Differential Effects of Fingolimod and Natalizumab on Magnetic Resonance Imaging Measures in Relapsing-Remitting Multiple Sclerosis

Fingolimod and natalizumab are approved disease-modifying drugs in relapsing-remitting multiple sclerosis (RRMS). The two drugs have different modes of action and may therefore influence different aspects of MS-related tissue damage. In this retrospective cohort study, we longitudinally compared patients treated with fingolimod and patients treated with natalizumab by measures based on structural magnetic resonance imaging (MRI). We included patients with RRMS given that two standardized MRI scans under the same drug were available with an interval of at least 6 months both from therapy start to baseline scan and from baseline scan to follow-up scan. After matching for age, baseline and follow-up scans from 93 patients (fingolimod, 48; natalizumab, 45) were investigated. Mean follow-up time was 1.9 years. We determined the number of new white matter lesions as well as thalamic, cortical, and whole-brain atrophy. After scaling for time of the interscan interval, measures were analyzed by group comparisons and, to account for demographic and clinical characteristics, by multiple regression models and a binary logistic regression model. Compared to natalizumab, fingolimod treatment went along with more new white matter lesions (median [interquartile range, IQR] 0.0 [0.0; 0.7] vs. 0.0 [0.0; 0.0] /year; p < 0.01) whereas whole-brain atrophy was lower (median [IQR] 0.2 [0.0; 0.5] vs. 0.5 [0.2; 1.0] %/year; p = 0.01). These significant differences were confirmed by multiple regression models and the binary logistic regression model. In conclusion, our observation is compatible with stronger neuroprotective properties of fingolimod compared to natalizumab.

Gadolinium-Enhanced 3D T1-Weighted Black-Blood MR Imaging for the Detection of Acute Optic Neuritis

BACKGROUND AND PURPOSE

A 3D T1-weighted black-blood sequence was recently shown to improve the detection of contrast-enhancing lesions in the brain in patients with MS compared with a 3D T1-weighted MPRAGE sequence. We compared a contrast-enhanced 3D T1-weighted black-blood sequence with a dedicated orbital contrast-enhanced T1-weighted Dixon sequence in patients with acute optic neuritis.

MATERIALS AND METHODS

MR imaging data (3T) of 51 patients showing symptoms of acute optic neuritis were analyzed retrospectively, including whole-brain contrast-enhanced 3D T1-weighted black-blood and dedicated orbital coronal 2D or 3D contrast-enhanced T1-weighted Dixon sequences. Two neuroradiologists assessed the images for overall image quality, artifacts, diagnostic confidence, and visual contrast enhancement. Furthermore, the standardized contrast-to-noise ratio was calculated. The final diagnosis of acute optic neuritis was established on the basis of clinical presentation, visually evoked potentials, and optical coherence tomography.

RESULTS

Thirty of 51 patients were diagnosed with acute optic neuritis. Of those, 21 showed contrast-enhancing lesions in the optic nerves, similarly detectable on contrast-enhanced T1-weighted Dixon and contrast-enhanced T1-weighted black-blood images. Thus, the accuracy for each sequence was identical, with a resulting sensitivity of 70% and specificity of 90% or 100% (depending on the reader). Overall image quality, diagnostic confidence, visual contrast enhancement, and artifacts were rated similarly in contrast-enhanced 3D T1-weighted black-blood and dedicated orbital contrast-enhanced T1-weighted Dixon sequences. There was no significant difference (P = .27) in the mean standardized contrast-to-noise ratio between contrast-enhanced T1-weighted black-blood (1.76 ± 1.07) and contrast-enhanced T1-weighted Dixon (2.29 ± 2.49) sequences.

CONCLUSIONS

Contrast-enhanced 3D T1-weighted black-blood imaging is comparable in accuracy and qualitative/quantitative features with dedicated orbital contrast-enhanced T1-weighted Dixon imaging for the detection of acute optic neuritis. Therefore, when used, it has the potential to considerably shorten total patient imaging time.

