New brain lesions with no impact on physical disability can impact cognition in early multiple sclerosis: A ten-year longitudinal study

Impairments of attention in RRMS patients: the role of disease duration

INTRODUCTION

The extent to which different types of attention are affected in RRMS based on disease duration has not been extensively analyzed. Therefore, the aim of this study was to determine whether MS patients differ compared to healthy individuals in a homogeneous sample of RRMS patients in terms of attention types and from which year of MS attention deficit starts. Another aim of the study was to examine the effect of MS duration and stimulus onset asynchrony on dual task performance.

METHODS

The sample consisted of RRMS patients (n = 53) and healthy participants (n = 30) between the ages of 20-49, who were at least primary school graduates. Healthy participants in the comparison group were reached by snowball sampling technique. Stroop Test, Cancellation Test, Paced Auditory Serial Addition Test, Coding Test, WMS-R Digit Span and Visual Memory Span subtests were administered to assess attention. Divided attention performance was assessed with a dual task developed based on psychological refractory period paradigm.

RESULTS

The results show that there is a significant difference between RRMS patients and healthy participants in terms of different types of attention (p < 0.05). Focused, sustained and divided attention of RRMS patients and the ability to resist interference showed a significant decline from the 7th year of the disease (p < 0.05); no significant difference was found between healthy participants and patients with 1-6 years of RRMS.

CONCLUSIONS

Although the results of the study are consistent with the literature which show that attention deficit develops in MS, it is important in terms of showing that attention deficit changes depending on the duration of the disease. Focused attention, sustained attention, interference resistance and divided attention performance of RRMS patients showed a significant decline after the 7th year of the disease.

Cortical Lesions as an Early Hallmark of Multiple Sclerosis: Visualization by 7 T MRI

OBJECTIVES

Compelling evidence indicates a significant involvement of cortical lesions in the progressive phase of multiple sclerosis (MS), significantly contributing to late-stage disability. Despite the promise of ultra-high-field magnetic resonance imaging (MRI) in detecting cortical lesions, current evidence falls short in providing insights into the existence of such lesions during the early stages of MS or their underlying cause. This study delineated, at the early stage of MS, (1) the prevalence and spatial distribution of cortical lesions identified by 7 T MRI, (2) their relationship with white matter lesions, and (3) their clinical implications.

MATERIALS AND METHODS

Twenty individuals with early-stage relapsing-remitting MS (disease duration <1 year) underwent a 7 T MRI session involving T1-weighted MP2RAGE, T2*-weighted multiGRE, and T2-weighted FLAIR sequences for cortical and white matter segmentation. Disability assessments included the Expanded Disability Status Scale, the Multiple Sclerosis Functional Composite, and an extensive evaluation of cognitive function.

RESULTS

Cortical lesions were detected in 15 of 20 patients (75%). MP2RAGE revealed a total of 190 intracortical lesions (median, 4 lesions/case [range, 0-44]) and 216 leukocortical lesions (median, 2 lesions/case [range, 0-75]). Although the number of white matter lesions correlated with the total number of leukocortical lesions ( r = 0.91, P < 0.001), no correlation was observed between the number of white matter or leukocortical lesions and the number of intracortical lesions. Furthermore, the number of leukocortical lesions but not intracortical or white-matter lesions was significantly correlated with cognitive impairment ( r = 0.63, P = 0.04, corrected for multiple comparisons).

CONCLUSIONS

This study highlights the notable prevalence of cortical lesions at the early stage of MS identified by 7 T MRI. There may be a potential divergence in the underlying pathophysiological mechanisms driving distinct lesion types, notably between intracortical lesions and white matter/leukocortical lesions. Moreover, during the early disease phase, leukocortical lesions more effectively accounted for cognitive deficits.

Active and non-active progression independent of relapse activity within the first 20 years of relapsing multiple sclerosis

BACKGROUND

Progression independent of relapse activity (PIRA) has been described since the early stage of relapsing multiple sclerosis (RMS). However, little is known about the relation between PIRA and inflammatory activity that is particularly important at this stage of the disease.

METHOD

We included 110 patients in a prospective study within 18 months of RMS onset. MRI examinations and clinical visits were scheduled on the same day for months 0, 6, 12, 24, 36, 60, 84, 120, 180 and 240.

