Pediatric multiple sclerosis: pathobiological, clinical, and magnetic resonance imaging features

Enhancing Mood, Cognition, and Quality of Life in Pediatric Multiple Sclerosis

Pediatric-onset multiple sclerosis (POMS), representing approximately 5% of all MS cases, affects the central nervous system during its ongoing development. POMS is most commonly diagnosed during adolescence but can occur in younger children as well. For pediatric patients with MS, it is critical to manage the full impact of the disease and monitor for any effects on school and social functioning. Disease management includes not only disease-modifying therapies but also strategies to optimize wellbeing. We review the interventions with the highest evidence of ability to improve the disease course and quality of life in POMS. High levels of vitamin D and a diet low in saturated fat are associated with lower relapse rates. Exercise ameliorates fatigue and sleep. Behavioral strategies for sleep hygiene and mood regulation can also improve fatigue and perceived health. POMS management should be addressed holistically, including assessing overall symptom burden as well as the psychological and functional impact of the disease.

Review Of The Safety, Efficacy And Tolerability Of Fingolimod In The Treatment Of Pediatric Patients With Relapsing-Remitting Forms Of Multiple Sclerosis (RRMS)

Pediatric-onset multiple sclerosis (POMS) is an immune-mediated, demyelinating, neurodegenerative disease that accounts for 3-5% of all multiple sclerosis (MS) cases. Although evidence suggests that it has similar risk factors and disease pathophysiology as adult-onset MS (AOMS), there are distinctive features in disease characteristics and patient demographics of POMS that require unique therapeutic development and treatment considerations. Gilenya^® (Novartis International AG, Basel, Switzerland) (fingolimod) is a sphingosine-1-phosphate (S1P) receptor modulator that prevents lymphocytic outflow from peripheral lymph nodes. It has demonstrated efficacy in AOMS. In POMS, there have been three observational studies and one pivotal clinical trial evaluating the efficacy, safety, and tolerability of fingolimod. Currently, fingolimod is the only Food and Drug Administration and European Medicines Agency approved disease-modifying therapy to treat POMS. This review will critically evaluate the available evidence of fingolimod in the treatment of POMS in detail, as well as discussing its treatment implications.

Neuroimaging of Infectious and Inflammatory Diseases of the Pediatric Cerebellum and Brainstem

Cerebellar involvement by infectious-inflammatory conditions is rare in children. Most patients present with acute ataxia, and are typically previously healthy, young (often preschool) children. Viral involvement is the most common cause and ranges from acute postinfectious ataxia to acute cerebellitis MR imaging plays a crucial role in the evaluation of patients suspected of harboring inflammatory-infectious involvement of the cerebellum and brainstem. Knowledge of the imaging features of these disorders and technical competence on pediatric MR imaging are necessary for a correct interpretation of findings, which in turn prompts further management.

Multiple sclerosis in Belgian children: A multicentre retrospective study

BACKGROUND

Although the diagnosis of multiple sclerosis (MS) in the paediatric population remains challenging, paediatric-onset MS is increasingly recognized worldwide.

METHODS

We report on the clinical and biochemical features of a Belgian multicentre cohort of paediatric MS patients in a national retrospective descriptive study.

RESULTS

Twenty one paediatric MS patients from four Belgian University Hospitals were included. In nine patients, onset of MS was before the age of ten years which makes the study cohort of special interest. We report a higher incidence of acute disseminated encephalomyelitis (ADEM)-like first MS attacks and an overall higher proportion of polysymptomatic episodes than in adult and most paediatric cohorts reported in the literature. The clinical presentation in our cohort was rather severe with high median EDSS-score during the first clinical manifestation and barely more than half of our study patients showing full recovery after their first clinical manifestation. Also, a significant proportion of children in our cohort has severe disease progression despite disease modifying therapy and 9.5% of patients showed transition to secondary progressive multiple sclerosis during adolescence.

CONCLUSION

An early and correct diagnosis of paediatric MS is essential to start early adequate treatment. As illustrated by our study cohort, current treatment options in childhood are unsatisfactory.

