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Cruz A, Pereira D, Batista S. [Use of Gadolinium in Follow-Up MRI of Multiple Sclerosis Patients: Current Recommendations]. ACTA MEDICA PORT 2024; 37:53-63. [PMID: 38183232 DOI: 10.20344/amp.20467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 10/30/2023] [Indexed: 01/07/2024]
Abstract
Multiple sclerosis is the most frequent demyelinating disease of the central nervous system and is characterized by early onset and progressive disability. Magnetic resonance imaging, due to its high sensitivity and specificity in the detection of demyelinating lesions, is the most useful diagnostic test for this disease, with the administration of gadolinium-based contrast agents being an important contribution to imaging interpretation. Although contrast is essential for diagnostic purposes, its routine use in monitoring disease activity, response to treatment, and related complications is controversial. This article aims to collate current recommendations regarding the use of gadolinium in the imaging follow-up of multiple sclerosis and establish effective and safe guidelines for clinical practice. The literature review was conducted in PubMed, using the terms 'multiple sclerosis', 'magnetic resonance imaging' and 'gadolinium', or 'contrast media'. Articles published between January 2013 and January 2023 concerning the safety of gadolinium and the use of these contrast agents in follow-up scans of adult patients diagnosed with multiple sclerosis were selected. Although no biological or clinical consequences have been unequivocally attributed to the retention of gadolinium in the brain, which were mostly reported with linear agents, health authorities have been recommending the restriction of contrast to essential clinical circumstances. In multiple sclerosis, the detection of subclinical contrast-enhancing lesions with no corresponding new/ enlarging T2-WI lesions is rare and has a questionable impact on therapeutic decisions. On the other hand, gadolinium has a higher sensitivity in the differential diagnosis of relapses, in the detection of recent disease activity, before and after treatment initiation, and in patients with a large lesion burden or diffuse/confluent T2-WI lesions. Contrary to progressive multifocal leukoencephalopathy screening, monitoring of immune restitution inflammatory syndrome also benefits from the administration of gadolinium. It is feasible and safe to exclude gadolinium-based contrast agents from routine follow-up scans of multiple sclerosis, despite their additional contribution in specific clinical circumstances that should be acknowledged by the neurologist and neuroradiologist.
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Affiliation(s)
- Andreia Cruz
- Faculdade de Medicina. Universidade de Coimbra. Coimbra. Portugal
| | - Daniela Pereira
- Área Funcional de Neurorradiologia. Serviço de Imagem Médica. Centro Hospitalar e Universitário de Coimbra. Coimbra. Portugal
| | - Sónia Batista
- Faculdade de Medicina. Universidade de Coimbra. Coimbra; Serviço de Neurologia. Centro Hospitalar e Universitário de Coimbra. Coimbra. Portugal
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2
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Gentili L, Capuano R, Gaetani L, Fiacca A, Bisecco A, d'Ambrosio A, Mancini A, Guercini G, Tedeschi G, Parnetti L, Gallo A, Di Filippo M. Impact of post-contrast MRI in the definition of active multiple sclerosis. J Neurol Sci 2022; 440:120338. [PMID: 35853292 DOI: 10.1016/j.jns.2022.120338] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 06/30/2022] [Accepted: 07/06/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND For multiple sclerosis (MS) phenotypes classification, the presence of "disease activity" can be defined by clinical relapses and/or by magnetic resonance imaging (MRI) through gadolinium-enhancing (Gd+) lesions or new/enlarged T2 lesions. Recent MRI and pathology findings have demonstrated Gd deposition in the brain, suggesting to avoid Gd administration when dispensable. In this scenario, we aimed to evaluate the contribution of post-contrast MRIs to the definition of "active" MS phenotype. METHODS We retrospectively selected 84 "active" relapsing-remitting MS (RRMS) patients according to Lublin 2013, calculating both the number of Gd+ lesions not detectable as new/unequivocally enlarged on T2 images and the proportion of patients who would be still correctly classified as "active" without Gd administration. RESULTS 13 out of 164 (7.9%) Gd+ lesions did not correspond to a new/enlarged T2 lesion. Gd administration did not modify the classification of MS as "active" in 83 out of 84 subjects (98.8%). CONCLUSION The contribution of Gd+ lesions to the correct classification of RRMS patients as "active" is marginal, thus limiting the need of routine Gd administration for this scope. Further studies are warranted to support these conclusions.