RESULTS

The mean (SD) age of patients was 30 (6.7) years at inclusion and median (range) follow-up 15 (9-20) years. Analysis of 1118 between-visit intervals revealed 93 confirmed disability accumulation events in 68 (62%) patients: 50 (54%) events related to relapse activity worsening and 43 (46%) PIRA events, including 17 (18%) with MRI activity. The risk of PIRA between two visits (stable event as the reference category) was associated with Expanded Disability Status Scale (EDSS) score (HR: 1.41; 95% CI: 1.18 to 1.69; p<0.001), disease duration (HR: 0.75; 95% CI: 0.62 to 0.90; p<0.005) and new lesions between the visits (HR: 1.09 per lesion; 95% CI: 1.01 to 1.17; p<0.05). As compared with PIRA events with MRI activity, PIRA events without such activity occurred in patients with more disability (mean EDSS score 3, p<0.05), longer disease duration (mean 11 years, p<0.001) and greater number of T2-weighted lesions (p<0.05).

CONCLUSION

This study evidenced that inflammatory activity increases the risk of PIRA in early RMS, arguing that a significant part of PIRA is accessible to treatment targeting inflammation in these patients.

Correlation between cognitive changes and neuroradiological changes over time in multiple sclerosis: a systematic review and meta-analysis

BACKGROUND

While many studies have examined relationships of neuroimaging variables to cognitive measures in multiple sclerosis (MS), longitudinal studies are lacking. The relationship of cognitive changes to neuroradiological changes in MS is thus incompletely understood. The present study systematically reviews all studies reporting a relationship between MRI changes and cognitive changes after at least one year of follow-up.

METHOD

An extensive and methodical search of online databases was conducted to identify qualified studies until August 2023. Among various cognitive tests and magnetic resonance imaging (MRI) measures, Symbol Digit Modalities Test (SDMT), Paced Auditory Serial Addition Test (PASAT), verbal fluency, T2 lesion volume (T2LV), white matter lesion volume (WML), and grey matter volume (GMV) qualified for inclusion in a meta-analysis investigating the association of cognitive changes to neuroradiological changes.

RESULTS

We identified 35 studies that explored the link between MRI changes and changes in cognitive outcomes. Of these, twenty studies (57.14%) investigated the association between SDMT/PASAT and MRI metrics. Eleven studies (31.42%) focused on the relationship between MRI metrics and verbal learning and memory, while ten studies (28.57%) reported associations with visuospatial learning and memory. Furthermore, eight studies (22.85%) analyzed the correlation between verbal fluency and MRI measures. Only 5 were eligible for inclusion in the meta-analysis. The meta-analysis evaluated correlations between SDMT/PASAT and GMV (rs = 0.67, 95% CI 0.44-0.91), and verbal fluency and T2LV (rs = 0.35, 95% CI 0.09-0.60).

CONCLUSION

In this rigorously conducted systematic review, we found a significant association of cognitive changes, specifically SDMT/PASAT and verbal fluency, to changes in T2LV and atrophy in individuals with MS. Findings should be interpreted cautiously due to the limited amount of high-quality research, small sample sizes, and variability in study methodologies.

Evaluation of a self-administered iPad®-based processing speed assessment for people with multiple sclerosis in a clinical routine setting

BACKGROUND

Limited resources often hinder regular cognitive assessment of people with multiple sclerosis (pwMS) in standard clinical care. A self-administered iPad®-based cognitive screening-tool (Processing Speed Test; PST) might mitigate this problem.

OBJECTIVE

To evaluate the PST in clinical routine.

METHODS

We investigated the feasibility of the PST in both a quiet and a waiting room setting. We assessed the validity of the PST in comparison with the established Symbol Digit Modalities Test (SDMT). We explored associations between processing speed assessments and the Brief International Cognitive Assessment for MS (BICAMS), magnetic resonance imaging (MRI) parameters, and psychological factors. Additionally, we explored the ability of the PST to detect impairment in processing speed compared to the SDMT.

