Canadian Expert Panel Recommendations for MRI Use in MS Diagnosis and Monitoring

[Use of Gadolinium in Follow-Up MRI of Multiple Sclerosis Patients: Current Recommendations]

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.

Efficacy and mechanism of Wuzi Yanzong pill on the prevention and treatment of EAE

Objective

Studies have shown that Wuzi Yanzong Pill (WYP) can be used to treat neurological diseases, but its mechanisms for multiple sclerosis (MS) remain unclear. This study aims to determine the effect of WYP on MS in an animal model of experimental autoimmune encephalomyelitis (EAE), and explore its mechanism. To provide theoretical basis for the clinical treatment of MS with WYP.

Methods

C57BL/6 female mice were randomly divided into Blank control, EAE control, low dose WYP, medium dose WYP, and high dose WYP groups. One week before model generation, the mice were gavaged with saline (50 mL/kg/d) in Blank control and EAE control groups. The treatment groups was gavaged with different doses of WYP solution (4, 8, or 16 g/kg/d respectively) Clinical scores were recorded daily. Sample collection was conducted on the 14th and 28th days, respectively The expressions of IL-10, IL-17, IL-12, TNF-α and IFN-γ in spleen were detected by ELISA. The expressions of ROCKII, P-MYPT1, TLR4, NF-κB/p65, MCP-1, CCR2 in spleen, brain and spinal cord were detected by Western Blot. The types of macrophages and the contents of intracellular IL-10 and IL-12 were detected by Flow Cytometry. The contents of TNF-α and TLR4 mRNA in the spleen were detected by RT-PCR.

Results

WYP treatment improved the clinical score of EAE mice in a significant dose-dependent manner, with the WYP high-dose group showed the most significant improvement in clinical score. Compared with the EAE control group, WYP high dose group had significantly lower levels of IL-17, IFN-γ, ROCKII, P-MYPT1, TLR4, NF-κB/p65, MCP-1, and CCR2 as well as TNF-α and TLR4 mRNA, but increased the number of M2 macrophages and IL-10.

Conclusion

WYP treatment relieves clinical symptoms in EAE mice, which may be related to regulate inflammatory pathway and inhibiting expressions of inflammatory cytokines.

Recommendations for the coordination of Neurology and Neuroradiology Departments in the management of patients with multiple sclerosis

INTRODUCTION

Magnetic resonance imaging (MRI) is widely used for the diagnosis and follow-up of patients with multiple sclerosis (MS). Coordination between neurology and neuroradiology departments is crucial for performing and interpreting radiological studies as efficiently and as accurately as possible. However, improvements can be made in the communication between these departments in many Spanish hospitals.

METHODS

A panel of 17 neurologists and neuroradiologists from 8 Spanish hospitals held in-person and online meetings to draft a series of good practice guidelines for the coordinated management of MS. The drafting process included 4 phases: 1) establishing the scope of the guidelines and the methodology of the study; 2) literature review on good practices or recommendations on the use of MRI in MS; 3) discussion and consensus between experts; and 4) validation of the contents.

RESULTS

The expert panel agreed a total of 9 recommendations for improving coordination between neurology and neuroradiology departments. The recommendations revolve around 4 main pillars: 1) standardising the process for requesting and scheduling MRI studies and reports; 2) designing common protocols for MRI studies; 3) establishing multidisciplinary committees and coordination meetings; and 4) creating formal communication channels between both departments.

CONCLUSIONS

These consensus recommendations are intended to optimise coordination between neurologists and neuroradiologists, with the ultimate goal of improving the diagnosis and follow-up of patients with MS.

Recommendations for the coordination of Neurology and Neuroradiology Departments in the management of patients with multiple sclerosis

INTRODUCTION

Magnetic resonance imaging (MRI) is widely used for the diagnosis and follow-up of patients with multiple sclerosis (MS). Coordination between Neurology and Neuroradiology departments is crucial for performing and interpreting radiological studies as efficiently and as accurately as possible. However, improvements can be made in the communication between these departments in many Spanish hospitals.

