters (pRNFL, GCIPL, INL) as dependent variables, and the number of PRLs as an independent variable adjusted for covariates. RESULTS We analyzed data from 107 pwMS (mean age 34.7 years (SD 10.9), 64.5% female, median disease duration 6 years (IQR 1-13), median EDSS 1.5 (range 0-6.5)). Higher number of PRLs was associated with lower pRNFL (β = -0.18; 95% CI -0.98, -0.03; p = 0.038) and GCIPL thickness (β = -0.21; 95% CI -0.58, -0.02; p = 0.039). CONCLUSION The association between higher number of PRLs and lower pRNFL and GCIPL thicknesses provides additional evidence that pwMS with PRLs are affected by a more pronounced neurodegenerative process.
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Affiliation(s)
- Nik Krajnc
- Department of Neurology, Medical University of Vienna, Vienna, Austria/Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia/Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | - Assunta Dal-Bianco
- Department of Neurology, Medical University of Vienna, Vienna, Austria/Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | - Fritz Leutmezer
- Department of Neurology, Medical University of Vienna, Vienna, Austria/Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | - Gregor Kasprian
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria/Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Berthold Pemp
- Department of Ophthalmology, Medical University of Vienna, Vienna, Austria
| | - Barbara Kornek
- Department of Neurology, Medical University of Vienna, Vienna, Austria/Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria/Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | - Paulus Stefan Rommer
- Department of Neurology, Medical University of Vienna, Vienna, Austria/Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | - Simon Hametner
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria/Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Hans Lassmann
- Center for Brain Research, Medical University of Vienna, Vienna, Austria
| | - Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria/Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
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8
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Wenzel N, Wittayer M, Weber CE, Platten M, Gass A, Eisele P. Multiple sclerosis iron rim lesions are linked to impaired cervical spinal cord integrity using the T1/T2-weighted ratio. J Neuroimaging 2023; 33:240-246. [PMID: 36504270 DOI: 10.1111/jon.13076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/27/2022] [Accepted: 11/29/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND AND PURPOSE In multiple sclerosis (MS), iron rim lesions (IRLs) are characterized by pronounced tissue matrix damage. The T1/T2-weighted (T1/T2w) ratio represents a postprocessing MRI approach to investigate tissue integrity, but studies investigating spinal cord pathology are missing until now. The aim of this study was to characterize tissue integrity using the T1/T2w ratio in lesions and the normal-appearing white and gray matter (NAWM, NAGM) in the spinal cord and brain in MS patients with and without brain IRLs. METHODS Forty MS patients (20 patients with at least one brain IRL and 20 age- and sex-matched patients without IRLs) were included. Normalized cross-sectional area (nCSA) of the upper cervical cord was calculated in addition to T1/T2w values and standard brain and spinal cord MRI parameters. RESULTS Patients with IRLs had higher disability scores, a smaller nCSA, and a higher cervical T2 lesion volume. T1/T2w values of brain IRLs were significantly lower compared to non-IRLs (p < .001). Furthermore, T1/T2w values of lesions were significantly lower compared to the NAGM and NAWM, both in the brain and the spinal cord (p < .05 for all comparisons). T1/T2w values of the NAGM and NAWM in the brain and spinal cord did not statistically differ between the IRL group and the non-IRL group. CONCLUSION IRLs constitute an imaging marker of disease severity. T1/T2w ratio maps represent an interesting technique to capture diffuse tissue properties. Calculation of T1/T2w ratio maps of the spinal cord might provide additional insights into the pathophysiological processes of MS.
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Affiliation(s)
- Nicolas Wenzel
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Mannheim, Germany
| | - Matthias Wittayer
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Mannheim, Germany
| | - Claudia E Weber
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Mannheim, Germany
| | - Michael Platten
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Mannheim, Germany.,DKTK CCU Neuroimmunology and Brain Tumor Immunology, DKFZ, Heidelberg, Germany
| | - Achim Gass
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Mannheim, Germany
| | - Philipp Eisele
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Mannheim, Germany
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Wittayer M, Weber CE, Kittel M, Platten M, Schirmer L, Tumani H, Gass A, Eisele P. Cerebrospinal fluid–related tissue damage in multiple sclerosis patients with iron rim lesions. Mult Scler 2023; 29:549-558. [PMID: 37119207 PMCID: PMC10152561 DOI: 10.1177/13524585231155639] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
Background: In multiple sclerosis (MS), iron rim lesions (IRLs) are associated with pronounced tissue damage, higher disease severity and have been suggested as an imaging marker of chronic active inflammation behind the blood–brain barrier indicating progression. Furthermore, chronic intrathecal compartmentalized inflammation has been suggested to be a mediator of a cerebrospinal fluid (CSF)–related tissue damage. Objective: To investigate CSF markers of intrathecal inflammation in patients with at least one IRL compared to patients without IRLs and to investigate tissue damage in lesions and normal-appearing white matter (NAWM) with proximity to CSF spaces. Methods: A total of 102 patients (51 with at least 1 IRL and 51 age-/sex-matched patients without IRL) scanned with the same 3T magnetic resonance imaging (MRI) and having CSF analysis data were included. Results: Patients with at least one IRL had higher disability scores, higher lesion volumes, lower brain volumes and a higher intrathecal immunoglobulin G (IgG) synthesis. Apparent diffusion coefficient (ADC) values in IRLs were higher compared to non-IRLs. We observed a negative linear correlation of ADC values in all tissue classes and distance to CSF, which was stronger in patients with high IgG quotients. Conclusion: IRLs are associated with higher intrathecal IgG synthesis. CSF-mediated intrathecal smouldering inflammation could explain a CSF-related gradient of tissue damage.