RESULTS

The PST was feasible in the waiting room setting. PST and SDMT correlated comparably with the BICAMS, MRI parameters, and psychological variables. Of 172 pwMS, 50 (30.8%) showed cognitive impairment according to the BICAMS; respective values were 47 (27.3%) for the SDMT and 9 (5.2%) for the PST.

CONCLUSIONS

The PST performed in a waiting room setting correlates strongly with established cognitive tests. It thus may be used to assess processing speed in a resource-efficient manner and complement cognitive assessment in clinical routine. Despite comparable validity of the PST and SDMT, we identified more pwMS with impaired processing speed using normative data of the SDMT compared to the PST and advise caution, that the common cut-off score of - 1.5 SD from the current PST is not appropriate in Europe.

Rest-Activity Rhythm, Pain, and Motor Activity in Multiple Sclerosis

BACKGROUND

Although the relationships among physical disability, mood disorders, and pain are well described in multiple sclerosis (MS), little is known about whether those symptoms are associated with sleep disturbances.

METHODS

Forty-six patients with MS experiencing pain participated. Sleep was indirectly measured by assessing rest-activity rhythm via actigraphy: interdaily stability, intradaily variability, and relative amplitude. Pain was assessed using visual and verbal analog scales, mood by the Beck Depression Inventory and Symptom Checklist-90, and physical disability by the Expanded Disability Status Scale.

RESULTS

Incorporating mood, pain, and physical disability into 1 regression model resulted in a significant association with interdaily stability.

CONCLUSIONS

Compared with intradaily variability and relative amplitude, interdaily stability seems to be the most vulnerable actigraphy variable for mood disturbances, pain, and physical disabilities.

Cognitive impairment and its treatment in patients with multiple sclerosis

Cognitive impairment (CI) is a relatively common manifestation of multiple sclerosis (MS), which can occur with any type of the disease course and activity. The largest CI prevalence and severity are observed in progressive MS. In relapsing-remitting MS the most prominent deterioration of cognitive functions is seen during relapses; however, in some patients it can continue also throughout remission. In a small number of patients CI can be the most significant symptom of the disease; in addition, it sometimes can be the only clinical feature of the relapse. Despite this, in clinical practice CI remains out of the focus of attention, and is not evaluated when assessing the disease severity and/or activity, while CI is not included into EDSS. Nonetheless, a number of specialized neuropsychological tests and batteries has been developed recently, which can be used for both screening and detailed assessment of CI in MS, as well as for assessment of its changes over time. CI has a negative impact on MS patients' quality of life, their social interactions, daily and occupational activities. The influence of disease-modifying agents on CI has been poorly investigated; however, there is evidence that they can reduce the degree of CI. The optimal choice of pathogenetic treatment in patients with CI remains understudied. There is no convincing evidence of the effectiveness of symptomatic pharmacological treatment of CI in MS, and cognitive rehabilitation is the only approach with confirmed effectiveness. Considering the limitations of this technique (its availability, quite a big number of sessions), there is a need to search for other methods to increase its efficacy, including non-invasive neuromodulation (in particular, transcranial direct current stimulation or transcranial magnetic stimulation). This article is focused on a brief review of the main diagnostic methods of CI in MS, its pathogenetic and symptomatic treatment, and cognitive rehabilitation techniques, as well as on the results of the studies on non-invasive neuromodulation.

A true isolated cognitive relapse in multiple sclerosis

Isolated cognitive relapses (ICRs) have been a matter of debate for the past few years. Currently, there is no clear consensus on such an entity, as cognitive decline usually accompanies typical multiple sclerosis (MS) relapses. Herein, we present the neuropsychological and neurophysiological manifestations of a patient who suddenly complained of confusion and memory loss, showing insight into her deficit, in absence of sensorimotor disturbances. Neuroimaging revealed a large tumefactive gadolinium-enhancing lesion localized in the left medial temporal lobe. The patient's symptoms persisted for months afterwards, despite corticosteroid treatment. We believe our patient experienced a true ICR. ICRs are rare entities in MS, but we should be alert to their existence in order to treat them promptly. Deepening their pathophysiology is equally important and neuropsychology combined with neurophysiology may be useful in this regard.

Is There Reduced Hemodynamic Brain Activation in Multiple Sclerosis Even with Undisturbed Cognition?