METHODS

A panel of 17 neurologists and neuroradiologists from 8 Spanish hospitals held in-person and online meetings to draft a series of good practice guidelines for the coordinated management of MS. The drafting process included 4 phases: 1) establishing the scope of the guidelines and the methodology of the study; 2) literature review on good practices or recommendations on the use of MRI in MS; 3) discussion and consensus between experts; and 4) validation of the contents.

RESULTS

The expert panel agreed a total of 9 recommendations for improving coordination between neurology and neuroradiology departments. The recommendations revolve around 4 main pillars: 1) standardising the process for requesting and scheduling MRI studies and reports; 2) designing common protocols for MRI studies; 3) establishing multidisciplinary committees and coordination meetings; and 4) creating formal communication channels between both departments.

CONCLUSIONS

These consensus recommendations are intended to optimise coordination between neurologists and neuroradiologists, with the ultimate goal of improving the diagnosis and follow-up of patients with MS.

Diagnosis and management of multiple sclerosis: MRI in clinical practice

Background

Recent changes in the understanding and management of multiple sclerosis (MS) have increased the role of MRI in supporting diagnosis and disease monitoring. However, published guidelines on the use of MRI in MS do not translate easily into different clinical settings and considerable variation in practice remains. Here, informed by published guidelines for the use of MRI in MS, we identified a clinically informative MRI protocol applicable in a variety of clinical settings, from district general hospitals to tertiary centres.

Methods

MS specialists geographically representing the UK National Health Service and with expertise in MRI examined existing guidelines on the use of MRI in MS and identification of challenges in their applications in various clinical settings informed the formulation of a feasible MRI protocol.

Results

We identified a minimum set of MRI information, based on clinical relevance, as well as on applicability to various clinical settings. This informed the selection of MRI acquisitions for scanning protocols, differentiated on the basis of their purpose and stage of the disease, and indication of timing for scans. Advice on standardisation of MRI requests and reporting, and proposed timing and frequency of MRI scans were generated.

Conclusions

The proposed MRI protocol can adapt to a range of clinical settings, aiding the impetus towards standardisation of practice and offering an example of research-informed service improvement to support optimisation of resources. Other neurological conditions, where a gap still exists between published guidelines and their clinical implementation, may benefit from this same approach.

Magnetic Resonance Imaging of Spinal Cord Lesions in Patients with Multiple Sclerosis in Saskatchewan, Canada

Background

Spinal cord lesions (SCLs) contribute to disability in multiple sclerosis (MS). Data in Saskatchewan, Canada, concerning SCLs and their association with disability levels in patients with MS are lacking. The study objectives were to identify clinicodemographic profiles of patients with MS with respect to spinal cord magnetic resonance imaging (MRI) involvement; determine the frequency of individuals with MRI SCLs; and explore differences between patients with MS with and without SCLs with respect to disability and disease-modifying therapy status.

Methods

A monocentric, cross-sectional, retrospective review of prospectively collected data from 532 research-consented patients seen at Saskatoon MS Clinic was performed. Data were collected from a database and electronic medical records.

Results

Of the 356 patients (66.9%) with an SCL, 180 (50.6%) had only cervical cord lesions. Median Expanded Disability Status Scale (EDSS), ambulation, and pyramidal scores of patients with SCLs were higher than those of patients without SCLs. Of patients with EDSS scores of at least 6, those with SCLs were younger than those without SCLs (P = .01). Patients with SCLs were 55% less likely to have been on continuous disease-modifying therapy since diagnosis than patients without SCLs (adjusted odds ratio, 0.45; 95% CI, 0.25-0.81; P = .008).

Conclusions

Prevalence and association with disability of SCLs in patients with MS are comparable with existing literature. Patients with MS with SCLs have higher levels of disability and attain EDSS scores of at least 6 at a younger age.