Imaging in Pediatric Demyelinating and Inflammatory Diseases of Brain- Part 2

Imaging plays an important role in diagnosis, management, prognostication and follow up of pediatric demyelinating and inflammatory diseases of brain and forms an integral part of the diagnostic criteria. This article reviews the spectrum of aquaporinopathies with an in-depth discussion on present criteria and differentiation from other demyelinating diseases with clinical vignettes for illustration; the latter part of article deals with the spectrum of CNS vasculitis.

Imaging in Pediatric Demyelinating and Inflammatory Diseases of the Brain- Part 1

Imaging plays an important role in the diagnosis, management, prognostication and follow up of pediatric demyelinating and inflammatory diseases of the brain and forms an integral part of the diagnostic criteria. Conventional and advanced MR imaging is the first and only reliable imaging modality. This article reviews the typical and atypical imaging features of common and some uncommon demyelinating and inflammatory diseases with emphasis on the criteria for categorization. Imaging protocols and the role of advanced imaging techniques are also covered appropriately.

Impaired growth of the cerebellum in pediatric-onset acquired CNS demyelinating disease

Background:

Acquired demyelinating syndromes (ADS) have the potential to negatively impact cerebellar growth, given the proclivity for infratentorial lesions in pediatric-onset multiple sclerosis (MS) and ADS.

Objective:

To investigate cerebellar growth longitudinally in pediatric ADS.

Methods:

Cerebellar volumes from 472 magnetic resonance imaging (MRI) scans of 98 patients with monophasic ADS (monoADS), monophasic acute disseminated encephalomyelitis (ADEM), and MS (49 girls; mean age: 11.4 years at first scan, mean follow-up: 3.1 years) imaged serially from onset and 897 MRI scans of 418 healthy children (223 girls, mean age: 11.3 years, mean follow-up: 2.9 years) were segmented automatically, analyzed with mixed-effect models, and compared with cerebral volume.

Results:

Cerebellar developmental trajectories followed a U-shaped curve, showing larger volumes in boys ( p < 0.001). Cerebellar volumes in all three patient groups failed to reach age-expected trajectories, leading to significantly smaller volumes, notably in the posterior lobes. Cerebellar volume reductions were of a similar magnitude to cerebral volume reductions. Cerebellar white matter volume declined in MS and ADEM patients over time, while in monoADS patients it remained similar to controls. Cerebellar volumes did not correlate either with lesion volumes at onset or with physical disability.

Conclusion:

MonoADS, ADEM, and MS in childhood lead to impaired age-expected growth of the cerebellum.

Paediatric brainstem: A comprehensive review of pathologies on MR imaging

The brainstem is a midline structure formed by the midbrain, pons and medulla and is a home for various vital neurological centres of the human body. A diverse spectrum of disease entities can involve the brainstem, which includes infections, metabolic disorders, demyelination, vascular conditions, neurodegenerative disorders and tumours. Brainstem involvement can be primary or secondary, i.e., as part of systemic disorders. Due to the overlapping clinical presentation and symptomatology, imaging plays a decisive role in the detection, localisation and characterisation of brainstem pathologies. Magnetic resonance imaging (MRI) is the modality of choice and the use of advanced MR techniques such as diffusion-weighted imaging and spectroscopy can be especially helpful in providing a tenable diagnoses. This article is a compilation of the MR imaging manifestations of a spectrum of common and uncommon brainstem pathologies that can be encountered in the paediatric age group.

Teaching Points

• The paediatric brainstem can be afflicted by many pathologies that may overlap clinico-radiologically.

• MRI is the best modality for the localisation and diagnosis of brainstem pathologies.

• Diffusion-weighted imaging is useful in the diagnosis of vascular and metabolic disorders.

• Occasionally, demyelination and neoplasms can be indistinguishable on imaging.