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Affiliation(s)
- Matthias Wittayer
- Department of Neurology, Mannheim Center of Translational Neurosciences (MCTN), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Claudia E Weber
- Department of Neurology, Mannheim Center of Translational Neurosciences (MCTN), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Maximilian Kittel
- Institute for Clinical Chemistry, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Michael Platten
- Department of Neurology, Mannheim Center of Translational Neurosciences (MCTN), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany/German
- Consortium of Translational Cancer Research (DKTK), Clinical Cooperation Unit Neuroimmunology and Brain Tumor Immunology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Lucas Schirmer
- Department of Neurology, Mannheim Center of Translational Neurosciences (MCTN), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany/Mannheim Institute for Innate Immunoscience, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | | | - Achim Gass
- Department of Neurology, Mannheim Center of Translational Neurosciences (MCTN), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Philipp Eisele
- Department of Neurology, Mannheim Center of Translational Neurosciences (MCTN), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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10
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Conti A, Treaba CA, Mehndiratta A, Barletta VT, Mainero C, Toschi N. An Interpretable Machine Learning Model to Predict Cortical Atrophy in Multiple Sclerosis. Brain Sci 2023; 13:brainsci13020198. [PMID: 36831740 PMCID: PMC9954500 DOI: 10.3390/brainsci13020198] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 01/14/2023] [Accepted: 01/19/2023] [Indexed: 01/26/2023] Open
Abstract
To date, the relationship between central hallmarks of multiple sclerosis (MS), such as white matter (WM)/cortical demyelinated lesions and cortical gray matter atrophy, remains unclear. We investigated the interplay between cortical atrophy and individual lesion-type patterns that have recently emerged as new radiological markers of MS disease progression. We employed a machine learning model to predict mean cortical thinning in whole-brain and single hemispheres in 150 cortical regions using demographic and lesion-related characteristics, evaluated via an ultrahigh field (7 Tesla) MRI. We found that (i) volume and rimless (i.e., without a "rim" of iron-laden immune cells) WM lesions, patient age, and volume of intracortical lesions have the most predictive power; (ii) WM lesions are more important for prediction when their load is small, while cortical lesion load becomes more important as it increases; (iii) WM lesions play a greater role in the progression of atrophy during the latest stages of the disease. Our results highlight the intricacy of MS pathology across the whole brain. In turn, this calls for multivariate statistical analyses and mechanistic modeling techniques to understand the etiopathogenesis of lesions.