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Affiliation(s)
- Lucia Gentili
- Section of Neurology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Rocco Capuano
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Napoli, Italy
| | - Lorenzo Gaetani
- Section of Neurology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Andrea Fiacca
- Section of Neuroradiology, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Alvino Bisecco
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Napoli, Italy
| | - Alessandro d'Ambrosio
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Napoli, Italy
| | - Andrea Mancini
- Section of Neurology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Giorgio Guercini
- Section of Neuroradiology, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Gioacchino Tedeschi
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Napoli, Italy
| | - Lucilla Parnetti
- Section of Neurology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Antonio Gallo
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Napoli, Italy
| | - Massimiliano Di Filippo
- Section of Neurology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy.
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3
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Arnold TC, Tu D, Okar SV, Nair G, By S, Kawatra KD, Robert-Fitzgerald TE, Desiderio LM, Schindler MK, Shinohara RT, Reich DS, Stein JM. Sensitivity of portable low-field magnetic resonance imaging for multiple sclerosis lesions. Neuroimage Clin 2022; 35:103101. [PMID: 35792417 PMCID: PMC9421456 DOI: 10.1016/j.nicl.2022.103101] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 06/23/2022] [Accepted: 06/24/2022] [Indexed: 12/25/2022]
Abstract
Paired, same-day, 3T and 64mT MRI studies were analyzed in 33 MS patients. 64mT MRI showed 94% sensitivity for detecting any lesions in 3T confirmed cases. The diameter of the smallest detected lesion was larger at 64mT compared to 3T. Total lesion volume estimates were strongly correlated between 3T and 64mT scans. Portable low-field MRI detects white matter lesions, but smaller lesions may be missed.
Magnetic resonance imaging (MRI) is a fundamental tool in the diagnosis and management of neurological diseases such as multiple sclerosis (MS). New portable, low-field strength, MRI scanners could potentially lower financial and technical barriers to neuroimaging and reach underserved or disabled populations, but the sensitivity of these devices for MS lesions is unknown. We sought to determine if white matter lesions can be detected on a portable 64mT scanner, compare automated lesion segmentations and total lesion volume between paired 3T and 64mT scans, identify features that contribute to lesion detection accuracy, and explore super-resolution imaging at low-field. In this prospective, cross-sectional study, same-day brain MRI (FLAIR, T1w, and T2w) scans were collected from 36 adults (32 women; mean age, 50 ± 14 years) with known or suspected MS using Siemens 3T (FLAIR: 1 mm isotropic, T1w: 1 mm isotropic, and T2w: 0.34–0.5 × 0.34–0.5 × 3–5 mm) and Hyperfine 64mT (FLAIR: 1.6 × 1.6 × 5 mm, T1w: 1.5 × 1.5 × 5 mm, and T2w: 1.5 × 1.5 × 5 mm) scanners at two centers. Images were reviewed by neuroradiologists. MS lesions were measured manually and segmented using an automated algorithm. Statistical analyses assessed accuracy and variability of segmentations across scanners and systematic scanner biases in automated volumetric measurements. Lesions were identified on 64mT scans in 94% (31/33) of patients with confirmed MS. The average smallest lesions manually detected were 5.7 ± 1.3 mm in maximum diameter at 64mT vs 2.1 ± 0.6 mm at 3T, approaching the spatial resolution of the respective scanner sequences (3T: 1 mm, 64mT: 5 mm slice thickness). Automated lesion volume estimates were highly correlated between 3T and 64mT scans (r = 0.89, p < 0.001). Bland-Altman analysis identified bias in 64mT segmentations (mean = 1.6 ml, standard error = 5.2 ml, limits of agreement = –19.0–15.9 ml), which over-estimated low lesion volume and under-estimated high volume (r = 0.74, p < 0.001). Visual inspection revealed over-segmentation was driven venous hyperintensities on 64mT T2-FLAIR. Lesion size drove segmentation accuracy, with 93% of lesions > 1.0 ml and all lesions > 1.5 ml being detected. Using multi-acquisition volume averaging, we were able to generate 1.6 mm isotropic images on the 64mT device. Overall, our results demonstrate that in established MS, a portable 64mT MRI scanner can identify white matter lesions, and that automated estimates of total lesion volume correlate with measurements from 3T scans.