Inner retinal layer thinning in radiologically isolated syndrome predicts conversion to multiple sclerosis

BACKGROUND AND PURPOSE

Individuals with radiologically isolated syndrome (RIS) are at increased risk of converting to multiple sclerosis (MS). Early identification of later converters is crucial for optimal treatment decisions. The purpose of this study was to assess the predictive potential of optical coherence tomography (OCT) measures in individuals with RIS regarding conversion to MS.

METHODS

This prospective observational cohort study included 36 individuals with RIS and 36 healthy controls recruited from two German MS centers. All individuals received baseline OCT and clinical examination and were longitudinally followed over up to 6 years. The primary outcome measure was the conversion to MS.

RESULTS

During clinical follow-up of 46 (26-58) months (median, 25%-75% interquartile range), eight individuals with RIS converted to MS. Individuals converting to MS showed a thinning of the peripapillary retinal nerve fiber layer (pRNFL) and the common ganglion cell and inner plexiform layer (GCIP) at baseline and during follow-up. Individuals with a pRNFL of 99 µm or lower or a GCIP of 1.99 mm³ or lower were at a 7.5- and 8.0-fold risk for MS conversion, respectively, compared to individuals with higher measures. After correction for other known risk factors, Cox proportional hazards regression revealed a hazard ratio of 1.08 for conversion to MS for each 1 µm decline in pRNFL.

CONCLUSIONS

Reduction of the pRNFL might be a novel and independent risk factor for conversion to MS in individuals with RIS. OCT might be useful for risk stratification and therapeutic decision-making in individuals with RIS.

T1-Weighted Intensity Increase After a Single Administration of a Linear Gadolinium-Based Contrast Agent in Multiple Sclerosis

Purpose

Through analysis of T1-weighted (T1w) images this study investigated gadolinium (Gd) deposition in the brain after administration of a linear (gadopentetic acid) and a cyclic (gadoteric acid) gadolinium-based contrast agent (GBCA) in patients with multiple sclerosis (MS), a disorder frequently requiring magnetic resonance imaging (MRI) scans over years.

Methods

A total of 3233 T1w images (unenhanced with respect to the same scanning session) of 881 MS patients were retrospectively analyzed. After spatial normalization and intensity scaling using a sphere within the pons, differences of all pairs of subsequent scans were calculated and attributed to either linear (n = 2718) or cyclic (n = 385) or no GBCA (n = 130) according to the first scan. Regional analyses were performed, focusing on the dentate nucleus, and whole brain analyses. By 1‑sample t‑tests, signal intensity increases within conditions were searched for; conditions were compared by 2‑sample t‑tests. Furthermore, recent hypotheses on the reversibility of GBCA deposition were tested.

Results

In the dentate nucleus, a significant increase was observed only after administration of linear GBCA even after a single GBCA administration. This increase differed significantly (p < 0.001) from the other conditions (cyclic and no GBCA). Whole brain analyses revealed T1w signal increases only after administration of linear GBCA within two regions, the dentate nucleus and globus pallidus. Additional analyses did not indicate any decline of Gd deposition in the brain.

Conclusion

The data point towards Gd deposition in the brain after administration of linear GBCA even after a single administration.

Evidence for a white matter lesion size threshold to support the diagnosis of relapsing remitting multiple sclerosis

BACKGROUND

The number of white matter lesions (WML) in brain MRI is the most established paraclinical tool to support the diagnosis of multiple sclerosis (MS) and to monitor its course. Diagnostic criteria have stipulated a minimum detectable diameter of 3 mm per WML, although this threshold is not evidence-based. We aimed to provide a rationale for a WML size threshold for three-dimensional MRI sequences at 3 T by comparing patients with relapsing-remitting MS (RRMS) to control subjects (CS).

METHODS

We analyzed MR images from two cohorts, obtained at scanners from two different vendors, each comprising patients with RRMS and CS. Both cohorts were examined with FLAIR and T1w sequences. In total, 232 patients with RRMS (Expanded Disability Status Scale: mean = 1.6 ± 1.2; age: mean = 36 ± 10) as well as 116 age- and sex-matched CS were studied. We calculated odds ratios across WML volumes. The WML size threshold, which discriminated best between patients and CS, was estimated with receiver operating characteristic curve analysis.

RESULTS

In both cohorts, odds ratios increased continuously with increasing WML volumes, and discriminative power was highest at a WML size threshold corresponding to a diameter of about 3 mm.

