MRI utility in the detection of disease activity in clinically stable patients with multiple sclerosis: a retrospective analysis of a community based cohort

The contemporary role of MRI in the monitoring and management of people with multiple sclerosis in the UK

BACKGROUND

Compare the contemporary use of magnetic resonance imaging (MRI) in the monitoring and management of people with MS in the UK to current consensus guidelines.

METHODS

This retrospective multicentre audit of clinical practice gathered data on 2567 patients with MS from 25 MS centres across the UK.

RESULTS

Routine monitoring (44.7%), and recent clinical relapse (20.3%) were the most common scan indications. In routine monitoring, the addition of spinal imaging to brain showed no significant difference in disease modifying treatment (DMT) decision at subsequent clinical review. Approximately 1 in 5 gadolinium administered scans showed enhancement, and in 1 in 20 patients, gadolinium enhancement was the only evidence of radiological disease activity. Mean inter-scan intervals in relapsing-remitting MS for routine monitoring was 19.2 months (SD 20.7) with wide variation between centres. Only 53.8% of patients under progressive multifocal leukoencephalopathy (PML) surveillance met the recommended scanning frequency. MRI protocols demonstrated heterogeneity in the sequences used for diagnostic, monitoring and PML surveillance scans.

CONCLUSIONS

MS centres across the UK demonstrate varied practice and protocols when using MRI to monitor people with MS. In this cohort, gadolinium use and spinal imaging demonstrates limited impact on subsequent DMT decisions.

Serum neurofilament light in MS: The first true blood-based biomarker?

A simple blood-derived biomarker is desirable in the routine management of multiple sclerosis (MS) patients and serum neurofilament light chain (sNfL) is the most promising candidate. Although its utility was first shown in cerebrospinal fluid (CSF), technological advancements have enabled reliable detection in serum and less frequently plasma, obviating the need for repeated lumbar punctures. In this review, after defining the knowledge gap in MS management that many hope sNfL could fill, we summarize salient studies demonstrating associations of sNfL levels with outcomes of interest. We group these outcomes into inflammatory activity, progression, treatment response, and prediction/prognosis. Where possible we focus on data from real-world perspective observational cohorts. While acknowledging the limitations of sNfL and highlighting key areas for ongoing work, we conclude with our opinion of the role for sNfL as an objective, convenient, and cost-effective adjunct to clinical assessment. Paving the way for other promising biomarkers both blood-derived and otherwise, sNfL is an incremental step toward precision medicine for MS patients.

In vivo detection of teriflunomide-derived fluorine signal during neuroinflammation using fluorine MR spectroscopy

Background: Magnetic resonance imaging (MRI) is indispensable for diagnosing neurological conditions such as multiple sclerosis (MS). MRI also supports decisions regarding the choice of disease-modifying drugs (DMDs). Determining in vivo tissue concentrations of DMDs has the potential to become an essential clinical tool for therapeutic drug monitoring (TDM). The aim here was to examine the feasibility of fluorine-19 (¹⁹F) MR methods to detect the fluorinated DMD teriflunomide (TF) during normal and pathological conditions.

Methods: We used ¹⁹F MR spectroscopy to detect TF in the experimental autoimmune encephalomyelitis (EAE) mouse model of multiple sclerosis (MS) in vivo. Prior to the in vivo investigations we characterized the MR properties of TF in vitro. We studied the impact of pH and protein binding as well as MR contrast agents.

Results: We could detect TF in vivo and could follow the ¹⁹F MR signal over different time points of disease. We quantified TF concentrations in different tissues using HPLC/MS and showed a significant correlation between ex vivo TF levels in serum and the ex vivo¹⁹F MR signal.

Conclusion: This study demonstrates the feasibility of ¹⁹F MR methods to detect TF during neuroinflammation in vivo. It also highlights the need for further technological developments in this field. The ultimate goal is to add ¹⁹F MR protocols to conventional ¹H MRI protocols in clinical practice to guide therapy decisions.