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Affiliation(s)
- T Campbell Arnold
- Department of Bioengineering, School of Engineering & Applied Science, University of Pennsylvania, Philadelphia, PA 19104, USA; Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Danni Tu
- Penn Statistics in Imaging and Visualization Center and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Serhat V Okar
- National Institute of Neurological Disorders and Stroke, National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Govind Nair
- National Institute of Neurological Disorders and Stroke, National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | | | - Karan D Kawatra
- National Institute of Neurological Disorders and Stroke, National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Timothy E Robert-Fitzgerald
- Penn Statistics in Imaging and Visualization Center and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Lisa M Desiderio
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Matthew K Schindler
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Russell T Shinohara
- Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, PA 19104, USA; Penn Statistics in Imaging and Visualization Center and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Daniel S Reich
- National Institute of Neurological Disorders and Stroke, National Institutes of Health (NIH), Bethesda, MD 20892, USA.
| | - Joel M Stein
- Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Danieli L, Roccatagliata L, Distefano D, Prodi E, Riccitelli GC, Diociasi A, Carmisciano L, Cianfoni A, Bartalena T, Kaelin-Lang A, Gobbi C, Zecca C, Pravatà E. Nonlesional Sources of Contrast Enhancement on Postgadolinium "Black-Blood" 3D T1-SPACE Images in Patients with Multiple Sclerosis. AJNR Am J Neuroradiol 2022; 43:872-880. [PMID: 35618421 DOI: 10.3174/ajnr.a7529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 04/08/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE We hypothesized that 3D T1-TSE "black-blood" images may carry an increased risk of contrast-enhancing lesion misdiagnosis in patients with MS because of the misinterpretation of intraparenchymal vein enhancement. Thus, the occurrence of true-positive and false-positive findings was compared between standard MPRAGE and volumetric interpolated brain examination techniques. MATERIALS AND METHODS Sampling perfection with application-optimized contrasts by using different flip-angle evolution (SPACE) images obtained from 232 patients with MS, clinically isolated syndrome, or radiologically isolated syndrome were compared with standard MPRAGE and volumetric interpolated brain examination images. The intraparenchymal vein contrast-to-noise ratio was estimated at the level of the thalami. Contrast-enhancing lesions were blindly detected by 2 expert readers and 1 beginner reader. True- and false-positives were determined by senior readers' consensus. True-positive and false-positive frequency differences and patient-level diagnosis probability were tested with the McNemar test and OR. The contrast-to-noise ratio and morphology were compared using the Mann-Whitney U and χ2 tests. RESULTS The intraparenchymal vein contrast-to-noise ratio was higher in SPACE than in MPRAGE and volumetric interpolated brain examination images (P < .001, both). There were 66 true-positives and 74 false-positives overall. SPACE detected more true-positive and false-positive results (P range < .001-.07) but did not increase the patient's true-positive likelihood (OR = 1 1.29, P = .478-1). However, the false-positive likelihood was increased (OR = 3.03-3.55, P = .008-.027). Venous-origin false-positives (n = 59) with contrast-to-noise ratio and morphology features similar to small-sized (≤14 mm3 P = .544) true-positives occurred more frequently in SPACE images (P < .001). CONCLUSIONS Small intraparenchymal veins may confound the diagnosis of enhancing lesions on postgadolinium black-blood SPACE images.