Cognitive impairments related to changes in deep gray matter and other brain regions occur in up to 70% of people with multiple sclerosis. But do such brain changes also occur in patients without significant cognitive impairment? Eighteen participants with relapsing-remitting multiple sclerosis (RRMS) and fifteen healthy controls participated in this study. Cognitive status, depression, and fatigue were assessed using the Multiple Sclerosis Inventory of Cognition (MUSIC), Beck's Depression Inventory (BDI-II), and the Fatigue Severity Scale (FSS). fMRI was recorded while a participant performed the modified attention network test (ANT). The effects of ANT executive attention network on hemodynamic activation of a priori defined regions of interest, including the hippocampus, anterior cingulate cortex (ACC), thalamus, caudate nucleus, pallidum, and putamen were studied. The individual lesion load was estimated. For fMRI data analysis a general linear model with randomization statistics including threshold-free cluster enhancement as implemented in the FSL software was used. Participants with RRMS showed reduced activation of the executive attention network in the hippocampus, pallidum, and ACC. The thalamus was involved in both group activations but did not differ between groups. In summary, functional changes in the brain can also be demonstrated in RRMS patients without cognitive deficits. The affected brain regions can best be assigned to the attention network for executive control. This association could likely serve as a biological indicator of susceptibility to imminent cognitive impairment in MS.

Applying multilayer analysis to morphological, structural, and functional brain networks to identify relevant dysfunction patterns

In recent years, research on network analysis applied to MRI data has advanced significantly. However, the majority of the studies are limited to single networks obtained from resting-state fMRI, diffusion MRI, or gray matter probability maps derived from T1 images. Although a limited number of previous studies have combined two of these networks, none have introduced a framework to combine morphological, structural, and functional brain connectivity networks. The aim of this study was to combine the morphological, structural, and functional information, thus defining a new multilayer network perspective. This has proved advantageous when jointly analyzing multiple types of relational data from the same objects simultaneously using graph- mining techniques. The main contribution of this research is the design, development, and validation of a framework that merges these three layers of information into one multilayer network that links and relates the integrity of white matter connections with gray matter probability maps and resting-state fMRI. To validate our framework, several metrics from graph theory are expanded and adapted to our specific domain characteristics. This proof of concept was applied to a cohort of people with multiple sclerosis, and results show that several brain regions with a synchronized connectivity deterioration could be identified.

CEST MRI and MALDI imaging reveal metabolic alterations in the cervical lymph nodes of EAE mice

BACKGROUND

Multiple sclerosis (MS) is a neurodegenerative disease, wherein aberrant immune cells target myelin-ensheathed nerves. Conventional magnetic resonance imaging (MRI) can be performed to monitor damage to the central nervous system that results from previous inflammation; however, these imaging biomarkers are not necessarily indicative of active, progressive stages of the disease. The immune cells responsible for MS are first activated and sensitized to myelin in lymph nodes (LNs). Here, we present a new strategy for monitoring active disease activity in MS, chemical exchange saturation transfer (CEST) MRI of LNs.

METHODS AND RESULTS

We studied the potential utility of conventional (T2-weighted) and CEST MRI to monitor changes in these LNs during disease progression in an experimental autoimmune encephalomyelitis (EAE) model. We found CEST signal changes corresponded temporally with disease activity. CEST signals at the 3.2 ppm frequency during the active stage of EAE correlated significantly with the cellular (flow cytometry) and metabolic (mass spectrometry imaging) composition of the LNs, as well as immune cell infiltration into brain and spinal cord tissue. Correlating primary metabolites as identified by matrix-assisted laser desorption/ionization (MALDI) imaging included alanine, lactate, leucine, malate, and phenylalanine.

CONCLUSIONS

Taken together, we demonstrate the utility of CEST MRI signal changes in superficial cervical LNs as a complementary imaging biomarker for monitoring disease activity in MS. CEST MRI biomarkers corresponded to disease activity, correlated with immune activation (surface markers, antigen-stimulated proliferation), and correlated with LN metabolite levels.

