Effect of intravenous methylprednisolone on the number, size and confluence of plaques in relapsing-remitting multiple sclerosis

A Hybrid Approach for MS Diagnosis Through Nonlinear EEG Descriptors and Metaheuristic Optimized Classification Learning

Multiple sclerosis (MS), a disease of the central nervous system, affects the white matter of the brain. Neurologists interpret magnetic resonance images that are often complicated, time-consuming, and contradictory. Using EEG signals, this disease can be analyzed and diagnosed more accurately. However, it is imperative that MS be diagnosed by specialists using assistive technology. Until now, a few methods have been proposed in this field that are sometimes associated with different challenges in analysis. This paper presents a hybrid approach to MS diagnosis in order to decrease classification error rates. Using the proposed method, EEG descriptors in both the time and frequency domains are analyzed. After the feature extraction stage, a modified version of the ant colony optimization method (m-ACO) was used to select the appropriate subset of features. Then, the support vector machine is used to determine whether the disease exists. A metaheuristic algorithm adjusts the support vector machine's parameters to withstand overfitting challenges. Despite a limited number of input channels, significant classification accuracy has been achieved using wavelet analysis techniques, dividing all five subbands of EEG signals, signal windowing, and extracting efficient features from the data. Additionally, alpha, beta, and gamma bands of the signal are important, and the accuracy, sensitivity, and specificity levels are higher than 98.5%. Compared to similar MS diagnostic methods, the proposed method achieved significantly higher diagnostic accuracy. Application and implementation of this method can be effective in treating neurological diseases, including multiple sclerosis.

Predictive MRI Biomarkers in MS—A Critical Review

Background and Objectives: In this critical review, we explore the potential use of MRI measurements as prognostic biomarkers in multiple sclerosis (MS) patients, for both conventional measurements and more novel techniques such as magnetization transfer, diffusion tensor, and proton spectroscopy MRI. Materials and Methods: All authors individually and comprehensively reviewed each of the aspects listed below in PubMed, Medline, and Google Scholar. Results: There are numerous MRI metrics that have been proven by clinical studies to hold important prognostic value for MS patients, most of which can be readily obtained from standard 1.5T MRI scans. Conclusions: While some of these parameters have passed the test of time and seem to be associated with a reliable predictive power, some are still better interpreted with caution. We hope this will serve as a reminder of how vast a resource we have on our hands in this versatile tool—it is up to us to make use of it.

Multiple sclerosis lesion segmentation from brain MRI using U-Net based on wavelet pooling

PURPOSE

The purpose of this work is to segment multiple sclerosis (MS) lesions in magnetic resonance imaging (MRI) images, in which lesions in different sizes are segmented with appropriate accuracy. Automated segmentation as a powerful tool can assist professionals to increase the accuracy of disease diagnosis and its level of progression.

METHODS

We present a deep neural network based on the U-Net architecture in which wavelet transform-based pooling replaces max pooling. In the first part of the network, the wavelet transform is used, and in the second part, it's inverse. In addition to decomposing the input image and reducing its size, the wavelet transform highlights sharp changes in the image and better describes local features. This transform has the multi-resolution characteristic, so its use provides improvement in the detection of lesions of different sizes and segmentation.

RESULTS

The results of this study show that the proposed method has a better Dice similarity coefficient (DSC) value compared to the max pooling and average pooling methods.

CONCLUSION

The proposed method has better results for segmenting MS lesions of different sizes in MRI images than the max and average pooling methods and other methods studied.

Efficacy and safety of oral prednisolone tapering following intravenous methyl prednisolone in patients with multiple sclerosis relapses: A randomized, double-blind, placebo-controlled trial

BACKGROUND

Relapse is one of the main features of multiple sclerosis (MS). Corticosteroids are the first line of management during MS relapse. Since tapering or non-tapering prednisolone after corticosteroid pulse has been a controversial issue, this clinical trial is designed to evaluate the efficacy and safety of the tapering regimen.