Treatment Optimization in Multiple Sclerosis: Canadian MS Working Group Recommendations

The Canadian Multiple Sclerosis Working Group has updated its treatment optimization recommendations (TORs) on the optimal use of disease-modifying therapies for patients with all forms of multiple sclerosis (MS). Recommendations provide guidance on initiating effective treatment early in the course of disease, monitoring response to therapy, and modifying or switching therapies to optimize disease control. The current TORs also address the treatment of pediatric MS, progressive MS and the identification and treatment of aggressive forms of the disease. Newer therapies offer improved efficacy, but also have potential safety concerns that must be adequately balanced, notably when treatment sequencing is considered. There are added discussions regarding the management of pregnancy, the future potential of biomarkers and consideration as to when it may be prudent to stop therapy. These TORs are meant to be used and interpreted by all neurologists with a special interest in the management of MS.

Toward a Shared-Care Model of Relapsing-Remitting Multiple Sclerosis: Role of the Primary Care Practitioner

The objective of this study was to develop a shared-care model to enable primary-care physicians to participate more fully in meeting the complex, multidisciplinary healthcare needs of patients with multiple sclerosis (MS).

DESIGN

The design consisted of development of consensus recommendations and a shared-care algorithm.

PARTICIPANTS

A working group of 11 Canadian neurologists involved in the management of patients with MS were included in this study.

MAIN MESSAGE

The clinical management of patients with multiple sclerosis is increasing in complexity as new disease-modifying therapies (DMTs) become available, and ongoing safety monitoring is required. A shared-care model that includes primary care physicians is needed. Primary care physicians can assist in the early detection of MS of individuals presenting with neurological symptoms. Additional key roles for family physicians are health promotion, symptom management, and safety and relapse monitoring of DMT-treated patients. General principles of health promotion include counseling MS patients on maintaining a healthy lifestyle; performing standard screening measures; and identifying and treating comorbidities. Of particular importance are depression and anxiety, which occur in >20% of MS patients. Standard work-ups and treatments are needed for common MS-related symptoms, such as fatigue, pain, bladder dysfunction, sexual dysfunction, spasticity, and sleep disorders. Ongoing safety monitoring is required for patients receiving specific DMTs. Multiple sclerosis medications are generally contraindicated during pregnancy, and patients should be counseled to practice effective contraception.

CONCLUSIONS

Multiple sclerosis is a complex, disabling illness, which, similar to other chronic diseases, requires ongoing multidisciplinary care to meet the evolving needs of patients throughout the clinical course. Family physicians can play an invaluable role in maintaining general health, managing MS-related symptoms and comorbidities, monitoring for treatment-related adverse effects and MS relapses, and coordinating allied health services to ensure continuity of care to meet the complex and evolving needs of MS patients through the disease course. RÉSUMÉ: Élaborer un modèle de soins partagés dans les cas de sclérose en plaques récurrente-rémittente. Objectif: Élaborer un modèle de soins partagés afin de permettre aux médecins de première ligne de mieux répondre aux besoins complexes et multidisciplinaires de patients atteints de la sclérose en plaques (SP). Conception : Recommandations résultant d'un consensus et élaboration d'un algorithme en matière de soins partagés.

PARTICIPANTS

Un groupe de travail formé de onze neurologues canadiens impliqués dans la prise en charge de patients atteints de la SP. Message-clé : La prise en charge clinique de patients atteints de la SP est de plus en plus complexe dans la mesure où des médicaments modificateurs de l'évolution de la maladie (MMSP) deviennent accessibles et où un suivi permanent en matière de sécurité est nécessaire. Soulignons aussi qu'un modèle de soins partagés incluant les médecins de première ligne est nécessaire. Ces professionnels peuvent permettre un dépistage plus rapide de la SP chez des individus présentant des symptômes neurologiques. Ils peuvent aussi jouer un rôle de premier plan en matière de promotion de la santé, de soulagement des symptômes et de suivi de patients traités avec des MMSP en ce qui a trait à leur sécurité et à de possibles rechutes. Parmi les principes généraux de promotion de la santé, on peut inclure les suivants : offrir aux patients atteints de la SP des conseils leur permettant de maintenir de saines habitudes de vie ; adopter des mesures de dépistage standards ; identifier et traiter les comorbidités. À cet égard, l'anxiété et la dépression sont d'une importance particulière et sont fréquemment signalées (> 20 %) chez les patients atteints de SP. Des démarches d'investigation et des traitements standards sont nécessaires dans le cas des symptômes courants reliés à la SP, par exemple de la fatigue, des douleurs, une dysfonction vésicale, des dysfonctions sexuelles, de la spasticité et des troubles du sommeil. On l'a dit, un suivi permanent s'impose dans le cas de patients bénéficiant d'un traitement spécifique avec des MMSP. Les médicaments associés à la SP sont généralement contre-indiqués durant la grossesse de sorte qu'on devrait conseiller aux patients d'adopter des méthodes de contraception efficaces.