Pain, cognition and disability in advanced multiple sclerosis

OBJECTIVES

In patients with multiple sclerosis (MS), a relationship between physical disability and pain has been observed. In addition a relationship between physical disability and cognition in MS has been suggested. However, cognitive functions and pain appear not to be correlated in MS patients. Therefore, we examined whether a possible relationship between pain and cognitive functioning may exist, and if so, if such a relationship is mediated by physical disability.

METHODS

Forty-five MS patients with chronic pain, and in an advanced stage of the disease were included. Physical disabilities were assessed by the Expanded Disability Status Scale (EDSS). Episodic memory was assessed by means of the Eight Words test, and Face and Picture Recognition. Executive functions (EF) were examined by Digit Span Backward for working memory, and the Rule Shift Cards and Category Fluency test for cognitive flexibility. Pain Intensity and Pain Affect were assessed by means of visual analogue scales and one verbal pain scale and mood (depression, anxiety) by the Beck Depression Inventory and the Symptom Check List (SCL-90). The research questions were analyzed by means of regression analyses and the Sobel test for mediation.

RESULTS

A significant relationship was found between Pain Affect and EF, but that relationship was not mediated by physical disabilities (EDSS). In addition, Pain Intensity and EF showed a significant relationship but only in combination with physical disabilities (EDSS). Finally, mood was related to pain affect.

DISCUSSION

The findings suggest that the lower the EF, exclusively or in combination with more physical disabilities, the more the patient may suffer from pain.

IMPLICATIONS

The more one is cognitively and physically impaired, the more one might suffer from pain, and, the less one is able to communicate pain. The latter could put MS patients at risk for underdiagnosing and undertreatment of pain.

Identifying Early Neuropsychological Indicators of Cognitive Involvement in Multiple Sclerosis

Multiple sclerosis (MS) is a debilitating disease of the central nervous system that is most commonly seen in early to middle adulthood, although it can be diagnosed during childhood or later in life. While cognitive impairment can become more prevalent and severe as the disease progresses, signs of cognitive involvement can be apparent in the early stages of the disease. In this review, we discuss the prevalence and types of cognitive impairment seen in early MS, including the specific measures used to identify them, as well as the challenges in characterizing their frequency and progression. In addition to examining the progression of early cognitive involvement over time, we explore the clinical factors associated with early cognitive involvement, including demographics, level of physical disability, disease modifying therapy use, vocational status, and psychological and physical symptoms. Given the prevalence and functional impact these impairments can have for persons with MS, considerations for clinicians are provided, such as the role of early cognitive screenings and the importance of comprehensive neuropsychological assessments.

Factors influencing daily treatment choices in multiple sclerosis: practice guidelines, biomarkers and burden of disease

At two meetings of a Central European board of multiple sclerosis (MS) experts in 2018 and 2019 factors influencing daily treatment choices in MS, especially practice guidelines, biomarkers and burden of disease, were discussed. The heterogeneity of MS and the complexity of the available treatment options call for informed treatment choices. However, evidence from clinical trials is generally lacking, particularly regarding sequencing, switches and escalation of drugs. Also, there is a need to identify patients who require highly efficacious treatment from the onset of their disease to prevent deterioration. The recently published European Committee for the Treatment and Research in Multiple Sclerosis/European Academy of Neurology clinical practice guidelines on pharmacological management of MS cover aspects such as treatment efficacy, response criteria, strategies to address suboptimal response and safety concerns and are based on expert consensus statements. However, the recommendations constitute an excellent framework that should be adapted to local regulations, MS center capacities and infrastructure. Further, available and emerging biomarkers for treatment guidance were discussed. Magnetic resonance imaging parameters are deemed most reliable at present, even though complex assessment including clinical evaluation and laboratory parameters besides imaging is necessary in clinical routine. Neurofilament-light chain levels appear to represent the current most promising non-imaging biomarker. Other immunological data, including issues of immunosenescence, will play an increasingly important role for future treatment algorithms. Cognitive impairment has been recognized as a major contribution to MS disease burden. Regular evaluation of cognitive function is recommended in MS patients, although no specific disease-modifying treatment has been defined to date. Finally, systematic documentation of real-life data is recognized as a great opportunity to tackle unresolved daily routine challenges, such as use of sequential therapies, but requires joint efforts across clinics, governments and pharmaceutical companies.