CONCLUSION

The stipulated WML size threshold of 3 mm in diameter for the diagnostic criteria of MS seems a reasonable choice for three-dimensional MRI sequences at 3 T.

Pre- and Postcontrast 3D Double Inversion Recovery Sequence in Multiple Sclerosis: A Simple and Effective MR Imaging Protocol

BACKGROUND AND PURPOSE

The double inversion recovery sequence is known to be very sensitive and specific for MS-related lesions. Our aim was to compare the sensitivity of pre- and postcontrast images of 3D double inversion recovery and conventional 3D T1-weighted images for the detection of contrast-enhancing MS-related lesions in the brain to analyze whether double inversion recovery could be as effective as T1WI.

MATERIALS AND METHODS

A postcontrast 3D double inversion recovery sequence was acquired in addition to the standard MR imaging protocol at 3T, including pre- and postcontrast 3D T1WI sequences as well as precontrast double inversion recovery of 45 consecutive patients with MS or clinically isolated syndrome between June and December 2013. Two neuroradiologists independently assessed precontrast, postcontrast, and subtraction images of double inversion recovery as well as T1WI to count the number of contrast-enhancing lesions. Afterward, a consensus reading was performed. Lin concordance was calculated between both radiologists, and differences in lesion detectability were assessed with the Student t test. Additionally, the contrast-to-noise ratio was calculated.

RESULTS

Significantly more contrast-enhancing lesions could be detected with double inversion recovery compared with T1WI (16%, 214 versus 185, P = .007). The concordance between both radiologists was almost perfect (ρ_c = 0.94 for T1WI and ρ_c = 0.98 for double inversion recovery, respectively). The contrast-to-noise ratio was significantly higher in double inversion recovery subtraction images compared with T1-weighted subtraction images (double inversion recovery, 14.3 ± 5.5; T1WI, 6.3 ± 7.1; P < .001).

CONCLUSIONS

Pre- and postcontrast double inversion recovery enables better detection of contrast-enhancing lesions in MS in the brain compared with T1WI and may be considered an alternative to the standard MR imaging protocol.

Tissue damage within normal appearing white matter in early multiple sclerosis: assessment by the ratio of T1- and T2-weighted MR image intensity

Histopathological and magnetic resonance imaging (MRI) studies have shown white matter (WM) damage in early stages of multiple sclerosis (MS) beyond the apparent T2-hyperintense lesions. These changes in normal appearing WM (NAWM) are important with regard to the clinical picture and prognosis. However, the detection of changes within NAWM has so far required special imaging techniques commonly not available in clinical routine and, hence, at large scale. The purpose of this study was to detect MS-related damage of NAWM by conventional MRI. As, within NAWM, the myelin content mainly drives the T1-weighted (T1w) signal, we scaled it by the T2w signal. We tested the hypothesis that the mean T1w/T2w ratio of NAWM is decreased in MS compared to healthy controls (HC) and that it correlates with clinical measures. We developed a pipeline to determine the individual mean values of this ratio within NAWM. We studied 244 patients in early disease stages of MS (mean age 37 ± 10 years, mean disease duration 3.1 ± 2.3, Expanded Disability Status Scale 1.3 ± 1), and 78 HC (mean age 31 ± 8 years). Compared to HC, the mean T1w/T2w ratio was lowered in the patient group (P < 0.001). The difference remained significant after restricting the analysis to patients with a disease duration of 5 years or less and without disease modifying drugs. Our measures also correlated with clinical scores. We believe that the mean T1w/T2w ratio is a promising candidate to assess MS-related tissue damage within NAWM at large scale.

Double inversion recovery sequence of the cervical spinal cord in multiple sclerosis and related inflammatory diseases

BACKGROUND AND PURPOSE

MR imaging plays an important role in diagnosing MS and other related inflammatory diseases; however, imaging of the spinal cord is still challenging. We hypothesized that a 3D double inversion recovery sequence for cervical spinal cord imaging would be more sensitive in detecting inflammatory lesions than a conventional 2D T2-weighted TSE sequence at 3T.