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Affiliation(s)
- L Danieli
- Form the Department of Neuroradiology (L.D., E. Prodi, A.C., E. Pravatà), Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - L Roccatagliata
- Dipartimento di Scienze della Salute (L.R., A.D.), Università degli Studi di Genova, Genoa, Italy
| | | | - E Prodi
- Form the Department of Neuroradiology (L.D., E. Prodi, A.C., E. Pravatà), Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - G C Riccitelli
- Department of Neurology (G.C.R., A.K.-L., C.G., C.Z., E. Pravatà), Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland.,Faculty of Biomedical Sciences (G.C.R., A.C., A.K.-L., C.G., C,Z., E. Pravatà), Università della Svizzera Italiana, Lugano, Switzerland
| | - A Diociasi
- Dipartimento di Scienze della Salute (L.R., A.D.), Università degli Studi di Genova, Genoa, Italy
| | - L Carmisciano
- Department of Health Sciences, Section of Biostatistics (L.C.), Università degli Studi di Genova, Genoa, Italy
| | - A Cianfoni
- Form the Department of Neuroradiology (L.D., E. Prodi, A.C., E. Pravatà), Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland.,Faculty of Biomedical Sciences (G.C.R., A.C., A.K.-L., C.G., C,Z., E. Pravatà), Università della Svizzera Italiana, Lugano, Switzerland
| | - T Bartalena
- Department of Radiology (T.B.), Pol. Zappi Bartalena, Imola, Italy
| | - A Kaelin-Lang
- Department of Neurology (G.C.R., A.K.-L., C.G., C.Z., E. Pravatà), Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland.,Faculty of Biomedical Sciences (G.C.R., A.C., A.K.-L., C.G., C,Z., E. Pravatà), Università della Svizzera Italiana, Lugano, Switzerland
| | - C Gobbi
- Department of Neurology (G.C.R., A.K.-L., C.G., C.Z., E. Pravatà), Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland.,Faculty of Biomedical Sciences (G.C.R., A.C., A.K.-L., C.G., C,Z., E. Pravatà), Università della Svizzera Italiana, Lugano, Switzerland
| | - C Zecca
- Department of Neurology (G.C.R., A.K.-L., C.G., C.Z., E. Pravatà), Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland.,Faculty of Biomedical Sciences (G.C.R., A.C., A.K.-L., C.G., C,Z., E. Pravatà), Università della Svizzera Italiana, Lugano, Switzerland
| | - E Pravatà
- Form the Department of Neuroradiology (L.D., E. Prodi, A.C., E. Pravatà), Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland .,Faculty of Biomedical Sciences (G.C.R., A.C., A.K.-L., C.G., C,Z., E. Pravatà), Università della Svizzera Italiana, Lugano, Switzerland
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5
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Karimian-Jazi K, Neuberger U, Schregel K, Brugnara G, Bendszus M, Breckwoldt MO, Schwarz D, Jäger LB, Wick W. Diagnostic value of gadolinium contrast administration for spinal cord magnetic resonance imaging in multiple sclerosis patients and correlative markers of lesion enhancement. Mult Scler J Exp Transl Clin 2021; 7:20552173211047978. [PMID: 34868625 PMCID: PMC8637714 DOI: 10.1177/20552173211047978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/02/2021] [Indexed: 11/17/2022] Open
Abstract
Background Magnetic resonance imaging is essential for monitoring people with multiple
sclerosis, but the diagnostic value of gadolinium contrast administration in
spine magnetic resonance imaging is unclear. Objective To assess the diagnostic value of gadolinium contrast administration in spine
magnetic resonance imaging follow-up examinations and identify imaging
markers correlating with lesion enhancement. Methods A total of 65 multiple sclerosis patients with at least 2 spinal magnetic
resonance imaging follow-up examinations were included. Spine magnetic
resonance imaging was performed at 3 Tesla with a standardized protocol
(sagittal and axial T2-weighted turbo spin echo and T1-weighted
post-contrast sequences). T2 lesion load and enhancing lesions were assessed
by two independent neuroradiologists for lesion size, localization, and T2
signal ratio (T2 signallesion/T2 signalnormal appearing
spinal cord). Results A total of 68 new spinal T2 lesions and 20 new contrast-enhancing lesions
developed during follow-up. All enhancing lesions had a discernable
correlate as a new T2 lesion. Lesion enhancement correlated with a higher T2
signal ratio compared to non-enhancing lesions (T2 signal ratio: 2.0 ± 0.4
vs. 1.4 ± 0.2, ****p < 0.001). Receiver operating
characteristics analysis showed an optimal cutoff value of signal ratio 1.78
to predict lesion enhancement (82% sensitivity and 97% specificity). Conclusion Gadolinium contrast administration is dispensable in follow-up spine magnetic
resonance imaging if no new T2 lesions are present. Probability of
enhancement correlates with the T2 signal ratio.
