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Keegan BM, Messina SA, Hanson D, Holmes D, Camp J, Sechi E, Nayak S, Barakat B, Ahmad R, Mandrekar J, Harmsen WS, Kantarci O, Weinshenker BG, Flanagan EP. MR Imaging Features of Critical Spinal Demyelinating Lesions Associated with Progressive Motor Impairment. AJNR Am J Neuroradiol 2024; 45:943-950. [PMID: 38754997 PMCID: PMC11286007 DOI: 10.3174/ajnr.a8304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/19/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND AND PURPOSE Progressive MS is typically heralded by a myelopathic pattern of asymmetric progressive motor weakness. Focal individual "critical" demyelinating spinal cord lesions anatomically associated with progressive motor impairment may be a compelling explanation for this clinical presentation as described in progressive solitary sclerosis (single CNS demyelinating lesion), progressive demyelination with highly restricted MR imaging lesion burden (2-5 total CNS demyelinating lesions; progressive paucisclerotic MS), and progressive, exclusively unilateral hemi- or monoparetic MS (>5 CNS demyelinating progressive unilateral hemi- or monoparetic MS [PUHMS] lesions). Critical demyelinating lesions appear strikingly similar across these cohorts, and we describe their specific spinal cord MR imaging characteristics. MATERIALS AND METHODS We performed a retrospective, observational MR imaging study comparing spinal cord critical demyelinating lesions anatomically associated with progressive motor impairment with any additional "noncritical" (not anatomically associated with progressive motor impairment) spinal cord demyelinating lesions. All spinal cord MR images (302 cervical and 91 thoracic) were reviewed by an experienced neuroradiologist with final radiologic assessment on the most recent MR imaging. Anatomic association with clinical progressive motor impairment was confirmed independently by MS subspecialists. RESULTS Ninety-one individuals (PUHMS, 37 [41%], progressive paucisclerosis 35 [38%], progressive solitary sclerosis 19 [21%]) with 91 critical and 98 noncritical spinal cord MR imaging demyelinating lesions were evaluated. MR imaging characteristics that favored critical spinal cord demyelinating lesions over noncritical lesions included moderate-to-severe, focal, lesion-associated spinal cord atrophy: 41/91 (45%) versus 0/98 (0%) (OR, 161.91; 9.43 to >999.9); lateral column axial location (OR, 10.43; 3.88-28.07); central region (OR, 3.23; 1.78-5.88); ventral column (OR, 2.98; 1.55-5.72); and larger lesion size of the axial width (OR, 2.01;1.49-2.72), transverse axial size (OR, 1.66; 1.36-2.01), or lesion area (OR, 1.14; 1.08-1.2). Multiple regression analysis revealed focal atrophy and lateral axial location as having the strongest association with critical demyelinating lesions. CONCLUSIONS Focal, lesion-associated atrophy, lateral column axial location, and larger lesion size are spinal cord MR imaging characteristics of critical demyelinating lesions. The presence of critical demyelinating lesions should be sought as these features may be associated with the development of progressive motor impairment in MS.
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Affiliation(s)
- B Mark Keegan
- From the Department of Neurology (B.M.K., E.S., S.N., B.B., R.A., J.M., O.K., B.G.W., E.P.F.), Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota
| | - Steven A Messina
- Department of Radiology (S.A.M.), Mayo Clinic, Rochester, Minnesota
| | - Dennis Hanson
- Biomedical Imaging Resource (D. Hanson, D. Holmes, J.C.), Mayo Clinic, Rochester, Minnesota
| | - David Holmes
- Biomedical Imaging Resource (D. Hanson, D. Holmes, J.C.), Mayo Clinic, Rochester, Minnesota
| | - Jon Camp
- Biomedical Imaging Resource (D. Hanson, D. Holmes, J.C.), Mayo Clinic, Rochester, Minnesota
| | - Elia Sechi
- From the Department of Neurology (B.M.K., E.S., S.N., B.B., R.A., J.M., O.K., B.G.W., E.P.F.), Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota
- Università degli Studi di Sassari (E.S.), Sassari, Italy
| | - Shreya Nayak
- From the Department of Neurology (B.M.K., E.S., S.N., B.B., R.A., J.M., O.K., B.G.W., E.P.F.), Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota
- St. Elizabeth Dearborn Hospital (S.N.), Lawrenceburg, Indiana
| | - Benan Barakat
- From the Department of Neurology (B.M.K., E.S., S.N., B.B., R.A., J.M., O.K., B.G.W., E.P.F.), Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota
- Mercy St. Vincent Medical Center (B.B.), Toledo, Ohio
| | - Rowaid Ahmad
- From the Department of Neurology (B.M.K., E.S., S.N., B.B., R.A., J.M., O.K., B.G.W., E.P.F.), Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota
- University of Texas Medical Branch (R.A.), Galveston, Texas
| | - Jay Mandrekar
- From the Department of Neurology (B.M.K., E.S., S.N., B.B., R.A., J.M., O.K., B.G.W., E.P.F.), Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota
- Quantitative Health Services (J.M., W.S.H,), Mayo Clinic, Rochester, Minnesota
| | - W Scott Harmsen
- Quantitative Health Services (J.M., W.S.H,), Mayo Clinic, Rochester, Minnesota
| | - Orhun Kantarci
- From the Department of Neurology (B.M.K., E.S., S.N., B.B., R.A., J.M., O.K., B.G.W., E.P.F.), Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota
| | - Brian G Weinshenker
- From the Department of Neurology (B.M.K., E.S., S.N., B.B., R.A., J.M., O.K., B.G.W., E.P.F.), Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota
- Department of Neurology (B.G.W.), University of Virginia Health, Charlottesville, Virginia
| | - Eoin P Flanagan
- From the Department of Neurology (B.M.K., E.S., S.N., B.B., R.A., J.M., O.K., B.G.W., E.P.F.), Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota
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Longbrake EE, Kalincik T. Early Treatment for Multiple Sclerosis: Time Is Brain. Neurology 2023; 101:549-550. [PMID: 37468283 DOI: 10.1212/wnl.0000000000207754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 06/21/2023] [Indexed: 07/21/2023] Open
Affiliation(s)
- Erin E Longbrake
- From the Department of Neurology (E.E.L., T.K.), Yale University, New Haven, CT; Neuroimmunology Centre (E.E.L., T.K.), Department of Neurology, Royal Melbourne Hospital; and CORe (E.E.L., T.K.), Department of Medicine, University of Melbourne, Australia.