MATERIALS AND METHODS

On a 3T MR imaging scanner, we examined 30 patients with suspected or established MS (MS, n = 16; clinically isolated syndrome, n = 12; isolated myelitis, n = 2) and 10 healthy controls. Newly developed 3D double inversion recovery and conventional 2D axial and sagittal T2-weighted TSE images of the cervical spinal cord were acquired. Two blinded neuroradiologists independently assessed the scans in pseudorandomized order for lesion numbers and rated lesion visibility and overall image quality on 5-point scales. A subsequent consensus reading delivered definite lesion counts. Standardized contrast-to-noise ratios were calculated in representative lesions of each patient.

RESULTS

Overall, 28% more lesions could be detected with 3D double inversion recovery than with conventional T2WI (119 versus 93, P < .002). On average, the standardized contrast-to-noise ratio was significantly higher (P < .001) in double inversion recovery than in T2WI. Lesion visibility was rated significantly higher (P < .001) in double inversion recovery compared with T2WI despite lower image quality.

CONCLUSIONS

The novel 3D double inversion recovery sequence allowed better detection of lesions in MS and related inflammatory diseases of the cervical spinal cord, compared with conventional 2D T2WI.

Effect of APOE genotype on amyloid plaque load and gray matter volume in Alzheimer disease

OBJECTIVE

To examine the influence of the APOE genotype on levels of beta-amyloid (Abeta) plaque load and atrophy in patients with Alzheimer disease (AD) in vivo.

METHODS

Thirty-two patients with moderate AD were divided into carriers and noncarriers of the epsilon4 allele. These groups were matched for age, disease duration, education, and cognitive impairment. In all subjects, [11C]PIB-PET was performed for measurement of cerebral Abeta plaque deposition and cranial MRI for the assessment of gray matter volume by voxel-based morphometry (VBM) and for correction of partial volume effects (PVE) in the PET data. Voxel-based comparisons (SPM5) were performed between patient groups and healthy control populations and completed with multiple regression analyses between imaging data and epsilon4 allele frequency.

RESULTS

Compared to controls, AD-typical patterns of [11C]PIB retention and atrophy were detected in both epsilon4-positive and epsilon4-negative patient groups. In direct comparison, significantly stronger and more extended [11C]PIB uptake was found in epsilon4-positive patients in bilateral temporoparietal and frontal cortex, surviving PVE correction. VBM analysis demonstrated comparable levels of atrophy in both patient groups. Regression analyses revealed a linear association between higher epsilon4 allele frequency and stronger temporoparietal Abeta plaque deposition, independently of other confounds. No major correlation between epsilon4 allele frequency and gray matter decrease was observed.

CONCLUSION

These results indicate that the epsilon4-positive APOE genotype not only represents a risk factor for Alzheimer disease (AD), but also results in higher levels of Abeta plaque deposition in epsilon4-positive patients with AD compared to age-matched epsilon4-negative patients with similar levels of cognitive impairment and brain atrophy. The potential role of Abeta plaque imaging for patient inclusion and follow-up in anti-amyloid therapy trials is strengthened by these findings.

Voxel-based morphometry in individual patients: a pilot study in early Huntington disease

BACKGROUND AND PURPOSE

Voxel-based morphometry (VBM) has proved a powerful method to detect subtle changes of gray matter (GM) at the group level but the role of VBM for the detection of GM changes in single subjects, especially in those with suspected neurodegenerative disorder, remains uncertain. Here, we performed single subject analyses in 22 patients in early stages of Huntington disease (HD), a neurodegenerative disorder with a well-known and characteristic pattern of GM loss.

MATERIALS AND METHODS

We applied an ANCOVA with age and gender as covariates and corrected for multiple statistical tests by false discovery rate (P < 0.05). Each patient was compared to 133 healthy controls. The same procedure was applied to 22 of the controls matched for age and gender in a pair-wise manner.

RESULTS

Our analyses yielded biologically plausible results in HD patients in which GM decrease within the caudate nucleus could be identified in 15 of the 16 most affected patients while GM decrease was found in only 1 control subject. Lowering the size of the control group yielded comparable results with 99 and 66 control subjects whereas sensitivity decreased with 33 control subjects.