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Affiliation(s)
- Kianush Karimian-Jazi
- Clinical Cooperation Unit Neurooncology, German Cancer Consortium, German Cancer Research Center, Heidelberg, Germany
| | - Ulf Neuberger
- Clinical Cooperation Unit Neurooncology, German Cancer Consortium, German Cancer Research Center, Heidelberg, Germany
| | - Katharina Schregel
- Clinical Cooperation Unit Neurooncology, German Cancer Consortium, German Cancer Research Center, Heidelberg, Germany
| | - Gianluca Brugnara
- Clinical Cooperation Unit Neurooncology, German Cancer Consortium, German Cancer Research Center, Heidelberg, Germany
| | - Martin Bendszus
- Clinical Cooperation Unit Neurooncology, German Cancer Consortium, German Cancer Research Center, Heidelberg, Germany
| | - Michael O Breckwoldt
- Clinical Cooperation Unit Neurooncology, German Cancer Consortium, German Cancer Research Center, Heidelberg, Germany
| | - Daniel Schwarz
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Wolfgang Wick
- Clinical Cooperation Unit Neurooncology, German Cancer Consortium (DKTK) within the German Cancer Research Center (DKFZ), Heidelberg, Germany Neurology Clinic and National Center for Tumor Diseases, University Hospital Heidelberg, Heidelberg, Germany
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Prosperini L, Mancinelli C, Haggiag S, Cordioli C, De Giglio L, De Rossi N, Galgani S, Rasia S, Ruggieri S, Tortorella C, Pozzilli C, Gasperini C. Minimal evidence of disease activity (MEDA) in relapsing-remitting multiple sclerosis. J Neurol Neurosurg Psychiatry 2020; 91:271-277. [PMID: 31974130 DOI: 10.1136/jnnp-2019-322348] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 12/17/2019] [Accepted: 12/22/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE This study aimed to define the minimal evidence of disease activity (MEDA) during treatment that can be tolerated without exposing patients with relapsing-remitting multiple sclerosis at risk of long-term disability. METHODS We retrospectively collected data of patients followed up to 10 years after starting interferon beta or glatiramer acetate. Survival analyses explored the association between the long-term risk of reaching an Expanded Disability Status Scale≥6.0 and early clinical and MRI activity assessed after the first and second year of treatment. Early disease activity was classified by the so-called 'MAGNIMS score' (low: no relapses and <3 new T2 lesions; medium: no relapses and ≥3 new T2 lesions or 1 relapse and 0-2 new T2 lesions; high: 1 relapse and ≥3 new T2 lesions or ≥2 relapses) and the absence or presence of contrast-enhancing lesions (CELs). RESULTS At follow-up, 148/1036 (14.3%) patients reached the outcome: 61/685 (8.9%) with low score (reference category), 57/241 (23.7%) with medium score (HR=1.94, p=0.002) and 30/110 (27.3%) with high score (HR=2.47, p<0.001) after the first year of treatment. In the low score subgroup, the risk was further reduced in the absence (49/607, 8.1%) than in the presence of CELs (12/78, 15.4%; HR=2.11, p=0.01). No evident disease activity and low score in the absence of CELs shared the same risk (p=0.54). Similar findings were obtained even after the second year of treatment. CONCLUSIONS Early marginal MRI activity of one to two new T2 lesions, in the absence of both relapses and CELs, is associated with a minor risk of future disability, thus representing a simple and valuable definition for MEDA.
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Affiliation(s)
- Luca Prosperini
- Multiple Sclerosis Center, San Camillo-Forlanini Hospital, Roma, Italy
| | - Chiara Mancinelli
- Multiple Sclerosis Center, Spedali Civili di Brescia, Presidio di Montichiari, Brescia, Italy
| | - Shalom Haggiag
- Multiple Sclerosis Center, San Camillo-Forlanini Hospital, Roma, Italy
| | - Cinzia Cordioli
- Multiple Sclerosis Center, Spedali Civili di Brescia, Presidio di Montichiari, Brescia, Italy
| | - Laura De Giglio
- Dept. of Human Neuroscience, Sapienza University, Rome, Italy.,Neurology Unit, San Filippo Neri Hospital, Rome, Italy
| | - Nicola De Rossi
- Multiple Sclerosis Center, Spedali Civili di Brescia, Presidio di Montichiari, Brescia, Italy
| | - Simonetta Galgani
- Multiple Sclerosis Center, San Camillo-Forlanini Hospital, Roma, Italy
| | - Sarah Rasia
- Multiple Sclerosis Center, Spedali Civili di Brescia, Presidio di Montichiari, Brescia, Italy
| | - Serena Ruggieri
- Multiple Sclerosis Center, San Camillo-Forlanini Hospital, Roma, Italy.,Dept. of Human Neuroscience, Sapienza University, Rome, Italy
| | - Carla Tortorella
- Multiple Sclerosis Center, San Camillo-Forlanini Hospital, Roma, Italy
| | - Carlo Pozzilli
- Dept. of Human Neuroscience, Sapienza University, Rome, Italy.,Multiple Sclerosis Center, Sant'Andrea Hospital, Rome, Italy
| | - Claudio Gasperini
- Multiple Sclerosis Center, San Camillo-Forlanini Hospital, Roma, Italy
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