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Affiliation(s)
- Allegra Conti
- Department of Biomedicine and Prevention, University of Rome ‘Tor Vergata’, Via Montpellier 1, 00133 Rome, Italy
- Correspondence: ; Tel.: +39-06-72596393
| | - Constantina Andrada Treaba
- Massachusetts General Hospital, Boston, MA 02114, USA
- A. A. Martinos Center for Biomedical Imaging, Boston, MA 02129, USA
| | - Ambica Mehndiratta
- Massachusetts General Hospital, Boston, MA 02114, USA
- A. A. Martinos Center for Biomedical Imaging, Boston, MA 02129, USA
| | - Valeria Teresa Barletta
- Massachusetts General Hospital, Boston, MA 02114, USA
- A. A. Martinos Center for Biomedical Imaging, Boston, MA 02129, USA
| | - Caterina Mainero
- Massachusetts General Hospital, Boston, MA 02114, USA
- A. A. Martinos Center for Biomedical Imaging, Boston, MA 02129, USA
| | - Nicola Toschi
- Department of Biomedicine and Prevention, University of Rome ‘Tor Vergata’, Via Montpellier 1, 00133 Rome, Italy
- Massachusetts General Hospital, Boston, MA 02114, USA
- A. A. Martinos Center for Biomedical Imaging, Boston, MA 02129, USA
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11
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Wittayer M, Weber CE, Krämer J, Platten M, Schirmer L, Gass A, Eisele P. Exploring (peri-) lesional and structural connectivity tissue damage through T1/T2-weighted ratio in iron rim multiple sclerosis lesions. Magn Reson Imaging 2023; 95:12-18. [PMID: 36270415 DOI: 10.1016/j.mri.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 10/11/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In multiple sclerosis (MS), iron rim lesions (IRLs) on magnetic resonance imaging (MRI) are associated with pronounced intralesional tissue damage. The aim of this study was to investigate (peri-)lesional and structural connectivity tissue damage in IRLs compared to non-IRLs. MATERIAL AND METHODS MRI was acquired on a 3 T system. Tissue integrity was assessed using the T1/T2-weighted (T1/T2w) ratio. Furthermore, we assessed the impact on structural network connectivity accounting for differences in lesion volumes and T1/T2w values. RESULTS Seventy-six patients (38 with at least one IRL and 38 age- and sex-matched patients without IRLs) were included. In the IRL-group, T1/T2w ratios of IRLs were significantly lower compared to non-IRLs (p < 0.05). When comparing the T1/T2w ratios in non-IRLs between the IRL-group and non-IRL group, there was no significant difference (p = 0.887). We observed a centrifugal decrease in microstructural damage from lesions to the perilesional white matter. In the IRL-group, T1/T2w ratios in the perilesional white matter 3-8 mm distant to the lesion were significantly lower in IRLs compared to non-IRLs. We found no significant differences in the amount of network disruption between both lesion types (p = 0.122). CONCLUSION T1/T2w represents an interesting candidate to capture a pronounced intra- and perilesional tissue damage of IRLs. However, our preliminary results suggest that a pronounced tissue damage might not result in a higher disruption to structural connectivity networks in IRLs.
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Affiliation(s)
- Matthias Wittayer
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Theodor-Kutzer-Ufer 1 - 3, 68167 Mannheim, Germany
| | - Claudia E Weber
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Theodor-Kutzer-Ufer 1 - 3, 68167 Mannheim, Germany
| | - Julia Krämer
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1; Gebäude A1, Westturm, Ebene 5, 48149 Münster, Germany
| | - Michael Platten
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Theodor-Kutzer-Ufer 1 - 3, 68167 Mannheim, Germany; German Consortium of Translational Cancer Research (DKTK), Clinical Cooperation Unit Neuroimmunology and Brain Tumor Immunology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Lucas Schirmer
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Theodor-Kutzer-Ufer 1 - 3, 68167 Mannheim, Germany; Institute for Innate Immunoscience, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Achim Gass
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Theodor-Kutzer-Ufer 1 - 3, 68167 Mannheim, Germany
| | - Philipp Eisele
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Theodor-Kutzer-Ufer 1 - 3, 68167 Mannheim, Germany.
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12
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Hemond CC, Baek J, Ionete C, Reich DS. Paramagnetic rim lesions are associated with pathogenic CSF profiles and worse clinical status in multiple sclerosis: A retrospective cross-sectional study. Mult Scler 2022; 28:2046-2056. [PMID: 35748669 PMCID: PMC9588517 DOI: 10.1177/13524585221102921] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Paramagnetic rims have been observed as a feature of some multiple sclerosis (MS) lesions on susceptibility-sensitive magnetic resonance imaging (MRI) and indicate compartmentalized inflammation. OBJECTIVE To investigate clinical, MRI, and intrathecal (cerebrospinal fluid, CSF) associations of paramagnetic rim lesions (PRLs) using 3T MRI in MS. METHODS This is a retrospective, cross-sectional analysis. All patients underwent 3T MRI using a T2*-weighted sequence with susceptibility postprocessing (susceptibility-weighted angiography (SWAN) protocol, GE). SWAN-derived filtered-phase maps and corresponding T2-FLAIR images were manually reviewed to determine PRL. Descriptive statistics, t-tests, and regression determined demographic, clinical, MRI, and CSF associations with PRL. RESULTS A total of 147 MS patients were included; 79 of whom had available CSF. Forty-three percent had at least one PRL. PRL status (presence/absence) did not vary by sex or Expanded Disability Status Scale (EDSS) but was associated with younger age, shorter disease duration, worse disease severity, high-efficacy therapy use, and poorer dexterity, as well as lower age-adjusted brain volumes and cognitive processing speeds. PRL status was moreover associated with blood-brain barrier disruption as determined by pathologically elevated albumin quotient. Sensitivity analyses remained supportive of these findings. CONCLUSION PRLs, an emerging noninvasive biomarker of chronic neuroinflammation, are confirmed to be associated with greater disease severity and newly shown to be preliminarily associated with blood-brain barrier disruption.