CONCLUSIONS

Our pilot study demonstrates a potential role of VBM for the detection of cerebral GM changes in single subjects with suspected neurodegenerative disorder.

[Differential diagnosis of neuralgic amyotrophy and vertebral artery dissection]

In most cases the definite diagnosis of neuralgic amyotrophy is not possible, so it is based on the typical course of symptoms after other diagnoses have been excluded. We report an otherwise healthy woman who presented with symptoms typical of neuralgic amyotrophy. However we could diagnose a vertebral artery dissection that probably caused the symptoms by compression of the cervical roots. The differential diagnosis of neuralgic amyotrophy and vertebral artery dissection is discussed.

Neural representations of pantomimed and actual tool use: Evidence from an event-related fMRI study

Pantomime of tool use is a highly sensitive test to detect apraxia. The relationship to real-life performance is however unclear since apraxic patients frequently improve substantially when allowed to actually use tools. In the present study, the neural correlates of pantomimed and actual tool use were directly compared in healthy subjects using an event-related functional magnetic resonance imaging (fMRI) paradigm. Subjects were requested to demonstrate the use of various tools either as pantomimes or with the tool in hand. Movement and pre-movement events were evaluated. The comparison of all conditions versus rest revealed a widespread activation including parietal, posterior temporal, frontal, and subcortical areas with some characteristic activation for the different events. The direct comparison between pantomime and actual use conditions revealed no or only minor differential activations for pre-movement events. During the movement event, actual tool use induced the expected additional activation in sensory and motor areas, but also representations presumably related to tool-use knowledge at parietal, posterior temporal, and frontal sites. The opposite contrast of pantomimed versus actual tool use revealed differential activation only in the left intraparietal sulcus in a corresponding region-of-interest analysis. We conclude that planning and preparing of either pantomimed or actual tool use share large parts of a common network. Characteristic differences in the kinematics and dynamics of both movement conditions may be defined just before or during the initiation of the movement when sensory cues about the tool and environment are available in the actual use condition. Sensory and cognitive cues may provide apraxic patients the capacity to evoke a correct action program despite impaired pantomime.

Voxel-based morphometry indicates relative preservation of the limbic prefrontal cortex in early Huntington disease

In Huntington disease (HD), both the genetic defect and mutant gene product huntington are known but the exact mechanisms that lead to neuronal loss are poorly understood. Until now, the distribution of tissue loss throughout the brain has been investigated intensively. Here we searched for areas that, antipodal to the striatum, display grey-matter (GM) preservation. We performed high resolution T1-weighted magnetic resonance imaging and voxel-based morphometry in 46 patients in early HD and 46 healthy controls. We applied an analysis of covariance (ANCOVA) model with the total GM volume of each participant as covariate. In accordance with earlier reports, group comparisons revealed GM decrease in the striatum, insula, and thalamus as well as in dorsolateral frontal and occipital areas. In contrast, the limbic prefrontal cortex displayed GM preservation. Our findings support hypotheses that postulate differential involvement of frontosubcortical circuits in the pathophysiology of HD.

Bilateral grey-matter increase in the putamen in primary blepharospasm

BACKGROUND

Primary blepharospasm is a focal dystonia characterised by excessive involuntary closure of the eyelids. The pathophysiology of primary blepharospasm is unresolved.

AIM

To pinpoint grey-matter changes that are associated with primary blepharospasm.

METHODS

16 right-handed patients with primary blepharospasm (mean age 67.4 (SD 4.3) years; 12 women) were compared with 16 healthy volunteers matched for sex and age. High-resolution T1-weighted magnetic resonance imaging of each participant was obtained and analysed by voxel-based morphometry, a method to detect regionally specific differences in grey matter between patients and control group. To evaluate whether the identified grey-matter changes were correlated with the duration of primary blepharospasm or botulinum neurotoxin treatment (BoNT), separate regression analyses were carried out.

RESULTS

In patients with primary blepharospasm, grey-matter increase in the putamina was observed, whereas regression analyses did not indicate a correlation between grey-matter increases and the duration of primary blepharospasm or BoNT. Grey-matter decrease was detected in the left inferior parietal lobule; here regression analyses of grey-matter decrease showed a significant (p = 0.013) correlation of grey-matter decrease with the duration of BoNT.