METHODS

Having been treated by intravenous methylprednisolone (IVMP) pulse, sixty-six patients with MS-relapse were randomly assigned to receive oral prednisolone tapering (OPT) or placebo. The regimen was administered in line with the study protocol and the dose was tapered over 20 days. Demographics and symptoms, impact on activities of daily living (ADL), and management procedures were recorded according to Assessing Relapse in Multiple Sclerosis (ARMS) Questionnaire. The incidence of adverse events was assessed using the same questionnaire. Patients' disability improvement was assessed using the Extended Disability Scale (EDSS) during relapse, and over the first, third, sixth months following treatment.

RESULTS

As shown by the results of the questionnaire, 75% reported that their ADL was not or minimally affected by OPT and there was no significant difference in terms of ADL after treatment between the two groups (p=0.3). The effect of treatment on return to the previous state of health (RSH) showed that there were no differences between the two groups of the study (p=0.5). The improvement of disability in the two groups of oral prednisolone and placebo did not indicate a difference in terms of EDSS in the first and third and six months (p = 0.5, p = 0.9, p=0.3, respectively). Also, the occurrence of some side effects such as weight gain (p = 0.000) and increased appetite (p = 0.004) was higher in the OPT group.

CONCLUSION

The findings of this study revealed that the efficacy of an OPT after a corticosteroid pulse is non-superior to IVMP plus only in case the safety and tolerability profile are comparable.

Long term effects of corticosteroids in multiple sclerosis in terms of the "no evidence of disease activity" (NEDA) domains

BACKGROUND

Multiple sclerosis (MS) is a chronic immune-mediated inflammatory disease of the central nervous system (CNS) that usually is clinically characterized by multiple subacute relapses and remissions. The established therapeutic strategies include intravenous methylprednisolone (IV-MP) for treatment of relapses and immunomodulatory or immunosuppressive treatment to prevent new relapses and progression of disability. Despite not being one of the recommended immunomodulatory or immunosuppressive treatments, monthly IV-MP is frequently seen in clinical practice especially in the low income developing countries.

OBJECTIVES

To review the evidences for the possible disease modifying potential of corticosteroids in the treatment of MS in terms of the NEDA 3 domains.

MATERIALS & METHODS

Available literature from PubMed search and personal experiences on corticosteroid treatment in multiple sclerosis were reviewed.

RESULTS

There is some evidence that pulsed treatment with methylprednisolone have beneficial long-term effects on relapse rate, MRI findings and disability progression.

CONCLUSION

More data is needed to determine long-term disease modifying effects of corticosteroids. The findings of this study suggest that, perhaps, regular pulse glucocorticoid treatment may have important long-term consequences (beneficial) for patients with MS and it may achieve the NEDA target. Certainly, the magnitude of the reported effects deserves further investigation in both relapsing and progressive MS populations.

An Automated Statistical Technique for Counting Distinct Multiple Sclerosis Lesions

BACKGROUND AND PURPOSE

Lesion load is a common biomarker in multiple sclerosis, yet it has historically shown modest association with clinical outcome. Lesion count, which encapsulates the natural history of lesion formation and is thought to provide complementary information, is difficult to assess in patients with confluent (ie, spatially overlapping) lesions. We introduce a statistical technique for cross-sectionally counting pathologically distinct lesions.

MATERIALS AND METHODS

MR imaging was used to assess the probability of a lesion at each location. The texture of this map was quantified using a novel technique, and clusters resembling the center of a lesion were counted. Validity compared with a criterion standard count was demonstrated in 60 subjects observed longitudinally, and reliability was determined using 14 scans of a clinically stable subject acquired at 7 sites.

RESULTS

The proposed count and the criterion standard count were highly correlated (r = 0.97, P < .001) and not significantly different (t₅₉ = -.83, P = .41), and the variability of the proposed count across repeat scans was equivalent to that of lesion load. After accounting for lesion load and age, lesion count was negatively associated (t₅₈ = -2.73, P < .01) with the Expanded Disability Status Scale. Average lesion size had a higher association with the Expanded Disability Status Scale (r = 0.35, P < .01) than lesion load (r = 0.10, P = .44) or lesion count (r = -.12, P = .36) alone.

CONCLUSIONS

This study introduces a novel technique for counting pathologically distinct lesions using cross-sectional data and demonstrates its ability to recover obscured longitudinal information. The proposed count allows more accurate estimation of lesion size, which correlated more closely with disability scores than either lesion load or lesion count alone.

Inhibition of CD40-TRAF6 interactions by the small molecule inhibitor 6877002 reduces neuroinflammation

BACKGROUND

The influx of leukocytes into the central nervous system (CNS) is a key hallmark of the chronic neuro-inflammatory disease multiple sclerosis (MS). Strategies that aim to inhibit leukocyte migration across the blood-brain barrier (BBB) are therefore regarded as promising therapeutic approaches to combat MS. As the CD40L-CD40 dyad signals via TNF receptor-associated factor 6 (TRAF6) in myeloid cells to induce inflammation and leukocyte trafficking, we explored the hypothesis that specific inhibition of CD40-TRAF6 interactions can ameliorate neuro-inflammation.

METHODS

Human monocytes were treated with a small molecule inhibitor (SMI) of CD40-TRAF6 interactions (6877002), and migration capacity across human brain endothelial cells was measured. To test the therapeutic potential of the CD40-TRAF6-blocking SMI under neuro-inflammatory conditions in vivo, Lewis rats and C57BL/6J mice were subjected to acute experimental autoimmune encephalomyelitis (EAE) and treated with SMI 6877002 for 6 days (rats) or 3 weeks (mice).

RESULTS

We here show that a SMI of CD40-TRAF6 interactions (6877002) strongly and dose-dependently reduces trans-endothelial migration of human monocytes. Moreover, upon SMI treatment, monocytes displayed a decreased production of ROS, tumor necrosis factor (TNF), and interleukin (IL)-6, whereas the production of the anti-inflammatory cytokine IL-10 was increased. Disease severity of EAE was reduced upon SMI treatment in rats, but not in mice. However, a significant reduction in monocyte-derived macrophages, but not in T cells, that had infiltrated the CNS was eminent in both models.

CONCLUSIONS

Together, our results indicate that SMI-mediated inhibition of the CD40-TRAF6 pathway skews human monocytes towards anti-inflammatory cells with reduced trans-endothelial migration capacity, and is able to reduce CNS-infiltrated monocyte-derived macrophages during neuro-inflammation, but minimally ameliorates EAE disease severity. We therefore conclude that SMI-mediated inhibition of the CD40-TRAF6 pathway may represent a beneficial treatment strategy to reduce monocyte recruitment and macrophage activation in the CNS and has the potential to be used as a co-treatment to combat MS.

Adrenocorticotropic hormone versus methylprednisolone added to interferon β in patients with multiple sclerosis experiencing breakthrough disease: a randomized, rater-blinded trial

BACKGROUND

The objective of this study was to evaluate monthly intramuscular adrenocorticotropic hormone (ACTH) gel versus intravenous methylprednisolone (IVMP) add-on therapy to interferon β for breakthrough disease in patients with relapsing forms of multiple sclerosis.

METHODS

This was a prospective, open-label, examiner-blinded, 15-month pilot study evaluating patients with Expanded Disability Status Scale (EDSS) score 3.0-6.5 and at least one clinical relapse or new T2 or gadolinium-enhanced lesion in the previous year. Twenty-three patients were randomized to ACTH (n = 12) or IVMP (n = 11) and completed the study. The primary outcome measure was the cumulative number of relapses. Secondary outcomes included EDSS, Mental Health Inventory (MHI), plasma cytokines, MS Functional Composite (MSFC), Quality-of-Life (MS-QOL) score, bone mineral density (BMD), and new or worsened psychiatric symptoms per month. Brain magnetic resonance imaging was analyzed post hoc. This was a preliminary and small-scale study.

RESULTS

Relapse rates differed significantly [ACTH 0.08, 95% confidence interval (CI) 0.01-0.54 versus IVMP 0.80, 95% CI 0.36-1.75; rate ratio, IVMP versus ACTH: 9.56, 95% CI 1.23-74.6; p = 0.03]. ACTH improved (p = 0.03) MHI (slope 0.95 ± 0.38 points/month; p = 0.02 versus slope -0.38 ± 0.43 points/month; p = 0.39). On-study decreases (all p < 0.05) in eight cytokine levels occurred only in the ACTH group. However, on-study EDSS, MSFC, MS-QOL, BMD, and MRI lesion changes were not significant between groups. Psychiatric symptoms per patient were greater with IVMP than ACTH (0.55, 95% CI 0.12-2.6 versus 0; p < 0.0001). Other common adverse events were insomnia and urinary tract infections (IVMP, seven events each) and fatigue or flu symptoms (ACTH, five events each).

CONCLUSIONS

This study provided class II evidence that ACTH produced better examiner-assessed cumulative rates of relapses per patient than IVMP in the adjunctive treatment of breakthrough disease in multiple sclerosis.

Optimizing the use of radiologist seed points for improved multiple sclerosis lesion segmentation

Many current methods for multiple sclerosis (MS) lesion segmentation require radiologist seed points as input, but do not necessarily allow the expert to work in an intuitive or efficient way. Ironically, most methods also assume that the points are placed optimally. This paper examines how seed points can be processed with intuitive heuristics, which provide improved segmentation accuracy while facilitating quick and natural point placement. Using a large set of MRIs from an MS clinical trial, two radiologists are asked to seed the lesions while unaware that the points would be fed into a classifier, based on Parzen windows, that automatically delineates each marked lesion. To evaluate the impact of the new heuristics, an interactive region-growing method is used to provide ground truth and the Dice coefficient (DC) and Spearman’s rank correlation are used as the primary measures of agreement. A stratified analysis is performed to determine the effect on scans with low-, medium-, and high lesion loads. Compared to the unenhanced classifier, the heuristics dramatically improve the DC (+32.91 pt.) and correlation (+0.50) for the scans with low lesion loads, and also improve the DC (+14.55 pt.) and correlation (+0.15) for the scans with medium lesion loads, while having aminimal effect for the scans with high lesion loads, which are already segmented accurately by Parzen windows.With the heuristics, the DC is close to 80% and the correlation is above 0.9 for all three load categories.

Glucocorticoid treatment of multiple sclerosis

Glucorticorticoids have both anti-inflammatory and immunosuppressive properties and both synthetic and natural glucocorticoid medications have been used to treat a number of inflammatory and autoimmune conditions, including the management of acute multiple sclerosis (MS) attacks. Many of the studies supporting the use of this approach to MS treatment have important limitations. Nevertheless, on balance, the data seem to support the notion that a brief glucocorticoid treatment regimen (~2 weeks) hastens recovery from an acute MS flare and that this treatment, in general, is well tolerated. However, such treatment does not seem to alter the final degree of recovery from the MS attack. Among the practice community, even within MS centers, there seems to be a general belief that the selection of the optimal agent, route of administration, and the duration of therapy can be made on the basis of personal experience and/or theoretic considerations. As a result, currently, there are a variety of idiosyncratic regimens (often vigorously defended), which are commonly used to treat patients. Nevertheless, it is important to recognize that the best route of administration, the optimal dose and duration of treatment, and the preferred agent or agents have yet to be firmly established. Moreover, although it may well turn out that some of these factors are more important than others, the best current evidence for the efficacy of glucocorticoid treatment in MS, by far, comes from the optic neuritis treatment trial, which used high-dose intravenous methylprednisolone for the first 3 days followed by an 11-day course of low-dose oral prednisone.

Quantitative MRI analysis in children with multiple sclerosis: a multicenter feasibility pilot study

BACKGROUND

Pediatric multiple sclerosis (MS) is a rare disorder with significant consequences. Quantitative MRI measurements may provide significant insights, however multicenter collaborative studies are needed given the small numbers of subjects. The goal of this study is to demonstrate feasibility and evaluate lesion volume (LV) characteristics in a multicenter cohort of children with MS.

METHODS

A common MRI-scanning guideline was implemented at six member sites of the U.S. Network of Pediatric MS Centers of Excellence. We included in this study the first ten scans performed at each site on patients meeting the following inclusion criteria: pediatric RRMS within 3 years of disease onset, examination within 1 month of MRI and no steroids 1 month prior to MRI. We quantified T2 number, T2-LV and individual lesion size in a total of 53 MRIs passing quality control procedures and assessed gadolinium-enhancing lesion number and LV in 55 scans. We studied MRI measures according to demographic features including age, race, ethnicity and disability scores, controlling for disease duration and treatment duration using negative binomial regression and linear regression.

RESULTS

The mean number of T2 lesions was 24.30 ± 19.68 (range:1-113) and mean gadolinium-enhancing lesion count was 1.85 ± 5.84, (range:0-32). Individual lesion size ranged from 14.31 to 55750.60 mm3. Non-white subjects had higher T2-LV (unadjusted pT2-LV = 0.028; adjusted pT2-LV = 0.044), and maximal individual T2-LV (unadjusted pMax = 0.007; adjusted pMax = 0.011) than white patients. We also found a trend toward larger mean lesion size in males than females (p = 0.07).

CONCLUSION

Assessment of MRI lesion LV characteristics is feasible in a multicenter cohort of children with MS.

A randomized clinical trial of oral versus intravenous methylprednisolone for relapse of MS

Background:

Steroids improve multiple sclerosis (MS) relapses but therapeutic window and dose, frequency and administration route remain uncertain.

Objective:

The objective of this paper is to compare the clinical and radiologic efficacy, tolerability and safety of intravenous methylprednisolone (ivMP) vs oral methylprednisolone (oMP), at equivalent high doses, for MS relapse.

Methods:

Forty-nine patients with moderate or severe relapse within the previous 15 days were randomized in a double-blind, noninferiority, multicenter trial to receive ivMP or oMP and their matching placebos. Expanded Disability Status Scale (EDSS) scores were determined at baseline and weeks 1, 4 and 12. Brain MRI were assessed at baseline and at weeks 1 and 4. Primary endpoint was a noninferiority assessment of EDSS improvement at four weeks (noninferiority margin of one point), with further key efficacy assessments of number and volume of T1 gadolinium-enhancing (Gd+), and new or enlarged T2 lesions at four weeks’ post-treatment initiation. Secondary outcomes were safety and tolerability.

Results:

The study achieved the main outcome of noninferiority at four weeks for improved EDSS score. No differences were found between ivMP and oMP in the number of Gd+ lesions (0 (0–1) vs 0 (0–0.5), p = 0.630), volume of Gd+ lesions (0 (0–88.0) vs 0 (0–32.9) mm3, p = 0.735), or new or enlarged T2 lesions (0 (0–194) vs 0 (0–123), p = 0.769). MP was well tolerated, and no serious adverse events were reported.

Conclusions:

This study provides confirmatory evidence that oMP is not inferior to ivMP in reducing EDSS, similar in MRI lesions at four weeks for MS relapses and is equally well tolerated and safe.

Trial registration:

clinicaltrials.gov identifier: NCT00753792

Cuprizone-induced demyelination as a tool to study remyelination and axonal protection

In the brain of multiple sclerosis (MS) patients, the conduction block of axons due to demyelination and inflammation underlies early neurological symptoms, whereas axonal transection accounts for permanent deficits occurring during later disease stages. The beneficial function of myelin for the protection of the axonal compartment and network stability between neurons has been shown in numerous studies. Thus, rapid and adequate remyelination is an important factor for axonal patronage during neuroinflammatory conditions. In this review article, we discuss frequently used experimental in vivo and in vitro animal models to examine remyelination and repair in MS. The focus of the discussion is the relevance of the toxin model 'cuprizone' to study the pathology of demyelination and the physiology of remyelination. This also includes recent findings in this animal model which implicate that axonal damage is an ongoing process independent of the initiation of endogenous remyelination.