| | - Tomas Kalincik
- From the Department of Neurology (E.E.L., T.K.), Yale University, New Haven, CT; Neuroimmunology Centre (E.E.L., T.K.), Department of Neurology, Royal Melbourne Hospital; and CORe (E.E.L., T.K.), Department of Medicine, University of Melbourne, Australia
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Berkovich R, Negroski D, Wynn D, Sellers D, Bzdek KG, Lublin AL, Rawlings AM, Quach C, Wells DP, Dumlao M, Bora A, Ranno AE, Luo KL, Chavin J, Hua LH, Becker D. Effectiveness and safety of switching to teriflunomide in older patients with relapsing multiple sclerosis: A real-world retrospective multicenter analysis. Mult Scler Relat Disord 2023; 70:104472. [PMID: 36566698 DOI: 10.1016/j.msard.2022.104472] [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: 09/20/2022] [Revised: 12/05/2022] [Accepted: 12/17/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The prevalence of multiple sclerosis (MS) in older people is increasing due to population aging and availability of effective disease-modifying therapies (DMTs). Treating older people with MS is complicated by age-related and MS-related comorbidities, immunologic effects of prior DMTs, and immunosenescence. Teriflunomide is a once-daily oral immunomodulator that has demonstrated efficacy and acceptable safety in clinical trials of adults with relapsing forms of MS (RMS). However, there are limited clinical trial and real-world data regarding teriflunomide use in people with MS aged >55 years. We analyzed real-world data to assess the effectiveness and safety of teriflunomide in older people with RMS who had switched to this agent from other DMTs. METHODS People with RMS (relapsing remitting and active secondary progressive MS) aged ≥55 years who had switched from other DMTs to teriflunomide (7 mg or 14 mg) for ≥1 year were identified retrospectively by chart review at four sites in the United States. Data were extracted from medical records from 1 year pre-index to 2 years post-index (index defined as the teriflunomide start date). Assessments of effectiveness included annualized relapse rate (ARR), Expanded Disability Status Scale (EDSS) score, and magnetic resonance imaging (MRI) outcomes. Assessments of safety included lymphocyte counts, infections, and malignancies. We examined the effectiveness outcomes and lymphocyte counts within sub-groups defined by age (55-64, ≥65 years), sex, MS type, and prior route of DMT administration (oral, injectable, infusible). RESULTS In total, 182 patients with RMS aged ≥55 years who switched from other DMTs to teriflunomide were identified (mean [SD] age: 62.5 [5.4] years). Mean ARR decreased from the start of teriflunomide treatment (mean [SD]: 0.43 [0.61]) to year 1 post-index (0.13 [0.65]) and year 2 post-index (0.05 [0.28]). Mean EDSS score remained unchanged from index (mean [SD]: 4.5 [1.8]) to 1 year post-treatment (4.5 [1.8]) and increased slightly at 2 years post-treatment (4.7 [1.7]). MRI scans from index and years 1 and 2 post-index compared with scans from the previous year indicated that most patients had stable or improved MRI outcomes at index (87.7%) and remained stable or improved at years 1 (96.0%) and 2 (93.6%). Lymphopenia decreased at years 1 (21.4%) and 2 post-index (14.8%, compared to index (23.5%). By 1 year post-index, fewer patients had grade 3 or 4 lymphopenia, and at 2 years post-index, there were no patients with grade 3 or 4 lymphopenia. Infection incidence was low (n = 40, 22.0%) and none were related to teriflunomide. The decreases in lymphopenia were driven by decreases among people who switched from a prior oral DMT; there were no notable differences in lymphopenia across the other sub-groups examined. ARR, EDSS score, and MRI outcomes across all sub-groups were similar to the results of the overall population. CONCLUSION Our multicenter, longitudinal, retrospective study demonstrated that patients with RMS aged 55 or older switching to teriflunomide from other DMTs had significantly improved ARR, stable disability, and stable or improved MRI over up to 2 years' follow up. Safety results were acceptable with fewer patients exhibiting lymphopenia at years 1 and 2 post-index.
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Affiliation(s)
- Regina Berkovich
- Regina Berkovich MD PhD Inc MS Neurology, West Hollywood, CA, United States; USC-LAC Neurology, Los Angeles, CA, United States
| | | | - Daniel Wynn
- Consultants in Neurology MS Center, Northbrook, IL, United States
| | | | - Kristen G Bzdek
- Sanofi, Cambridge, MA, United States; Worldwide Clinical Trials, Research Triangle Park, NC, United States
| | | | | | - Cuc Quach
- Sanofi, Cambridge, MA, United States
| | | | | | | | | | | | | | - Le H Hua
- Lou Ruvo Center for Brain Health, Las Vegas, NV, United States
| | - Daniel Becker
- International Neurorehabilitation Institute, Baltimore, MD, USA; Johns Hopkins Hospital, Baltimore, MD, United States.
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