CONCLUSIONS

La SP est une maladie complexe et invalidante qui, à l'instar d'autres maladies chroniques, exige des soins multidisciplinaires continus afin de répondre, en lien avec un tableau clinique précis, aux besoins en constante évolution des patients. Les médecins de première ligne peuvent jouer un rôle irremplaçable à plusieurs égards : dans le maintien d'une bonne santé ; le suivi et le soulagement des symptômes et des comorbidités reliés à la SP ; le suivi des rechutes et des effets indésirables associés aux traitements. N'oublions pas non plus la coordination des services paramédicaux afin d'assurer, durant l'évolution de la SP, une continuité des soins répondant aux besoins complexes et en constante évolution des patients atteints de cette maladie.

MRI utilization during the diagnostic and post-diagnostic phases in multiple sclerosis

BACKGROUND

Magnetic resonance imaging (MRI) plays an important role in the diagnosis and monitoring of people with multiple sclerosis (MS). MRI rates in MS populations are poorly understood. Although Canada has universal health care, socioeconomic status (SES) is associated with MRI use. It is unknown if such disparities persist for specific conditions such as MS when care is managed centrally, or how disease-specific characteristics may affect MRI use.

OBJECTIVE

To assess magnetic resonance imaging (MRI) use in MS and control participants and its association with participant characteristics.

METHODS

Using administrative and clinical data from Manitoba, Canada, we assessed MRI use in MS and control participants during the five years pre-index (first demyelinating claim in the administrative cohort or symptom onset in the clinical cohort), between index and diagnosis (third demyelinating claim in the administrative cohort or diagnosis date in the clinical cohort), and the five years post-diagnosis. Using zero-inflated Poisson regression, we assessed associations between participant characteristics and index year, and MRI use during these three phases.

RESULTS

We included 2,763 MS cases and 13,815 controls in the administrative cohort, and 961 MS cases in the clinical cohort. MRI use increased over time, but more in cases than in controls. Pre-index, individuals aged <50 years at the index date had lower MRI rates than those aged ≥50 years. Sex, socioeconomic status and region were not associated with MRI use. Disease-modifying therapy use was associated with 25% more MRIs post-diagnosis (adjusted rate ratio: 1.25; 95%CI:1.09-1.43) in the clinical cohort.

CONCLUSION

Our findings suggest equity of access to MRI across sex, region and socioeconomic status in MS.

Guidelines for the use of magnetic resonance imaging in diagnosing and monitoring the treatment of multiple sclerosis: recommendations of the Swedish Multiple Sclerosis Association and the Swedish Neuroradiological Society

Multiple sclerosis (MS) is associated with inflammatory lesions in the brain and spinal cord. The detection of such inflammatory lesions using magnetic resonance imaging (MRI) is important in the consideration of the diagnosis and differential diagnoses of MS, as well as in the monitoring of disease activity and predicting treatment efficacy. Although there is strong evidence supporting the use of MRI for both the diagnosis and monitoring of disease activity, there is a lack of evidence regarding which MRI protocols to use, the frequency of examinations, and in what clinical situations to consider MRI examination. A national workshop to discuss these issues was held in Stockholm, Sweden, in August 2015, which resulted in a Swedish consensus statement regarding the use of MRI in the care of individuals with MS. The aim of this consensus statement is to provide practical advice for the use of MRI in this setting. The recommendations are based on a review of relevant literature and the clinical experience of workshop attendees. It is our hope that these recommendations will benefit individuals with MS and guide healthcare professionals responsible for their care.

Effect of Fingolimod on Brain Volume Loss in Patients with Multiple Sclerosis

Brain atrophy occurs at a faster rate in patients with multiple sclerosis (MS) than in healthy individuals. In three randomized, controlled, phase III trials, fingolimod reduced the annual rate of brain volume loss (BVL) in patients with relapsing MS (RMS) by approximately one-third relative to that in individuals receiving placebo or intramuscular interferon beta-1a. Analysis of brain volume changes during study extensions has shown that this reduced rate of BVL is sustained in patients with RMS receiving fingolimod continuously. Subgroup analyses of the core phase III and extension studies have shown that reductions in the rate of BVL are observed irrespective of levels of inflammatory lesion activity seen by magnetic resonance imaging at baseline and on study; levels of disability at baseline; and treatment history. The rate of BVL in these studies was predicted independently by T2 lesion and gadolinium-enhancing lesion burdens at baseline, and correlations observed between BVL and increasing levels of disability strengthened over time. In another phase III trial in patients with primary progressive MS (PPMS), fingolimod did not reduce BVL overall relative to placebo; however, consistent with findings in RMS, there was a treatment effect on BVL in patients with PPMS with gadolinium-enhancing lesion activity at baseline. The association between treatment effects on BVL and future accumulation of disability argues in favor of measuring BVL on a more routine basis and with a more structured approach than is generally the case in clinical practice. Despite several practical obstacles, progress is being made in achieving this goal.

Brain health: time matters in multiple sclerosis

INTRODUCTION

We present international consensus recommendations for improving diagnosis, management and treatment access in multiple sclerosis (MS). Our vision is that these will be used widely among those committed to creating a better future for people with MS and their families.

METHODS

Structured discussions and literature searches conducted in 2015 examined the personal and economic impact of MS, current practice in diagnosis, treatment and management, definitions of disease activity and barriers to accessing disease-modifying therapies (DMTs).

RESULTS

Delays often occur before a person with symptoms suggestive of MS sees a neurologist. Campaigns to raise awareness of MS are needed, as are initiatives to improve access to MS healthcare professionals and services. We recommend a clear treatment goal: to maximize neurological reserve, cognitive function and physical function by reducing disease activity. Treatment should start early, with DMT and lifestyle measures. All parameters that predict relapses and disability progression should be included in the definition of disease activity and monitored regularly when practical. On suboptimal control of disease activity, switching to a DMT with a different mechanism of action should be considered. A shared decision-making process that embodies dialogue and considers all appropriate DMTs should be implemented. Monitoring data should be recorded formally in registries to generate real-world evidence. In many jurisdictions, access to DMTs is limited. To improve treatment access the relevant bodies should consider all costs to all parties when conducting economic evaluations and encourage the continuing investigation, development and use of cost-effective therapeutic strategies and alternative financing models.

CONCLUSIONS

The consensus findings of an international author group recommend a therapeutic strategy based on proactive monitoring and shared decision-making in MS. Early diagnosis and improved treatment access are also key components.

Possible association of CCDC62 rs12817488 polymorphism and Parkinson's disease risk in Chinese population: a meta-analysis

Conflicting results identifying the association between coiled-coil domain containing 62 (CCDC62) polymorphism, rs12817488, and Parkinson’s disease (PD) have been reported. To clarify whether rs12817488 is related to PD risk in Chinese population, we carried out this meta-analysis by searching literature from PubMed and Embase database regarding this polymorphism. Three eligible studies involving 1616 cases and 1649 controls were included in this meta-analysis. Our results showed statistically significant association between rs12817488 and PD risk in all four genetic models. Stratification by gender revealed similar results in both subgroup in these genetic models except for recessive model, in which rs12817488 was not significantly associated with PD in male subgroup. Unstable result was found in recessive model via sensitivity analysis, and publication bias was observed in recessive model as well, indicating that the pooled result from recessive model should be cautiously treated. Our meta-analysis implicates a possible relationship between rs12817488 and PD risk in Chinese population. Further validation of this association in large sample size study with different gender is warranted.