CONCLUSIONS

The data suggest structural changes in primary blepharospasm and point to a crucial role of the putamen for the pathophysiology of this focal dystonia.

Structural Brain Changes in Tinnitus

Tinnitus is a common but poorly understood disorder characterized by ringing or buzzing in the ear. Central mechanisms must play a crucial role in generating this auditory phantom sensation as it persists in most cases after severing the auditory nerve. One hypothesis states that tinnitus is caused by a reorganization of tonotopic maps in the auditory cortex, which leads to an overrepresentation of tinnitus frequencies. Moreover, the participation of the limbic system in generating tinnitus has been postulated. Here we aimed at identifying brain areas that display structural change in tinnitus. We compared tinnitus sufferers with healthy controls by using high-resolution magnetic resonance imaging and voxel-based morphometry. Within the auditory pathways, we found gray-matter increases only at the thalamic level. Outside the auditory system, gray-matter decrease was found in the subcallosal region including the nucleus accumbens. Our results suggest that reciprocal involvement of both sensory and emotional areas are essential in the generation of tinnitus.

Force level independent representations of predictive grip force–load force coupling: A PET activation study

The existence of forward internal models is a fundamental principle in theories of predictive motor control. There are indications that internal models are represented in the cerebellum. So far, no conclusive data exist on automated procedures involving predictive motor behavior. In particular, it is unknown whether single or multiple task-specific internal models handle the broad range of behavioral situations in which they occur. Using H2(15)O PET in eight subjects, we examined predictive motor control in an automated grip force-load force coupling task at three differing load force levels. In the experimental condition, subjects pulled a grasped object against an isometric resistance while simultaneously producing anticipatory grip forces. There were three control conditions (pull force isolated; grip force isolated; motor rest). A 2 x 2 factorial design was chosen to reveal the interaction effect of grip force-pull force coupling. The factors were pull force (with/without) and grip force (with/without). Grip and load forces were well matched between experimental and control conditions. Conjunction inference and interaction analyses identified force coupling related activity in the ipsilateral posterior cerebellum that was independent of force levels. Interaction effects were also identified in the anterior cingulate and frontal association regions, the right caudate nucleus, and the left lingual gyrus. These data demonstrate the existence of modular representations for predictive force coupling, with the ipsilateral cerebellum playing a major role. Moreover, the data implicate that the representations for predictive force control are applicable to a range of different environmental affordances.

Multiple progressive intracerebral hemorrhages due to an angiosarcoma: a case report

Identification of intracerebral hemorrhage (ICH) and the underlying cause is a common clinical problem. Rare causes of ICH can be particularly difficult to diagnose. We describe a man on oral anticoagulation with multiple progressive ICHs, who initially showed no signs of a malignant disease. After normalisation of all coagulation tests, the ICHs continued to spread. Autopsy examination revealed an angiosarcoma. Multiple progressive ICHs caused by an angiosarcoma that mainly affects the brain have not yet been described. In the presence of normal coagulation tests, further progression of ICH should raise questions about common causes of ICH such as oral anticoagulation in our case.

Incidence of sporadic infections due to enterotoxigenic Escherichia coli (ETEC) in the population of Hamburg, north Germany

In two studies (1982 and 1985/86), the presence of enterotoxigenic E. coli (ETEC) and other enteropathogenic bacteria was investigated in 779 stool specimens from children and adults with and without diarrhoeal disease. ETEC was isolated from 2% of diseased children and 1.6% of adult patients, but also from 0.5% of asymptomatic persons. Mixed infections with two different ETEC strains or with other enteropathogenic bacteria were identified in 4 of 9 infected persons. The ETEC strains belonged to 10 different serovars, eight of which produced only heat-stable enterotoxin. One infection had been contracted in a tropical country. After Salmonella and Campylobacter, ETEC was more frequently isolated than Yersinia and Shigella; the difference of ETEC infections in diseased and asymptomatic persons was, however, not statistically significant (p greater than 0.05). Analysis of the isolated serovars suggests that most ETEC strains implicated in sporadic cases of diarrhoea in Hamburg are unrelated to those which are widely spread in the developing world.