Multiple sclerosis, relapses, and the mechanism of action of adrenocorticotropic hormone

Relapses in multiple sclerosis (MS) are disruptive and frequently disabling for patients, and their treatment is often a challenge to clinicians. Despite progress in the understanding of the pathophysiology of MS and development of new treatments for long-term management of MS, options for treating relapses have not changed substantially over the past few decades. Corticosteroids, a component of the hypothalamic-pituitary-adrenal axis that modulate immune responses and reduce inflammation, are currently the mainstay of relapse treatment. Adrenocorticotropic hormone (ACTH) gel is another treatment option. Although it has long been assumed that the efficacy of ACTH in treating relapses depends on the peptide’s ability to increase endogenous corticosteroid production, evidence from research on the melanocortin system suggests that steroidogenesis may only partly account for ACTH influences. Indeed, the melanocortin peptides [ACTH and α-, β-, γ-melanocyte-stimulating hormones (MSH)] and their receptors (Melanocortin receptors, MCRs) exert multiple actions, including modulation of inflammatory and immune mediator production. MCRs are widely distributed within the central nervous system and in peripheral tissues including immune cells (e.g., macrophages). This suggests that the mechanism of action of ACTH includes not only steroid-mediated indirect effects, but also direct anti-inflammatory and immune-modulating actions via the melanocortin system. An increased understanding of the role of the melanocortin system, particularly ACTH, in the immune and inflammatory processes underlying relapses may help to improve relapse management.

Is multiple sclerosis a generalized disease of the central nervous system? An MRI perspective

PURPOSE OF REVIEW

Is multiple sclerosis (MS) a generalized disease of the central nervous system? Or put another way, is MS pathology primarily focal with global consequences or global with focal consequences? Consideration of this question depends on how you view it both spatially and temporally. In this review, we address some of the main themes underlying this issue, drawing on evidence especially from MRI, but also from histopathological studies.

RECENT FINDINGS

Pathology in MS is not confined only to white matter lesions; apparently normal appearing tissues, including the grey matter, are also affected. Within what is classified as normal-appearing tissue, there may be variable degrees of demyelination, particularly in the grey matter, along with regions that will eventually become overtly lesion containing and areas of remyelination. It remains uncertain whether changes within the normal-appearing tissues are immediately associated with, or a direct consequence of, lesion formation.

SUMMARY

At present, it is not possible to determine whether lesion formation, or a more diffuse process, is the principal pathological event in MS.

Favorable effect of immunomodulator therapy on bone mineral density in multiple sclerosis

BACKGROUND

Osteoporosis is a complication of multiple sclerosis (MS), especially if corticosteroid therapy is given. Little is known about the effect on bone of immunomodulatory therapy (IMT) for MS.

AIM

We sought to evaluate bone mass in patients with MS on IMT.

METHODS

We measured bone mineral density (BMD) by dual energy X-ray absorptiometry (DXA) in 37 patients with MS who received IMT. Different IMTs were administered: interferon beta-1a in 70%, interferon beta-1b in 27% and Glatiramer in 3%. High-dose pulse corticosteroid therapy (intravenous methylprednisolone 500 mg) was given to 81% ranging from 1 to 17 courses.

RESULTS

Both mean BMD Z-score at spine of 0.53 (CI, 0.15-0.92; P = 0.0084) and mean BMD Z-score at femur of 0.72 (CI, 0.42-1.01; P < 0.0001) were significantly greater than zero.

CONCLUSIONS

IMT may have a favorable effect on bone in patients with MS even in the presence of pulse steroid therapy.