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Affiliation(s)
- Christopher C. Hemond
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, Massachusetts
| | - Jonggyu Baek
- Department of Population and Quantitative Health, University of Massachusetts Chan Medical School, Worcester, Massachusetts
| | - Carolina Ionete
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, Massachusetts
| | - Daniel S. Reich
- Translational Neuroradiology Section, Division of Neuroimmunology and Neurovirology, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
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13
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Combes AJ, Clarke MA, O'Grady KP, Schilling KG, Smith SA. Advanced spinal cord MRI in multiple sclerosis: Current techniques and future directions. Neuroimage Clin 2022; 36:103244. [PMID: 36306717 PMCID: PMC9668663 DOI: 10.1016/j.nicl.2022.103244] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 09/02/2022] [Accepted: 10/19/2022] [Indexed: 11/11/2022]
Abstract
Spinal cord magnetic resonance imaging (MRI) has a central role in multiple sclerosis (MS) clinical practice for diagnosis and disease monitoring. Advanced MRI sequences capable of visualizing and quantifying tissue macro- and microstructure and reflecting different pathological disease processes have been used in MS research; however, the spinal cord remains under-explored, partly due to technical obstacles inherent to imaging this structure. We propose that the study of the spinal cord merits equal ambition in overcoming technical challenges, and that there is much information to be exploited to make valuable contributions to our understanding of MS. We present a narrative review on the latest progress in advanced spinal cord MRI in MS, covering in the first part structural, functional, metabolic and vascular imaging methods. We focus on recent studies of MS and those making significant technical steps, noting the challenges that remain to be addressed and what stands to be gained from such advances. Throughout we also refer to other works that presend more in-depth review on specific themes. In the second part, we present several topics that, in our view, hold particular potential. The need for better imaging of gray matter is discussed. We stress the importance of developing imaging beyond the cervical spinal cord, and explore the use of ultra-high field MRI. Finally, some recommendations are given for future research, from study design to newer developments in analysis, and the need for harmonization of sequences and methods within the field. This review is aimed at researchers and clinicians with an interest in gaining an overview of the current state of advanced MRI research in this field and what is primed to be the future of spinal cord imaging in MS research.
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Affiliation(s)
- Anna J.E. Combes
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, 1161 21st Avenue South, Medical Center North, AA-1105, Nashville, TN 37232-2310, United States,Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Medical Center North, 1161 21st Ave. South, Nashville, TN 37232, United States,Corresponding author at: 1161 21st Ave S, MCN AA1105, Nashville, TN 37232, USA.
| | - Margareta A. Clarke
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, 1161 21st Avenue South, Medical Center North, AA-1105, Nashville, TN 37232-2310, United States
| | - Kristin P. O'Grady
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, 1161 21st Avenue South, Medical Center North, AA-1105, Nashville, TN 37232-2310, United States,Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Medical Center North, 1161 21st Ave. South, Nashville, TN 37232, United States,Department of Biomedical Engineering, Vanderbilt University, 2301 Vanderbilt Place, PMB 351826, Nashville, TN 37235-1826, United States
| | - Kurt G. Schilling
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, 1161 21st Avenue South, Medical Center North, AA-1105, Nashville, TN 37232-2310, United States,Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Medical Center North, 1161 21st Ave. South, Nashville, TN 37232, United States
| | - Seth A. Smith
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, 1161 21st Avenue South, Medical Center North, AA-1105, Nashville, TN 37232-2310, United States,Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Medical Center North, 1161 21st Ave. South, Nashville, TN 37232, United States,Department of Biomedical Engineering, Vanderbilt University, 2301 Vanderbilt Place, PMB 351826, Nashville, TN 37235-1826, United States
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14
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Martire MS, Moiola L, Rocca MA, Filippi M, Absinta M. What is the potential of paramagnetic rim lesions as diagnostic indicators in multiple sclerosis? Expert Rev Neurother 2022; 22:829-837. [PMID: 36342396 DOI: 10.1080/14737175.2022.2143265] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
INTRODUCTION In multiple sclerosis (MS), paramagnetic rim lesions (PRLs) on MRI identify a subset of chronic active lesions (CALs), which have been linked through clinical and pathological studies to more severe disease course and greater disability accumulation. Beside their prognostic relevance, increasing evidence supports the use of PRL as a diagnostic biomarker. AREAS COVERED This review summarizes the most recent updates regarding the MRI pathophysiology of PRL, their prevalence in MS (by clinical phenotypes) vs mimicking conditions, and their potential role as diagnostic MS biomarkers. We searched PubMed with terms including 'multiple sclerosis' AND 'paramagnetic rim lesions' OR 'iron rim lesions' OR 'rim lesions' for manuscripts published between January 2008 and July 2022. EXPERT OPINION Current research suggests that PRL can improve the diagnostic specificity and the overall accuracy of MS diagnosis when used together with the dissemination in space MRI criteria and the central vein sign. Nevertheless, future prospective multicenter studies should further define the real-world prevalence and specificity of PRL. International guidelines are needed to establish methodological criteria for PRL identification before its implementation into clinical practice.
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Affiliation(s)
| | - Lucia Moiola
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria Assunta Rocca
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Division of Neuroscience, Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Filippi
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Division of Neuroscience, Vita-Salute San Raffaele University, Milan, Italy.,Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Martina Absinta
- Division of Neuroscience, Vita-Salute San Raffaele University, Milan, Italy.,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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15
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Altokhis AI, Hibbert AM, Allen CM, Mougin O, Alotaibi A, Lim SY, Constantinescu CS, Abdel-Fahim R, Evangelou N. Longitudinal clinical study of patients with iron rim lesions in multiple sclerosis. Mult Scler 2022; 28:2202-2211. [PMID: 36000485 PMCID: PMC9679801 DOI: 10.1177/13524585221114750] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background: Iron rims (IRs) surrounding white matter lesions (WMLs) are suggested to predict a more severe disease course. Only small longitudinal cohorts of patients with and without iron rim lesions (IRLs) have been reported so far. Objective: To assess whether the presence and number of IRLs in patients with clinically isolated syndrome (CIS) and multiple sclerosis (MS) are associated with long-term disability or progressive disease. Methods: Ninety-one CIS/MS patients were recruited between 2008 and 2013 and scanned with 7 T magnetic resonance imaging (MRI). Expanded Disability Status Scale (EDSS) was used to calculate Age-related Multiple Sclerosis Severity Score (ARMSS) at the time of scan and at the latest clinical follow-up after 9 years. WMLs were assessed for the presence of IRL using Susceptibility weighted imaging (SWI)-filtered phase images. Results: In all, 132 IRLs were detected in 42 patients (46%); 9% of WMLs had IRs; 54% of the cohort had no rims, 30% had 1–3 rims and 16% had ⩾4. Patients with IRL had a higher EDSS and ARMSS. Presence of IRL was also a predictor of long-term disability, especially in patients with ⩾4 IRLs. IRLs have a greater impact on disability compared to the WML number and volume. Conclusion: The presence and number of perilesional IR on MRI hold prognostic value for long-term clinical disability in MS.
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Affiliation(s)
- Amjad I Altokhis
- Mental Health and Clinical Neuroscience Academic Unit, University of Nottingham, Nottingham, UK/Department of Neurology, Nottingham University Hospital NHS Trust, Nottingham, UK/Division of Health and Rehabilitation Sciences, Princess Nourah Bint Abdulrahman University, Riyadh, SA
| | - Aimee M Hibbert
- Department of Neurology, Nottingham University Hospital NHS Trust, Nottingham, UK
| | - Christopher M Allen
- Mental Health and Clinical Neuroscience Academic Unit, University of Nottingham, Nottingham, UK/Department of Neurology, Nottingham University Hospital NHS Trust, Nottingham, UK
| | - Olivier Mougin
- Sir Peter Mansfield Imaging Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Abdulmajeed Alotaibi
- Mental Health and Clinical Neuroscience Academic Unit, University of Nottingham, Nottingham, UK/Department of Neurology, Nottingham University Hospital NHS Trust, Nottingham, UK/Department of Radiological Sciences, School of Applied Medical Sciences, King Saud bin Abdul-Aziz University for Health Sciences, Riyadh, Saudi Arabia/Radiology and Neurosciences unit, King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia
| | - Su-Yin Lim
- Mental Health and Clinical Neuroscience Academic Unit, University of Nottingham, Nottingham, UK/School of Medicine, Faculty of Health and Medical Sciences, Taylor's University, Subang Jaya, Malaysia
| | | | - Rasha Abdel-Fahim
- Department of Neurology, Nottingham University Hospital NHS Trust, Nottingham, UK
| | - Nikos Evangelou
- Mental Health and Clinical Neuroscience Academic Unit, University of Nottingham, Nottingham, UK/Department of Neurology, Nottingham University Hospital NHS Trust, Nottingham, UK
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16
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KOPF HALS – Eisenringläsionen als Marker für den Schweregrad der Multiplen Sklerose. ROFO-FORTSCHR RONTG 2022. [DOI: 10.1055/a-1855-6233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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17
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Eisele P, Wittayer M, Weber CE, Platten M, Schirmer L, Gass A. Impact of disease-modifying therapies on evolving tissue damage in iron rim multiple sclerosis lesions. Mult Scler 2022; 28:2294-2298. [PMID: 35778799 DOI: 10.1177/13524585221106338] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We investigated the impact of disease-modifying therapies (DMTs) on the evolving tissue damage in iron rim multiple sclerosis lesions using a novel post-processing magnetic resonance imaging (MRI) approach, the T1/T2 ratio. In this study, on baseline and 1-year follow-up, T1/T2 ratios of iron rim lesions (IRLs) in patients starting DMT (dimethyl fumarate, fingolimod, ocrelizumab) did not statistically differ compared to patients without DMT. At the second follow-up, T1/T2 ratios were significantly lower in IRLs in patients without DMT (p = 0.002), suggesting that DMTs have a beneficial delayed effect on lesion evolution and tissue matrix damage in IRLs.
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Affiliation(s)
- Philipp Eisele
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Mannheim, Germany
| | - Matthias Wittayer
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Mannheim, Germany
| | - Claudia E Weber
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Mannheim, Germany
| | - Michael Platten
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Mannheim, Germany/German Consortium of Translational Cancer Research (DKTK), Clinical Cooperation Unit Neuroimmunology and Brain Tumor Immunology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Lucas Schirmer
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Mannheim, Germany/Institute for Innate Immunoscience, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Achim Gass
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Mannheim, Germany
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18
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Krajnc N, Bsteh G, Kasprian G, Zrzavy T, Kornek B, Berger T, Leutmezer F, Rommer P, Lassmann H, Hametner S, Dal-Bianco A. Peripheral Hemolysis in Relation to Iron Rim Presence and Brain Volume in Multiple Sclerosis. Front Neurol 2022; 13:928582. [PMID: 35865643 PMCID: PMC9295598 DOI: 10.3389/fneur.2022.928582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/09/2022] [Indexed: 01/05/2023] Open
Abstract
Background: Iron rim lesions (IRLs) represent chronic lesion activity and are associated with a more severe disease course in multiple sclerosis (MS). How the iron rims around the lesions arise in patients with MS (pwMS), and whether peripheral hemolysis may be a source of iron in rim associated macrophages, is unclear. Objective To determine a potential correlation between peripheral hemolysis parameters and IRL presence in pwMS. Methods This retrospective study included pwMS, who underwent a 3T brain MRI between 2015 and 2020 and had a blood sample drawn at ± 2 weeks. Patients with vertigo served as a control group. Results We analyzed 75 pwMS (mean age 37.0 years [SD 9.0], 53.3% female) and 43 controls (mean age 38.3 years [SD 9.8], 51.2% female). Median number of IRLs was 1 (IQR 4), 28 (37.3%) pwMS had no IRLs. IRL patients showed significantly higher Expanded Disability Status Scale (EDSS) compared to non-IRL patients (median EDSS 2.3 [IQR 2.9] vs. 1.3 [IQR 2.9], p = 0.017). Number of IRLs correlated significantly with disease duration (rs = 0.239, p = 0.039), EDSS (rs = 0.387, p < 0.001) and Multiple Sclerosis Severity Scale (MSSS) (rs = 0.289, p = 0.014). There was no significant difference in hemolysis parameters between non-IRL, IRL patients (regardless of gender and/or disease type) and controls, nor between hemolysis parameters and the number of IRLs. Total brain volume was associated with fibrinogen (β= −0.34, 95% CI −1.32 to −0.145, p = 0.016), and absolute cortical and total gray matter volumes were associated with hemoglobin (β = 0.34, 95% CI 3.39–24.68, p = 0.011; β = 0.33, 95% CI 3.29–28.95, p = 0.015; respectively). Conclusion Our data do not suggest an association between hemolysis parameters and IRL presence despite a significant association between these parameters and markers for neurodegeneration.
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Affiliation(s)
- Nik Krajnc
- Medical University of Vienna, Department of Neurology, Vienna, Austria
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Gabriel Bsteh
- Medical University of Vienna, Department of Neurology, Vienna, Austria
| | - Gregor Kasprian
- Medical University of Vienna, Biomedical Imaging and Image-Guided Therapy, Vienna, Austria
| | - Tobias Zrzavy
- Medical University of Vienna, Department of Neurology, Vienna, Austria
| | - Barbara Kornek
- Medical University of Vienna, Department of Neurology, Vienna, Austria
| | - Thomas Berger
- Medical University of Vienna, Department of Neurology, Vienna, Austria
| | - Fritz Leutmezer
- Medical University of Vienna, Department of Neurology, Vienna, Austria
| | - Paulus Rommer
- Medical University of Vienna, Department of Neurology, Vienna, Austria
| | - Hans Lassmann
- Center for Brain Research, Medical University of Vienna, Vienna, Austria
| | - Simon Hametner
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Assunta Dal-Bianco
- Medical University of Vienna, Department of Neurology, Vienna, Austria
- *Correspondence: Assunta Dal-Bianco
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19
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Wittayer M, Weber CE, Platten M, Schirmer L, Gass A, Eisele P. Spatial distribution of multiple sclerosis iron rim lesions and their impact on disability. Mult Scler Relat Disord 2022; 64:103967. [PMID: 35728430 DOI: 10.1016/j.msard.2022.103967] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 06/07/2022] [Accepted: 06/13/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND In multiple sclerosis (MS), iron rim lesions (IRLs) on magnetic resonance imaging (MRI) have been suggested as an imaging marker of disease progression. However, the exact mechanisms how they contribute to disability are yet not completely known. Strategic lesion location may be an important factor concerning the impact of focal lesions on clinical disability. Therefore, the aim of this study was to investigate the spatial distribution of IRLs compared to non-IRLs and their impact on disability. METHODS We retrospectively identified 67 patients with at least one IRL on MRI and 67 age- and sex-matched patients without IRLs. We compared the spatial distribution of lesions between both groups and between IRLs and non-IRLs in patients with IRLs. Furthermore, we assessed the relationship between lesion localisation and disability on a voxel-by-voxel basis and investigated the impact on structural network disruptions. RESULTS Patients with IRLs had higher disability scores (median Expanded Disability Status Scale score (range): 3.0 (0 - 8.5) versus 1.5 (0 - 6.5); p = 0.001; median pyramidal functional system score (range): 1.0 (0 - 5) versus 0 (0 - 4); p = 0.003), significantly lower brain volumes (mean normal-appearing grey matter volume: 749.66 ± 60.58 versus 785.83 ± 53.71 mL; mean normal-appearing white matter volume: 723.58 ± 60.13 versus 753.25 ± 69.61 mL; mean deep grey matter volume: 33.21 ± 4.19 versus 35.85 ± 4.89 mL; p < 0.05 for all comparisons) and a significantly higher total T2 lesion volume (mean: 9.96 ± 11.6 versus 4.31 ± 8.9 mL; p < 0.001). We found no neuroanatomical regions that were more often affected by IRLs. Furthermore, comparing the overall network disruption in the IRL group, IRLs caused less network disruption/mL lesion size compared to non-IRLs (1.54% / mL versus 2.0% / mL; p < 0.05). CONCLUSION IRLs are associated with higher disability scores. However, our results suggest that a higher disability is not explained by the sheer topography of IRLs or their network disruption.
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Affiliation(s)
- Matthias Wittayer
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Theodor-Kutzer-Ufer 1 - 3, Mannheim 68167, Germany
| | - Claudia E Weber
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Theodor-Kutzer-Ufer 1 - 3, Mannheim 68167, Germany
| | - Michael Platten
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Theodor-Kutzer-Ufer 1 - 3, Mannheim 68167, Germany; DKTK CCU Neuroimmunology and Brain Tumor Immunology, DKFZ, Heidelberg, Germany
| | - Lucas Schirmer
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Theodor-Kutzer-Ufer 1 - 3, Mannheim 68167, Germany; Medical Faculty Mannheim, Institute for Innate Immunoscience, Heidelberg University, Mannheim, Germany
| | - Achim Gass
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Theodor-Kutzer-Ufer 1 - 3, Mannheim 68167, Germany
| | - Philipp Eisele
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Theodor-Kutzer-Ufer 1 - 3, Mannheim 68167, Germany.
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Wenzel N, Wittayer M, Weber CE, Schirmer L, Platten M, Gass A, Eisele P. MRI predictors for the conversion from contrast-enhancing to iron rim multiple sclerosis lesions. J Neurol 2022; 269:4414-4420. [PMID: 35332392 PMCID: PMC9293822 DOI: 10.1007/s00415-022-11082-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/11/2022] [Accepted: 03/11/2022] [Indexed: 12/22/2022]
Abstract
BACKGROUND In multiple sclerosis (MS), iron rim lesions (IRLs) are characterized by progressive tissue matrix damage. Therefore, early identification could represent an interesting target for therapeutic intervention to minimize evolving tissue damage. The aim of this study was to identify magnetic resonance imaging (MRI) parameters predicting the conversion from contrast-enhancing to IRLs. METHODS We retrospective identified MS patients scanned on the same 3 T MRI system presenting at least one supratentorial contrast-enhancing lesion (CEL) and a second MRI including susceptibility-weighted images after at least 3 months. On baseline MRI, pattern of contrast-enhancement was categorized as "nodular" or "ring-like", apparent diffusion coefficient (ADC) maps were assessed for the presence of a peripheral hypointense rim. Lesion localization, quantitative volumes (ADC, lesion volume) and the presence of a central vein were assessed. RESULTS Eighty-nine acute contrast-enhancing lesions in 54 MS patients were included. On follow-up, 16/89 (18%) initially CELs converted into IRLs. CELs that converted into IRLs were larger and demonstrated significantly more often a ring-like contrast-enhancement pattern and a peripheral hypointense rim on ADC maps. Logistic regression model including the covariables pattern of contrast-enhancement and presence of a hypointense rim on ADC maps showed the best predictive performance (area under the curve = 0.932). DISCUSSION The combination of a ring-like contrast-enhancement pattern and a peripheral hypointense rim on ADC maps has the ability to predict the evolution from acute to IRLs. This could be of prognostic value and become a target for early therapeutic intervention to minimize the associated tissue damage.
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Affiliation(s)
- Nicolas Wenzel
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Matthias Wittayer
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Claudia E Weber
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Lucas Schirmer
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.,Institute for Innate Immunoscience, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Michael Platten
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.,DKTK CCU Neuroimmunology and Brain Tumor Immunology, DKFZ, Heidelberg, Germany
| | - Achim Gass
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Philipp Eisele
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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Weber CE, Wittayer M, Kraemer M, Dabringhaus A, Bail K, Platten M, Schirmer L, Gass A, Eisele P. Long-term dynamics of multiple sclerosis iron rim lesions. Mult Scler Relat Disord 2022; 57:103340. [PMID: 35158450 DOI: 10.1016/j.msard.2021.103340] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/08/2021] [Accepted: 10/17/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Several studies have pointed out that seemingly chronic multiple sclerosis (MS) lesions may also be in inflammatory states. In pathological studies, up to 40% of chronic MS lesions are characterized as "chronic active" or "smoldering" lesions that are characterized by a rim of iron-laden proinflammatory macrophages/microglial cells at the lesion edge with low-grade continuous myelin breakdown. In vivo, these lesions can be visualized as "iron rim lesions" (IRLs) on susceptibility-weighted imaging (SWI). The aim of this study was to investigate the long-term dynamics of IRLs in vivo for a more detailed evolution of dynamic lesion volume changes occurring over time. METHODS We retrospectively identified patients with MS who were followed for at least 36 months (up to 72 months) and underwent at least an annual MRI on the same 3 Tsystem. Using Voxel-Guided Morphometry (VGM) we investigated regional volume changes within lesions and correlated these findings with SWI for the presence of a characteristic hypointense lesion rim. To estimate tissue damage, apparent diffusion coefficient (ADC) values for every lesion at baseline and follow-up MRIs were determined. RESULTS Forty-three patients were included in the study. Overall, we identified 302 supratentorial non-confluent MS lesions (52 persistent IRLs, nine transient IRLs, 228 non-IRLs and 13 acute contrast-enhancing lesions). During follow-up, persistent IRLs significantly enlarged, whereas non-IRLs showed a tendency to shrink. At baseline MRI, ADC values were significantly higher in persistent IRLs (1.23 × 10-3 mm/s2) compared to non-IRLs (1.01 × 10-3 mm/s2; p < 0.001), but not compared to transient IRLs (1.06 × 10-3 mm/s2; p = 0.15) and contrast-enhancing lesions (1.15 × 10-3 mm/s2; p = 1.0). During follow-up, ADC values significantly increased more often in persistent IRLs compared to all other lesion types (p < 0.0001). CONCLUSIONS Our long-term data demonstrate that persistent IRLs enlarge during disease duration, whereas non-IRLs show a tendency to shrink. Furthermore, IRLs are associated with sustained tissue damage, supporting the notion that IRLs could represent a new imaging biomarker in MS.
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Affiliation(s)
- Claudia E Weber
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Theodor-Kutzer-Ufer 1 - 3, 68167 Mannheim, Germany.
| | - Matthias Wittayer
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Theodor-Kutzer-Ufer 1 - 3, 68167 Mannheim, Germany.
| | - Matthias Kraemer
- VGMorph GmbH, Waterloostr. 32, 45472 Mülheim an der Ruhr, Germany; Neurocentrum, Am Ziegelkamp 1f, 41515 Grevenbroich, Germany.
| | | | - Kathrin Bail
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Theodor-Kutzer-Ufer 1 - 3, 68167 Mannheim, Germany.
| | - Michael Platten
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Theodor-Kutzer-Ufer 1 - 3, 68167 Mannheim, Germany; Institute for Innate Immunoscience, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
| | - Lucas Schirmer
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Theodor-Kutzer-Ufer 1 - 3, 68167 Mannheim, Germany; Institute for Innate Immunoscience, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany; Interdisciplinary Center for Neurosciences, Heidelberg University, Heidelberg, Germany.
| | - Achim Gass
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Theodor-Kutzer-Ufer 1 - 3, 68167 Mannheim, Germany.
| | - Philipp Eisele
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Theodor-Kutzer-Ufer 1 - 3, 68167 Mannheim, Germany.
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