Cognitive Dysfunction in the Early Stages of Multiple Sclerosis-How Much and How Important?

Purpose of Review

Multiple sclerosis (MS) is a demyelinating disease of the central nervous system that mainly affects young adults and that is one of the leading causes of disability in this age group, with cognitive impairment occurring early in the course of the disease. This article summarizes the current knowledge about cognitive dysfunction in the early phase of MS, including biomarkers, MRI correlates, and its value as a prognostic marker.

Recent Findings

New sets of neuropsychological tests have been established to screen for cognitive dysfunction more easily and accurately. Moreover, structural changes detected by brain MRI and several biomarkers found in cerebrospinal fluid and blood serum have been recently correlated with decreased cognitive performance. Additionally, factors influencing cognition in MS, such as disease-modifying therapy, mood disorders, and lifestyle, are better described.

Summary

Cognitive impairment early in the course of MS is suggested as a prognostic factor for disease progression. However, clear-cut definitions of the early stage of MS as well as unified criteria for the diagnosis of cognitive impairment are still lacking. New and more reliable tools for evaluating cognition in MS patients should be developed and introduced into everyday practice to facilitate the implementation of effective disease-modifying therapy, cognitive rehabilitation, and lifestyle management.

The Relevance of Neuroimaging Findings to Physical Disability in Multiple Sclerosis

Multiple sclerosis (MS) is a chronic inflammatory demyelinating disease of the central nervous system and one of the leading causes of disability in young adults. While some patients with MS have a benign course in which they develop limited disability even after many years, other patients have a rapidly progressive course resulting in severe disability. However, the progression of the disease, particularly disability, is currently a predictable course with neuroimaging features to some extend. Magnetic resonance imaging (MRI) is not only the main diagnostic tool but also used to monitor response to therapies, thanks to its high sensitivity and ability to identify clinically silent lesions. This report presents a literature review which examines in detail the relationship between MRI findings and disability.

Silent Free Fall at Disease Onset: A Perspective on Therapeutics for Progressive Multiple Sclerosis

Central nervous system (CNS) degeneration occurs during multiple sclerosis (MS) following several years of reversible autoimmune demyelination. Progressive CNS degeneration appears later during the course of relapsing-remitting MS (RRMS), although it starts insidiously at disease onset. We propose that there is an early subclinical phase also for primary-progressive (PP) MS. Consensus exists that many different cell types are involved during disease onset. Furthermore, the response to the initial damage, which is specific for each individual, would result in distinct pathological pathways that add complexity to the disease and the mechanisms underlying progressive CNS degeneration. Progressive MS is classified as either active or not active, as well as with or without progression. Different forms of progressive MS might reflect distinct or overlapping pathogenetic pathways. Disease mechanisms should be determined for each patient at diagnosis and the time of treatment. Until individualized and time-sensitive treatments that specifically target the molecular mechanisms of the progressive aspect of the disease are identified, combined therapies directed at anti-inflammation, regeneration, and neuroprotection are the most effective for preventing MS progression. This review presents selected therapeutics in support of the overall idea of a multidimensional therapy applied early in the disease. This approach could limit damage and increase CNS repair. By targeting several cellular populations (i.e., microglia, astrocytes, neurons, oligodendrocytes, and lymphocytes) and multiple pathological processes (e.g., inflammation, demyelination, synaptopathy, and excitatory/inhibitory imbalance) progressive MS could be attenuated. Early timing for such multidimensional therapy is proposed as the prerequisite for effectively halting progressive MS.

Recommendations for cognitive screening and management in multiple sclerosis care

Purpose:

To promote understanding of cognitive impairment in multiple sclerosis (MS), recommend optimal screening, monitoring, and treatment strategies, and address barriers to optimal management.

Methods:

The National MS Society (“Society”) convened experts in cognitive dysfunction (clinicians, researchers, and lay people with MS) to review the published literature, reach consensus on optimal strategies for screening, monitoring, and treating cognitive changes, and propose strategies to address barriers to optimal care.

Recommendations:

Based on current evidence, the Society makes the following recommendations, endorsed by the Consortium of Multiple Sclerosis Centers and the International Multiple Sclerosis Cognition Society: