Prognostic relevance of MRI in early relapsing multiple sclerosis: ready to guide treatment decision making?

Magnetic resonance imaging (MRI) of the brain and spinal cord plays a crucial role in the diagnosis and monitoring of multiple sclerosis (MS). There is conclusive evidence that brain and spinal cord MRI findings in early disease stages also provide relevant insight into individual prognosis. This includes prediction of disease activity and disease progression, the accumulation of long-term disability and the conversion to secondary progressive MS. The extent to which these MRI findings should influence treatment decisions remains a subject of ongoing discussion. The aim of this review is to present and discuss the current knowledge and scientific evidence regarding the utility of MRI at early MS disease stages for prognostic classification of individual patients. In addition, we discuss the current evidence regarding the use of MRI in order to predict treatment response. Finally, we propose a potential approach as to how MRI data may be categorized and integrated into early clinical decision making.

The role of sex and pregnancy in multiple sclerosis: what do we know and what should we do?

INTRODUCTION

Multiple sclerosis (MS) is more prevalent in women than in men. The sex of the patient, and pregnancy, are reported to be associated with the clinical features of MS. The mechanism of this is unclear.

AREAS COVERED

This review summarizes data about sex differences in MS and the role of pregnancy. Possible mechanisms for the effects of sex and pregnancy are summarized, and practical suggestions for addressing these issues are provided.

EXPERT OPINION

There is considerable interdependence of the variables that are associated with MS. Men have a worse outcome of MS, and this could be due to the same factors that lead to greater incidence of neurodegenerative disease in men. The possible role of parity on the long-term outcome of MS is of interest. Future studies that look at the mechanisms of the effects of the sex of the patient on the outcome of MS are required. However, there are some actions that can be taken without further research. We can concentrate on public health measures that address the modifiable risk factors for MS and ensure that disease is controlled in women who intend to become pregnant and use appropriate disease modifying agents during pregnancy.

Magnetic Resonance Imaging as a Prognostic Disability Marker in Clinically Isolated Syndrome and Multiple Sclerosis: A Systematic Review and Meta-Analysis

To date, there are no definite imaging predictors for long-term disability in multiple sclerosis (MS). Magnetic resonance imaging (MRI) is the key prognostic tool for MS, primarily at the early stage of the disease. Recent findings showed that white matter lesion (WML) counts and volumes could predict long-term disability for MS. However, the prognostic value of MRI in the early stage of the disease and its link to long-term physical disability have not been assessed systematically and quantitatively. A meta-analysis was conducted using studies from four databases to assess whether MS lesion counts and volumes at baseline MRI scans could predict long-term disability, assessed by the expanded disability status scale (EDSS). Fifteen studies were eligible for the qualitative analysis and three studies for meta-analysis. T2 brain lesion counts and volumes after the disease onset were associated with disability progression after 10 years. Four or more lesions at baseline showed a highly significant association with EDSS 3 and EDSS 6, with a pooled OR of 4.10 and 4.3, respectively. The risk increased when more than 10 lesions were present. This review and meta-analysis confirmed that lesion counts and volumes could be associated with disability and might offer additional valid guidance in treatment decision making. Future work is essential to determine whether these prognostic markers have high predictive potential.

Assessment of the optic nerve, optic disc, and perineural area using shear-wave elastography in patients with multiple sclerosis

PURPOSE

To observe and describe the stiffness changes of the optic nerve in the patients with multiple sclerosis (MS) with or without optic neuritis and healthy adults via shear wave elastography (SWE).

METHODS

70 optic nerves from 35 patients with MS and 60 optic nerves from 30 healthy subjects were included prospectively in the study. The optic nerve (ON), optic disc (OD), and perineural area were evaluated with SWE and optic nerve sheat diameter (ONSD) was measured by ultrasound.

RESULTS

The mean age of patients was 39.68 ± 9.99 years. There was no statistically significant difference between the groups in terms of ONSD, SWE ON, SWE OD, and SWE perineural area levels (P > .05). In the MS group; No statistically significant difference was found between patients with and without optic neuritis for the mean age, gender distribution, duration of MS, types of MS, ONSD, SWE ON, SWE OD, SWE perineural area, and Expanded Disability Status Scale (EDSS) scores (P > .05). No statistically significant difference in terms of ONSD, SWE ON, SWE OD, and SWE perineural area between the MS patients with or without optic neuritis and the control group (P > .05).

CONCLUSION

Shear wave elastography measurements of the optic nerve, optic disc, and perineural area do not contribute to the evaluation of optic neuritis in a patient with MS.

Prediction in treatment outcomes in multiple sclerosis: challenges and recent advances

INTRODUCTION

Multiple Sclerosis (MS) is a chronic autoimmune and neurodegenerative disease of the central nervous system with a course dependent on early treatment response. Increasing evidence also suggests that despite eliminating disease activity (relapses and lesions), many patients continue to accrue disability, highlighting the need for a more comprehensive definition of treatment success. Optimizing disability outcome measures, as well as continuously improving our understanding of neuroinflammatory and neurodegenerative biomarkers is required.

AREAS COVERED

This review describes the challenges inherent in classifying and monitoring disease phenotype in MS. The review also provides an assessment of clinical, radiological, and blood biomarker tools for current and future practice.

EXPERT OPINION

Emerging MRI techniques and standardized patient outcome assessments will increase the accuracy of initial diagnosis and understanding of disease progression.

Diverse MRI findings and clinical outcomes of acute Marchiafava-Bignami disease

BACKGROUND

The acute onset of Marchiafava-Bignami disease (MBD) is difficult to capture, and its clinical manifestations are overlapped. Magnetic resonance imaging (MRI) is very useful in the diagnosis of acute MBD.

PURPOSE

To investigate the MRI features and clinical outcomes of acute MBD.

MATERIALS AND METHODS

Sagittal T2-weighted (T2W) or T1-weighted (T1W) imaging, axial T1W and T2W imaging, and axial FLAIR and diffusion-weighted imaging (DWI) sequences were performed in 17 patients with acute MBD on 1.5-T MR. According to the different ranges of callosal restricted diffusion, MBD was divided into Type I (n = 7, the completely involved), Type II (n = 5, the mostly involved), and Type III (n = 5, the partly involved). The MRI findings and outcomes of each type were retrospectively analyzed.

RESULTS

With the reduced range of the callosal restricted diffusion, the callosal atrophy or cavitation was more common: no case of Type I; 1 (20%) case of Type II; and 3 (60%) cases of Type III. With the increased range of callosal restricted diffusion, the extracallosal involvement was more common: 6 (86%) cases of Type I; 3 (60%) cases of Type II; and 1 (20%) case of Type III. During the follow-up, five cases had neuropsychiatric sequelae: 1 (14%) case of type I; 1 (20%) case of Type II; 3 (60%) cases of Type III.

CONCLUSION

The MRI findings and clinical outcomes of acute MBD are regular. The extensive restricted diffusion of acute MBD may present the curable condition. Callosal heterogeneity may affect the outcome of acute MBD.

Radiomic analysis of the optic nerve at the first episode of acute optic neuritis: an indicator of optic nerve pathology and a predictor of visual recovery?

OBJECTIVE

Retinal nerve fiber layer thickness (RNFL) is a biomarker of neuroaxonal loss and index of visual function in multiple sclerosis (MS). We aimed to assess the correlation between radiomic features and RNFL, visual acuity (VA) at patients' presentation, visual outcome (VO), and clinical diagnosis.

METHODS

We reviewed imaging and clinical data of 25 patients with a first episode of optic neuritis (ON) (14 females, 11 males; 5 bilateral ON; 7 left ON; 13 right ON). All patients underwent a complete ophthalmological assessment, including visual acuity and RNFL, neurological evaluation, orbits MRI. Segmentation of the optic nerves was performed through 3D slicer open software to get radiomics analysis. All patients underwent a complete neuro-ophthalmological follow-up at 6 months to assess the VO, classified as: complete recovery, partial recovery, deficit persistence/relapse, or visual worsening and were diagnosed as MS or clinically isolated syndrome.

RESULTS

We observed significant correlations between radiomic features and RNFL and between radiomic features and VA. Regression model analysis identified 1 radiomic feature with significant association with VO (Gray Level non-uniformity Normalized, p = 0.004) and 6 radiomic features with significant correlation with diagnosis (High Gray Level Zone Emphasis, p < 0.001; Entropy, p < 0.001, for T1 segmentation; Mean Absolute Deviation, p < 0.001; Coarseness < 0.001; Small Area Low Gray Level Emphasis, p < 0.001; Contrast, p = 0.008, for STIR segmentation).

CONCLUSION

Orbits MRI analysis at the first episode of ON has the potential to assess the visual function and VO in ON patients, and predict MS development.

Prognostication and contemporary management of clinically isolated syndrome

Clinically isolated syndrome (CIS) patients present with a single attack of inflammatory demyelination of the central nervous system. Recent advances in multiple sclerosis (MS) diagnostic criteria have expanded the number of CIS patients eligible for a diagnosis of MS at the onset of the disease, shrinking the prevalence of CIS. MS treatment options are rapidly expanding, which is driving the need to recognise MS at its earliest stages. In CIS patients, finding typical MS white matter lesions on the patient's MRI scan remains the most influential prognostic investigation for predicting subsequent diagnosis with MS. Additional imaging, cerebrospinal fluid and serum testing, information from the clinical history and genetic testing also contribute. For those subsequently diagnosed with MS, there is a wide spectrum of long-term clinical outcomes. Detailed assessment at the point of presentation with CIS provides fewer clues to calculate a personalised risk of long-term severe disability.Clinicians should select suitable CIS cases for steroid treatment to speed neurological recovery. Unfortunately, there are still no neuroprotection or remyelination strategies available. The use of MS disease modifying therapy for CIS varies among clinicians and national guidelines, suggesting a lack of robust evidence to guide practice. Clinicians should focus on confirming MS speedily and accurately with appropriate investigations. Diagnosis with CIS provides an opportune moment to promote a healthy lifestyle, in particular smoking cessation. Patients also need to understand the link between CIS and MS. This review provides clinicians an update on the contemporary evidence guiding prognostication and management of CIS.

A novel decision tree approach to predict the probability of conversion to multiple sclerosis in Iranian patients with optic neuritis

BACKGROUND

assessing the risk of conversion to multiple sclerosis (MS) in patients with optic neuritis (ON) has been the topic of numerous studies. However, since the risk factors differ from population to population, the extension of conclusions is a matter of debate. This study focused on the Iranian patients with optic neuritis and assessed the probability of conversion to multiple sclerosis by using a machine-based learning decision tree.

METHODS

in this retrospective, observational study the medical records of patients with optic neuritis from 2008 to 2018 were reviewed. Baseline vision, the treatment modality, magnetic resonance imaging (MRI) findings, and patients' demographics were gathered to evaluate the odds of each factor for conversion to MS. The decision tree was then obtained from these data based on their specificity and sensitivity to predict the probability of conversion to MS.

RESULTS

the overall conversion rate to MS was 42.2% (117/277). 63.1 percent of patients had abnormal MRIs at baseline. The presence of white matter plaque had the highest odds for the conversion followed by the positive history of optic neuritis attack and gender. The regression tree showed that the presence of plaque was the most important predicting factor that increased the probability of conversion from 16 to 51 percent.

CONCLUSION

the decision tree could predict the probability of conversion to MS by considering multiple risk factors with acceptable precision.

Reaching an evidence-based prognosis for personalized treatment of multiple sclerosis

Personalized treatment is ideal for multiple sclerosis (MS) owing to the heterogeneity of clinical features, but current knowledge gaps, including validation of biomarkers and treatment algorithms, limit practical implementation. The contemporary approach to personalized MS therapy depends on evidence-based prognostication, an initial treatment choice and evaluation of early treatment responses to identify the need to switch therapy. Prognostication is directed by baseline clinical, environmental and demographic factors, MRI measures and biomarkers that correlate with long-term disability measures. The initial treatment choice should be a shared decision between the patient and physician. In addition to prognosis, this choice must account for patient-related factors, including comorbidities, pregnancy planning, preferences of the patients and their comfort with risk, and drug-related factors, including safety, cost and implications for treatment sequencing. Treatment response has traditionally been assessed on the basis of relapse rate, MRI lesions and disability progression. Larger longitudinal data sets have enabled development of composite outcome measures and more stringent standards for disease control. Biomarkers, including neurofilament light chain, have potential as early surrogate markers of prognosis and treatment response but require further validation. Overall, attainment of personalized treatment for MS is complex but will be refined as new data become available.

Recurrent Optic Neuritis as the Initial Symptom in Demyelinating Diseases

Background and Purpose

Optic neuritis (ON) is an inflammation of the optic nerve that can be recurrent, with unilateral or bilateral presentation. Diagnosing recurrent cases may be challenging. We aimed to compare patients with recurrent ON as their initial symptom according to their following final diagnoses: multiple sclerosis (MS), neuromyelitis optica spectrum disorders (NMOSD), or chronic relapsing inflammatory optic neuropathy (CRION).

Methods

The medical records of patients with initial recurrent ON who were followed at the Neuroimmunology Clinic of the Federal University of São Paulo between 2004 and 2016 were analyzed retrospectively. Patients were classified according to their final diagnosis into MS, NMOSD, or CRION, and the characteristics of these groups were compared to identify predictive factors.

Results

Thirty-three patients with recurrent ON were included, and 6, 14, and 13 had final diagnoses of MS, NMOSD, and CRION, respectively. Most of the patients were female with unilateral and severe ON in their first episode, and the initial Visual Functional System Score (VFSS) was ≥5 in 63.6%, 85.7%, and 16.7% of the patients with CRION, NMOSD, and MS, respectively. Anti-aquaporin-4 antibodies were detected in 9 of 21 (42.8%) tested patients. Seven of nine (77.8%) seropositive NMOSD patients experienced transverse myelitis episodes during the follow-up period. A multivariate regression analysis showed that the VFSS at the last medical appointment predicted the final diagnosis.

Conclusions

A lower VFSS at the last medical appointment was predictive of MS. Patients with NMOSD and CRION have similar clinical characteristics, whereas NMOSD patients tend to have worse visual acuity.

Prediction of Conversion from Clinically Isolated Syndrome to Multiple Sclerosis According to Baseline Characteristics: A Prospective Study

Objective

Clinically isolated syndrome (CIS) is a clinical state that proceeds with inflammation and demyelination, suggestive of multiple sclerosis (MS) in the central nervous system in the absence of other alternative diagnoses. The purpose of this study was to determine in a prospective cohort, the predictor factors in conversion from CIS to MS on the basis of clinical, magnetic resonance (MR) imaging and cerebrospinal fluid (CSF) findings.

Methods

Forty-one CIS patients were included in this study and followed up for at least two years.

Results

Clinically, polysymptomatic or sensorial involvement, good prognostic factors and complete response to pulse therapy were found to be of prognostic value in conversion to MS. A greater presence of oligoclonal bands in CSF was identified in the converted group (92.8%). In terms of localization, presence of callosal lesion (71.4%), periventricular lesion (97.1%), Gd-enhanced lesion (48.6%), black hole (54.2%) and brainstem lesion (57.1%) was statistically significant in terms of conversion to MS.

Conclusion

A carefully performed neurological assessment of symptoms and signs, and evaluation of lesions on MR combined with CSF findings are important for identifying the risk of conversion to MS. This information may be useful when considering treatment in CIS patients instead of waiting for conversion to MS.

Magnetic resonance imaging findings at the first episode of acute optic neuritis

BACKGROUND

Optic neuritis (ON) is a focal demyelinating event, which may evolve into multiple sclerosis (MS).

OBJECTIVE

To study MRI characteristics in the acute phase of the first ON episode.

METHODS

A prospective population-based study was performed on 31 patients with a first episode of acute ON with a one year follow-up. MRI, clinical evaluation, and detection of aquaporin-4 (AQP4)-IgG and myelin oligodendrocyte glycoprotein (MOG)-IgG was undertaken. For lesion characterization on MRI the optic nerves were divided into three segments: intra-orbital (IO), canalicular (CAN) and chiasmal (CHI).

RESULTS

Lesions of the optic nerve were observed in 80.6%(25/31), with IO location in 48%(12/25), CAN in 8% (2/25) and both IO and CAN in 44%(11/25). Patients who converted to MS had lesions located at IO in 77%(10/13), whereas the group with isolated ON had IO and CAN in 73% (8/11), p = 0.003. Brain lesions were observed in 84% (21/25) at onset of ON; 62%(13/25) progressed to MS with more frequent location in brainstem (p = 0.030) and lesions in periventricular areas (p = 0.015). Spinal cord lesions were detected only in patients who progressed to MS (p = 0.002). MOG-IgG was detected in one patient with an optic nerve lesion located at IO and CAN. Serum AQP4-IgG was detected in none. Follow-up MRI showed progression in optic nerve lesions in 55% (11/20) patients.

CONCLUSIONS

Specific location of optic nerve and brain lesions and the presence of spinal cord lesions in the acute phase of the first ON episode facilitated an MS diagnosis. The extension of optic nerve lesions following ON suggests a long-term progressive degeneration as an important element of ON pathology.

Prediction of a multiple sclerosis diagnosis in patients with clinically isolated syndrome using the 2016 MAGNIMS and 2010 McDonald criteria: a retrospective study

BACKGROUND

In 2016, the Magnetic Resonance Imaging in Multiple Sclerosis (MAGNIMS) network proposed modifications to the MRI criteria to define dissemination in space (DIS) and time (DIT) for the diagnosis of multiple sclerosis in patients with clinically isolated syndrome (CIS). Changes to the DIS definition included removal of the distinction between symptomatic and asymptomatic lesions, increasing the number of lesions needed to define periventricular involvement to three, combining cortical and juxtacortical lesions, and inclusion of optic nerve evaluation. For DIT, removal of the distinction between symptomatic and asymptomatic lesions was suggested. We compared the performance of the 2010 McDonald and 2016 MAGNIMS criteria for multiple sclerosis diagnosis in a large multicentre cohort of patients with CIS to provide evidence to guide revisions of multiple sclerosis diagnostic criteria.

METHODS

Brain and spinal cord MRI and optic nerve assessments from patients with typical CIS suggestive of multiple sclerosis done less than 3 months from clinical onset in eight European multiple sclerosis centres were included in this retrospective study. Eligible patients were 16-60 years, and had a first CIS suggestive of CNS demyelination and typical of relapsing-remitting multiple sclerosis, a complete neurological examination, a baseline brain and spinal cord MRI scan obtained less than 3 months from clinical onset, and a follow-up brain scan obtained less than 12 months from CIS onset. We recorded occurrence of a second clinical attack (clinically definite multiple sclerosis) at months 36 and 60. We evaluated MRI criteria performance for DIS, DIT, and DIS plus DIT with a time-dependent receiver operating characteristic curve analysis.

FINDINGS

Between June 16, 1995, and Jan 27, 2017, 571 patients with CIS were screened, of whom 368 met all study inclusion criteria. At the last evaluation (median 50·0 months [IQR 27·0-78·4]), 189 (51%) of 368 patients developed clinically definite multiple sclerosis. At 36 months, the two DIS criteria showed high sensitivity (2010 McDonald 0·91 [95% CI 0·85-0·94] and 2016 MAGNIMS 0·93 [0·88-0·96]), similar specificity (0·33 [0·25-0·42] and 0·32 [0·24-0·41]), and similar area under the curve values (AUC; 0·62 [0·57-0·67] and 0·63 [0·58-0·67]). Performance was not affected by inclusion of symptomatic lesions (sensitivity 0·92 [0·87-0·96], specificity 0·31 [0·23-0·40], AUC 0·62 [0·57-0·66]) or cortical lesions (sensitivity 0·92 [0·87-0·95], specificity 0·32 [0·24-0·41], AUC 0·62 [0·57-0·67]). Requirement of three periventricular lesions resulted in slightly lower sensitivity (0·85 [0·78-0·90], slightly higher specificity (0·40 [0·32-0·50], and similar AUC (0·63 [0·57-0·68]). Inclusion of optic nerve evaluation resulted in similar sensitivity (0·92 [0·87-0·96]), and slightly lower specificity (0·26 [0·18-0·34]) and AUC (0·59 [0·55-0·64]). AUC values were also similar for DIT (2010 McDonald 0·61 [0·55-0·67] and 2016 MAGNIMS 0·61 [0·55-0·66]) and DIS plus DIT (0·62 [0·56-0·67] and 0·64 [0·58-0·69]).

INTERPRETATION

The 2016 MAGNIMS criteria showed similar accuracy to the 2010 McDonald criteria in predicting the development of clinically definite multiple sclerosis. Inclusion of symptomatic lesions is expected to simplify the clinical use of MRI criteria without reducing accuracy, and our findings suggest that needing three lesions to define periventricular involvement might slightly increase specificity, suggesting that these two factors could be considered during further revisions of multiple sclerosis diagnostic criteria.

FUNDING

UK MS Society, National Institute for Health Research University College London Hospitals Biomedical Research Centre, Dutch MS Research Foundation.

Optimization and stratification of multiple sclerosis treatment in fast developing economic countries: a perspective from Qatar

OBJECTIVE

The introduction of disease-modifying therapies (DMTs) - with varying degrees of efficacy for reducing annual relapse rate and disability progression - has considerably transformed the therapeutic landscape of relapsing-remitting multiple sclerosis (RRMS). We aim to develop rational evidence-based treatment recommendations and algorithms for the management of clinically isolated syndrome (CIS) and RRMS that conform to the healthcare system in a fast-developing economic country such as Qatar.

RESEARCH DESIGN AND METHODS

We conducted a systematic review using a comprehensive search of MEDLINE, PubMed, and Cochrane Database of Systematic Reviews (1 January 1990 through 30 September 2016). Additional searches of the American Academy of Neurology and European Committee for Treatment and Research in Multiple Sclerosis abstracts from 2012 through 2016 were performed, in addition to searches of the Food and Drug Administration and European Medicines Agency websites to obtain relevant safety information on these DMTs.

RESULTS

For each of the DMTs, the mode of action, efficacy, safety and tolerability are briefly discussed. To facilitate the interpretation, the efficacy data of the pivotal phase III trials are expressed by their most clinically useful measure of therapeutic efficacy, the number needed to treat (NNT). In addition, an overview of head-to-head trials in RRMS is provided as well as a summary of the several different RRMS management strategies (lateral switching, escalation, induction, maintenance and combination therapy) and the potential role of each DMT. Finally, algorithms were developed for CIS, active and highly active or rapidly evolving RRMS and subsequent breakthrough disease or suboptimal treatment response while on DMTs. The benefit-to-risk profiles of the DMTs, taking into account patient preference, allowed the provision of rational and safe patient-tailored treatment algorithms.

CONCLUSIONS

Recommendations and algorithms for the management of CIS and RRMS have been developed relevant to the healthcare system of this fast-developing economic country.

Periventricular lesions and MS diagnostic criteria in young adults with typical clinically isolated syndromes

In patients who present with a clinically isolated syndrome (CIS), whose features are suggestive of multiple sclerosis (MS), fulfilling McDonald 2010 magnetic resonance imaging (MRI) criteria for dissemination in space (DIS) and dissemination in time (DIT) enables a diagnosis of MS. While ⩾1 periventricular lesion is included in the 2010 DIS criteria, earlier McDonald criteria required ⩾3 periventricular lesions to confirm DIS and recent Magnetic Resonance Imaging in Multiple Sclerosis (MAGNIMS)-recommended DIS criteria also require ⩾3 lesions. We investigated the effect of varying the required number of periventricular lesions and found that the best combination of specificity and sensitivity for clinically definite MS was seen for ⩾1 periventricular lesion using both the McDonald 2010 and MAGNIMS 2016 criteria.

Lesion Activity on Brain MRI in a Chinese Population with Unilateral Optic Neuritis

Longitudinal studies have shown that brain white matter lesions are strong predictors of the conversion of unilateral optic neuritis to multiple sclerosis (MS) in Caucasian populations. Consequently brain MRI criteria have been developed to improve the prediction of the development of clinically definite multiple sclerosis (CDMS). In Asian populations, optic neuritis may be the first sign of classical or optic-spinal MS. These signs add to the uncertainty regarding brain MRI changes with respect to the course of unilateral optic neuritis. The aim of this study was to examine the association between brain lesion activity and conversion to CDMS in Chinese patients with unilateral optic neuritis. A small prospective cohort study of 40 consecutive Chinese patients who presented with unilateral optic neuritis was conducted. Brain lesion activity was recorded as the incidence of Gd-enhanced lesions and new T2 lesions. Brain lesions on MRI that were characteristic of MS were defined according to the 2010 revisions of the McDonald criteria. The primary endpoint was the development of CDMS. We found that nineteen patients (48%) had brain lesions that were characteristic of MS on the initial scan. One of these patients (3%) had Gd-enhanced brain lesions. A significantly lower percentage of the patients (10%, p<0.001) presented with new T2 brain lesions on the second scan. During a median of 5 years of follow-up, seven patients (18%) developed CDMS. There was no significant difference in the conversion rate to CDMS between patients with and without brain lesions that were characteristic of MS (4/19 and 3/21, respectively; Fisher exact test, one-sided, p = 0.44). We conclude that brain lesions characteristic of MS are common in Chinese patients with unilateral optic neuritis; however, these patients exhibit low lesion activity. The predictive value of brain lesion activity for CDMS requires investigation in additional patients.

Evidence-based guidelines: MAGNIMS consensus guidelines on the use of MRI in multiple sclerosis--establishing disease prognosis and monitoring patients

The role of MRI in the assessment of multiple sclerosis (MS) goes far beyond the diagnostic process. MRI techniques can be used as regular monitoring to help stage patients with MS and measure disease progression. MRI can also be used to measure lesion burden, thus providing useful information for the prediction of long-term disability. With the introduction of a new generation of immunomodulatory and/or immunosuppressive drugs for the treatment of MS, MRI also makes an important contribution to the monitoring of treatment, and can be used to determine baseline tissue damage and detect subsequent repair. This use of MRI can help predict treatment response and assess the efficacy and safety of new therapies. In the second part of the MAGNIMS (Magnetic Resonance Imaging in MS) network's guidelines on the use of MRI in MS, we focus on the implementation of this technique in prognostic and monitoring tasks. We present recommendations on how and when to use MRI for disease monitoring, and discuss some promising MRI approaches that may be introduced into clinical practice in the near future.

Hormonal and gender-related immune changes in multiple sclerosis

Similarly to many other autoimmune diseases, multiple sclerosis (MS) is more common among women than men, and its incidence among women is rising. There are also qualitative differences in the disease course between men and women, with male patients experiencing increased disease progression, brain atrophy, and cognitive impairment. During pregnancy, women with MS typically have a greatly reduced relapse rate, whereas very soon after the delivery, the disease activity returns, often even at a higher level than seen in the prepregnancy year. The reasons for the increased postpartum activity are not entirely clear, but factors such as the abrupt decrease in estrogen levels immediately after the delivery and the loss of the immunosuppressive state of pregnancy are likely of importance. There is compelling evidence that estrogen, progesterone, and testosterone control MS pathology by influencing immune responses and by contributing to repair mechanisms in the nervous system. Hormones may thus offer important insights into MS disease prevention and treatment. In this review, the possible reasons for the sex bias in autoimmune diseases will be discussed. The pregnancy-related alterations in MS, including the effect of pregnancy on disease activity, long-term disability accumulation, and prevalence will be reviewed, as well as the hormonal and immunological mechanisms potentially underlying these changes. Finally, the present thinking on the effect of hormones on the changing incidence of MS will be elucidated.

Baseline magnetic resonance imaging of the optic nerve provides limited predictive information on short-term recovery after acute optic neuritis

Background

In acute optic neuritis, magnetic resonance imaging (MRI) may help to confirm the diagnosis as well as to exclude alternative diagnoses. Yet, little is known on the value of optic nerve imaging for predicting clinical symptoms or therapeutic outcome.

Purpose

To evaluate the benefit of optic nerve MRI for predicting response to appropriate therapy and recovery of visual acuity.

Methods

Clinical data as well as visual evoked potentials (VEP) and MRI results of 104 patients, who were treated at the Department of Neurology with clinically definite optic neuritis between December 2010 and September 2012 were retrospectively reviewed including a follow up within 14 days.

Results

Both length of the Gd enhancing lesion (r = -0.38; p = 0.001) and the T2 lesion (r = -0.25; p = 0.03) of the optic nerve in acute optic neuritis showed a medium correlation with visual acuity after treatment. Although visual acuity pre-treatment was little but nonsignificantly lower if Gd enhancement of the optic nerve was detected via orbital MRI, improvement of visual acuity after adequate therapy was significantly better (0.40 vs. 0.24; p = 0.04). Intraorbitally located Gd enhancing lesions were associated with worse visual improvement compared to canalicular, intracranial and chiasmal lesions (0.35 vs. 0.54; p = 0.02).

Conclusion

Orbital MRI is a broadly available, valuable tool for predicting the improvement of visual function. While the accurate individual prediction of long-term outcomes after appropriate therapy still remains difficult, lesion length of Gd enhancement and T2 lesion contribute to its prediction and a better short-term visual outcome may be associated with detection and localization of Gd enhancement along the optic nerve.

Consensus recommendations for the diagnosis and treatment of multiple sclerosis: the Middle East North Africa Committee for Treatment and Research In Multiple Sclerosis (MENACTRIMS)

With evolving diagnostic criteria and the advent of new oral and parenteral therapies for MS, most current diagnostic and treatment algorithms need re-evaluation and updating. The diagnosis of MS relies on incorporating clinical and paraclinical findings to prove dissemination in space and in time, and exclude alternative diseases that can explain the findings at hand. The differential diagnostic workup should be guided by clinical and laboratory red flags to avoid unnecessary tests. Appropriate multiple sclerosis (MS) therapy selection is critical to maximize patient benefit. The current guidelines review the scientific evidence supporting treatment of acute relapses, radiologically isolated syndrome, clinically isolated syndrome, relapsing remitting MS, secondary progressive MS, and primary progressive MS. The purpose of these guidelines is to provide practical recommendations and algorithms for the diagnosis and treatment of MS based on current scientific evidence and clinical experience.

Sex-Based Differences in Multiple Sclerosis (Part I): Biology of Disease Incidence

Multiple sclerosis (MS) is a chronic autoimmune demyelinating disease that leads to neuron damage and progressive disability. One major feature of multiple sclerosis (MS) is that it affects women three times more often than men. In this chapter, we overview the evidence that the autoimmune component of MS, which predominates in the early stages of this disease, is more robust in women than in men and undergoes a sharp increase with the onset of puberty. In addition, we discuss the common rodent models of MS that have been used to study the sex-based differences in the development of central nervous system (CNS) autoimmunity. We then address the biological underpinnings of this enhanced MS risk in women by first reviewing the autoimmune mechanisms that are thought to lead to the initiation of this disease and then honing in on how these mechanisms differ between the sexes. Finally, we review what is known about the hormonal and genetic basis of these sex differences in CNS autoimmunity.

Clinically isolated syndromes and the relationship to multiple sclerosis

The most common presentation of multiple sclerosis (MS) is with a clinically isolated syndrome (CIS) affecting the optic nerves, brainstem or spinal cord. Two thirds of patients with CIS will have further episodes of neurological dysfunction and convert to relapsing-remitting MS, while the remaining patients have a monophasic illness, at least clinically. Abnormalities on a baseline MRI scan predict the subsequent development of MS in patients with CIS. In the long term, about 80% of patients with an abnormal MRI convert to MS compared with 20% with a normal MRI. For patients who develop MS the long term prognosis is varied. After 20 years, almost half will have developed secondary progressive MS, while around one third have a benign disease course with little physical disability. Disease-modifying treatments delay conversion to MS in selected CIS patients with abnormal MRI but an effect on long term disability has not been demonstrated. In this review we discuss recent advances in the diagnosis, management and prognostication of patients with CIS.

Consensus guidelines for the diagnosis and treatment of multiple sclerosis

The diagnosis of multiple sclerosis (MS) is dependent on the presence of clinical and paraclinical evidence demonstrating dissemination of central nervous system lesions in both space and time, as well as the exclusion of other disorders. Diagnostic criteria were originally promulgated in 1965 by the Schumacher committee and modified subsequently by the Poser committee to include paraclinical evidence. The most recent criteria are the 2010 modifications of the 2001 McDonald criteria, which are focused on making an earlier diagnosis of MS. This article provides guidelines, derived from clinical experience as well as evidence-based medicine, for the diagnosis and management of MS with special emphasis on practices in the Middle East.

Sexual disparities in the incidence and course of MS

Multiple sclerosis (MS) affects three times more women than men and this ratio appears to be increasing. However male patients experience increased disease progression, brain atrophy, and cognitive impairment. Gonadal hormones may modulate these sex differences. For example, female puberty heralds an increased risk of MS, and during pregnancy disease activity is milder, with an increased risk of postpartum relapses. Gonadal hormones likely have complex and inflammatory and neuroprotective effects, and may interact with other disease modulators, such as vitamin D. Sex differences in the heritability of disease susceptibility genes implicate a role for epigenetic modification. Many questions remain, including the impact of sex on treatment response and epigenetic changes, and the modulatory potential of hormonal treatments. This article summarizes what is known about sexual dimorphism in MS onset and course, as well as potential interactions between sex and other factors influencing MS pathogenesis, incidence and severity.

The effect of gender in clinically isolated syndrome (CIS): a meta-analysis

Background/Objective: A clinically isolated syndrome compatible with demyelination (CIS) is the initial presentation for the majority of people that go on to develop multiple sclerosis (MS). There has previously been little work examining the effect of gender on the development and progression of CIS.

Methods: Data from observational studies of CIS were used. In total, 33 suitable studies with 4732 subjects were identified.

Results: The overall relative risk (RR) of CIS in females compared with males was 2.12 (95% CI 1.94–2.32). The RR of females developing MS following CIS was 1.20 (95% CI 0.98–1.46) compared with males.

Conclusions: These data imply that the gender bias seen in MS is caused by factors acting early in the disease process.

Accuracy of diagnostic tests in multiple sclerosis--a systematic review

New diagnostic criteria for multiple sclerosis (MS) have been recently proposed and further updates are upcoming. This systematic literature review summarizes diagnostic studies in suspected MS to clarify the value of diagnostic tests. We included studies of at least 40 patients followed up for 2 years. All studies are limited by the fact that no gold standard to validate diagnostic tests is available. A second relapse is used as a surrogate in relapsing-remitting MS, but long follow-up of at least 5 years is necessary to detect all cases. Many studies showed selection bias, partly because of the vague definition of a clinically isolated syndrome. Based on these limitations, sensitivity of magnetic resonance imaging (MRI) criteria was between 35% and 100%, and specificity was between 36% and 92%. Cerebrospinal fluid (CSF) oligoclonal banding showed sensitivities between 69% and 91% with specificities between 59% and 94%. Combination studies of MRI and CSF indicate enhanced sensitivity (56-100%) and specificity (53-96%). Studies on evoked potentials did not justify conclusions about their value. A combination of simplified MRI criteria with CSF might be the best approach for an early MS diagnosis. However, the value of a very early diagnosis stays questionable as patients' benefit of new diagnostic criteria has never been addressed.

The association of intrathecal immunoglobulin synthesis and cortical lesions predicts disease activity in clinically isolated syndrome and early relapsing–remitting multiple sclerosis

Background: The intrathecal production of immunoglobulin (Ig) is a major biological feature of multiple sclerosis (MS), and immunopathological studies have suggested a primary role of the humoral immune response in causing irreversible brain damage.

Objective: To evaluate whether, in the early phases of MS, intrathecal Ig synthesis correlates with the presence of cortical lesions (CLs), and if their association could predict the clinical course of the disease.

Methods: Eighty-six patients presenting with symptoms and signs suggestive of MS underwent a diagnostic work-up that included magnetic resonance imaging and cerebrospinal fluid examination. The risk ratios (RR) for conversion to MS and for a new disease activity were calculated.

Results: Patients with clinically isolated syndromes (CIS) having CLs and intrathecal synthesis of Ig had the highest risk of conversion to MS (RR = 3.4; Wald 95% CI = 1.7–7.0, p < 0.001) whereas CIS patients without CLs and intrathecal synthesis of Ig had the lowest risk of conversion to MS (RR = 0.1, Wald 95% CI = 0.02–0.7, p < 0.001). The highest risk of having disease-related activity during the follow-up was observed in CIS and relapsing–remitting MS patients showing CLs and intrathecal Ig synthesis (RR = 2.1; Wald 95% CI = 1.5–3.1, p < 0.001) while the lowest in CIS and relapsing–remitting MS patients without CLs and intrathecal Ig synthesis (RR = 0.3; Wald 95% CI = 0.1–0.7, p < 0.001).

Conclusion: We observed that the association of intrathecal immunoglobulin synthesis and CLs was highly predictive of an earlier CIS conversion to MS as well as of a higher disease activity.

Optic neuritis

AIMS

The aim of this study is to provide a clinical update on optic neuritis (ON), its association with multiple sclerosis (MS), and neuromyelitis optica (NMO).

METHODS

This study included a PubMed review of the literature written in the English language.

RESULTS

ON in adults is typically idiopathic or demyelinating, and is characterised by unilateral, subacute, painful loss of vision that is not associated with any systemic or other neurological symptoms. Demyelinating ON is associated with MS, and we review the key studies of ON including the ON treatment trial and several other MS treatment trials and NMO.

CONCLUSION

Acute demyelinating ON can occur in isolation or be associated with MS. Typical ON does not require additional evaluation other than cranial magnetic resonance imaging. NMO is likely a separate disorder from MS and the ON in NMO has a different treatment and prognosis.

METHODOLOGY

The authors conducted an English language search using Pubmed from the years 1964 to 2010 using the search terms 'ON', 'MS' and 'NMO'. The authors included original articles, review articles, and case reports, which revealed new aspects as far as epidemiology, histopathology, clinical manifestations, imaging, genetics, and treatment of ON. Titles were reviewed for topicality and full references were obtained. Letters to the editor, unpublished work, and abstracts were not included in this review.

Role of gender in multiple sclerosis: clinical effects and potential molecular mechanisms

Multiple sclerosis (MS) is more prevalent in females than males, and this female predominance is increasing as time goes by. Additionally, gender appears to play critical roles in development, progression and treatment of MS, and is therefore an aspect that should always be considered in the design and interpretation of research and clinical trials for MS. In this review, factors that could potentially explain the gender-biased observations in MS are discussed. These include sex-specific differences between the male and female immune systems and nervous systems, genetic and epigenetic or environmental-related effects, the effects of gonadal hormones, and materno-fetal interactions.

Gender issues in multiple sclerosis: an update

Although multiple sclerosis (MS) affects both women and men, women are more susceptible to MS than men. Accumulating evidence indicates that the incidence and prevalence of MS is increasing, more so in women than in men. Owing to pregnancy, differing hormonal states and distinct social roles, the impact of MS differs between women and men. Since Patricia K Coyle published a review on gender issues in MS, multiple studies have added to the body of knowledge. This update will summarize the current thinking on gender-related issues in MS and we will address incidence and prevalence, hormonal factors, pregnancy and breastfeeding, genetics, course and prognosis, imaging, treatment and psychosocial aspects. Future progression within this field will help elucidate the cause of and define the treatment of MS.

Predictive factors for multiple sclerosis in patients with clinically isolated spinal cord syndrome

OBJECTIVES

To identify predictors of conversion to definite multiple sclerosis (MS) in patients with a cord clinically isolated syndrome.

METHODS

The predictive values for conversion to MS of clinical, magnetic resonance imaging (MRI) and cerebrospinal fluid (CSF) variables in 114 patients with acute partial myelitis confirmed by a spinal cord lesion on MRI were studied. Other causes of cord syndromes were excluded.

RESULTS

MS was diagnosed in 78 patients (86%) during 4.0 ± 1.9 years of follow-up. Some 67 of these patients had a second clinical episode. The diagnosis of isolated myelitis was maintained for 36 patients, 78% of whom (28 cases) were followed for at least 2 years, comparable to the MS patients. Age, bladder involvement, ≥ 2 cord lesions on MRI, ≥ 9 brain lesions, ≥ 3 periventricular lesions and intrathecal IgG synthesis predicted conversion to clinically definite MS. Multivariate logistic analysis identified three predictors of MS diagnosis: age ≤ 40 years, inflammatory CSF and ≥ 3 periventricular lesions on brain MRI.

CONCLUSION

Two out of three baseline factors (age, periventricular lesions and inflammatory CSF) predicted conversion to MS with better accuracy than the revised McDonald criteria for dissemination in space.