The role of the cerebellum in multiple sclerosis

In multiple sclerosis (MS), cerebellar signs and symptoms as well as cognitive dysfunction are frequent and contribute to clinical disability with only poor response to symptomatic treatment. The current consensus paper highlights the broad range of clinical signs and symptoms of MS patients, which relate to cerebellar dysfunction. There is considerable evidence of cerebellar involvement in MS based on clinical, histopathological as well as structural and functional magnetic resonance imaging (MRI) studies. The review of the recent literature, however, also demonstrates a high variability of results. These discrepancies are, at least partially, caused by the use of different techniques and substantial heterogeneity among the patient cohorts in terms of disease duration, number of patients, and progressive vs. relapsing disease courses. Moreover, the majority of studies were cross-sectional, providing little insight into the dynamics of cerebellar involvement in MS. Some links between the histopathological changes, the structural and functional abnormalities as captured by MRI, cerebellar dysfunction, and the clinical consequences are starting to emerge and warrant further study. A consensus is formed that this line of research will benefit from advances in neuroimaging techniques that allow to trace cerebellar involvement at higher resolution. Using a prospective study design, multimodal high-resolution cerebellar imaging is highly promising, particularly in patients who present with radiologically or clinically isolated syndromes or newly diagnosed MS.

Acquired demyelinating disorders of central nervous system: A pediatric cohort

Objective:

This is a retrospective chart review of consecutive children with acquired demyelinating disorders presenting to a north Indian tertiary care hospital over 4 years. The aim of this review is to describe all the patients (with single event as well as those with recurrences) with detailed description of those who recurred.

Materials and Methods:

Overall 35 cases were reviewed and their clinical presentations, diagnosis, management, and follow-up are being presented.

Results:

Out of 35 cases, 24 did not show any recurrences (seven acute disseminated encephalomyelitis (ADEM) and 17 clinically isolated syndromes). Amongst the 11 patients with recurrent demyelination, majority were multiple sclerosis (8/11, 72.7%) followed by neuromyelitis optica (NMO; 2/11), and multiphasic ADEM (1/11). The median disease duration and follow-up since onset for those with recurrent episodes is 4 years (2.5-4.5 years). Steroids caused significant improvement in acute episodes of demyelination. However, recurrent demyelinating disorders like multiple sclerosis and NMO required long-term immunomodulation. Azathioprine currently is the most favored long-term immunomodulator used in NMO. Interferon-β and glatiramer acetate are currently recommended for multiple sclerosis. However, azathioprine may be a suitable alternative in a resource-limited setting.

Conclusion:

The consensus definitions for these groups of disorders need further validation in the pediatric age group. Studies with larger population size are required to characterize features that predict future recurrences.

Longitudinally extensive myelopathy in children

When children present with acute myelopathy manifested by sensory, motor, or bowel and bladder symptoms, MRI of the neuraxis with contrast agent is the most important imaging study to obtain. Although occasionally normal, MRI often demonstrates signal abnormality within the spinal cord. Classically, longitudinally extensive transverse myelitis (≥3 vertebral bodies in length) has been described with neuromyelitis optica (NMO), but alternative diagnoses should be considered. This pictorial essay reviews the differential diagnoses that may present with longitudinally extensive spinal cord signal abnormalities. Multiple inflammatory, infectious, vascular, metabolic and neurodegenerative etiologies can present with a myelopathy. Thus, radiologists can assist in the diagnosis by familiarizing themselves with the spectrum of diseases in childhood that result in longitudinally extensive signal abnormalities in the absence of trauma.

Multiple sclerosis in children: an update on clinical diagnosis, therapeutic strategies, and research

The clinical features, diagnostic challenges, neuroimaging appearance, therapeutic options, and pathobiological research progress in childhood-and adolescent-onset multiple sclerosis have been informed by many new insights in the past 7 years. National programmes in several countries, collaborative research efforts, and an established international paediatric multiple sclerosis study group have contributed to revised clinical diagnostic definitions, identified clinical features of multiple sclerosis that differ by age of onset, and made recommendations regarding the treatment of paediatric multiple sclerosis. The relative risks conveyed by genetic and environmental factors to paediatric multiple sclerosis have been the subject of several large cohort studies. MRI features have been characterised in terms of qualitative descriptions of lesion distribution and applicability of MRI aspects to multiple sclerosis diagnostic criteria, and quantitative studies have assessed total lesion burden and the effect of the disease on global and regional brain volume. Humoral-based and cell-based assays have identified antibodies against myelin, potassium-channel proteins, and T-cell profiles that support an adult-like T-cell repertoire and cellular reactivity against myelin in paediatric patients with multiple sclerosis. Finally, the safety and efficacy of standard first-line therapies in paediatric multiple sclerosis populations are now appreciated in more detail, and consensus views on the future conduct and feasibility of phase 3 trials for new drugs have been proposed.