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Müller J, Cagol A, Lorscheider J, Tsagkas C, Benkert P, Yaldizli Ö, Kuhle J, Derfuss T, Sormani MP, Thompson A, Granziera C, Kappos L. Harmonizing Definitions for Progression Independent of Relapse Activity in Multiple Sclerosis: A Systematic Review. JAMA Neurol 2023; 80:1232-1245. [PMID: 37782515 DOI: 10.1001/jamaneurol.2023.3331] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Importance Emerging evidence suggests that progression independent of relapse activity (PIRA) is a substantial contributor to long-term disability accumulation in relapsing-remitting multiple sclerosis (RRMS). To date, there is no uniform agreed-upon definition of PIRA, limiting the comparability of published studies. Objective To summarize the current evidence about PIRA based on a systematic review, to discuss the various terminologies used in the context of PIRA, and to propose a harmonized definition for PIRA for use in clinical practice and future trials. Evidence Review A literature search was conducted using the search terms multiple sclerosis, PIRA, progression independent of relapse activity, silent progression, and progression unrelated to relapses in PubMed, Embase, Cochrane, and Web of Science, published between January 1990 and December 2022. Findings Of 119 identified single records, 48 eligible studies were analyzed. PIRA was reported to occur in roughly 5% of all patients with RRMS per annum, causing at least 50% of all disability accrual events in typical RRMS. The proportion of PIRA vs relapse-associated worsening increased with age, longer disease duration, and, despite lower absolute event numbers, potent suppression of relapses by highly effective disease-modifying therapy. However, different studies used various definitions of PIRA, rendering the comparability of studies difficult. Conclusion and Relevance PIRA is the most frequent manifestation of disability accumulation across the full spectrum of traditional MS phenotypes, including clinically isolated syndrome and early RRMS. The harmonized definition suggested here may improve the comparability of results in current and future cohorts and data sets.
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Affiliation(s)
- Jannis Müller
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
- Translational Imaging in Neurology (ThINk) Basel, Department of Biomedical Engineering, Faculty of Medicine, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurologic Clinic and Policlinic, Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Alessandro Cagol
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
- Translational Imaging in Neurology (ThINk) Basel, Department of Biomedical Engineering, Faculty of Medicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Johannes Lorscheider
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
- Neurologic Clinic and Policlinic, Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Charidimos Tsagkas
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
- Translational Imaging in Neurology (ThINk) Basel, Department of Biomedical Engineering, Faculty of Medicine, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurologic Clinic and Policlinic, Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Pascal Benkert
- Department of Clinical Research, Clinical Trial Unit, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Özgür Yaldizli
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
- Translational Imaging in Neurology (ThINk) Basel, Department of Biomedical Engineering, Faculty of Medicine, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurologic Clinic and Policlinic, Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Jens Kuhle
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
- Neurologic Clinic and Policlinic, Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Tobias Derfuss
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
- Neurologic Clinic and Policlinic, Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Maria Pia Sormani
- Department of Health Sciences, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Alan Thompson
- Queen Square MS Centre, UCL Institute of Neurology, London, United Kingdom
- NIHR University College London Hospitals Biomedical Research Centre, London, United Kingdom
| | - Cristina Granziera
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
- Translational Imaging in Neurology (ThINk) Basel, Department of Biomedical Engineering, Faculty of Medicine, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurologic Clinic and Policlinic, Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Ludwig Kappos
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
- Translational Imaging in Neurology (ThINk) Basel, Department of Biomedical Engineering, Faculty of Medicine, University Hospital Basel and University of Basel, Basel, Switzerland
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Wauschkuhn J, Solorza Buenrostro G, Aly L, Asseyer S, Wicklein R, Hartberger JM, Ruprecht K, Mühlau M, Schmitz-Hübsch T, Chien C, Berthele A, Brandt AU, Korn T, Paul F, Hemmer B, Zimmermann HG, Knier B. Retinal ganglion cell loss is associated with future disability worsening in early relapsing-remitting multiple sclerosis. Eur J Neurol 2023; 30:982-990. [PMID: 36635219 DOI: 10.1111/ene.15681] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/03/2022] [Accepted: 12/29/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND PURPOSE Thinning of the retinal combined ganglion cell and inner plexiform layer (GCIP) as measured by optical coherence tomography (OCT) is a common finding in patients with multiple sclerosis. This study aimed to investigate whether a single retinal OCT analysis allows prediction of future disease activity after a first demyelinating event. METHODS This observational cohort study included 201 patients with recently diagnosed clinically isolated syndrome or relapsing-remitting multiple sclerosis from two German tertiary referral centers. Individuals underwent neurological examination, magnetic resonance imaging, and OCT at baseline and at yearly follow-up visits. RESULTS Patients were included at a median disease duration of 2.0 months. During a median follow-up of 59 (interquartile range = 43-71) months, 82% of patients had ongoing disease activity as demonstrated by failing the no evidence of disease activity 3 (NEDA-3) criteria, and 19% presented with confirmed disability worsening. A GCIP threshold of ≤77 μm at baseline identified patients with a high risk for NEDA-3 failure (hazard ratio [HR] = 1.7, 95% confidence interval [CI] = 1.1-2.8, p = 0.04), and GCIP measures of ≤69 μm predicted disability worsening (HR = 2.2, 95% CI = 1.2-4.3, p = 0.01). Higher rates of annualized GCIP loss increased the risk for disability worsening (HR = 2.5 per 1 μm/year increase of GCIP loss, p = 0.03). CONCLUSIONS Ganglion cell thickness as measured by OCT after the initial manifestation of multiple sclerosis may allow early risk stratification as to future disease activity and progression.
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Affiliation(s)
- Josephine Wauschkuhn
- Department of Neurology, Klinikum rechts der Isar, TUM School of Medicine, Technical University of Munich, Munich, Germany
| | - Gilberto Solorza Buenrostro
- Experimental and Clinical Research Center, a cooperation between the Max Delbrück Center for Molecular Medicine and the Helmholtz Association, Charité - University Medicine Berlin, Berlin, Germany
- Experimental and Clinical Research Center, Charité - University Medicine Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
| | - Lilian Aly
- Department of Neurology, Klinikum rechts der Isar, TUM School of Medicine, Technical University of Munich, Munich, Germany
| | - Susanna Asseyer
- Experimental and Clinical Research Center, a cooperation between the Max Delbrück Center for Molecular Medicine and the Helmholtz Association, Charité - University Medicine Berlin, Berlin, Germany
- Experimental and Clinical Research Center, Charité - University Medicine Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
| | - Rebecca Wicklein
- Department of Neurology, Klinikum rechts der Isar, TUM School of Medicine, Technical University of Munich, Munich, Germany
| | - Julia Maria Hartberger
- Department of Neurology, Klinikum rechts der Isar, TUM School of Medicine, Technical University of Munich, Munich, Germany
| | - Klemens Ruprecht
- Department of Neurology, Charité - University Medicine Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Mark Mühlau
- Department of Neurology, Klinikum rechts der Isar, TUM School of Medicine, Technical University of Munich, Munich, Germany
| | - Tanja Schmitz-Hübsch
- Experimental and Clinical Research Center, a cooperation between the Max Delbrück Center for Molecular Medicine and the Helmholtz Association, Charité - University Medicine Berlin, Berlin, Germany
- Experimental and Clinical Research Center, Charité - University Medicine Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
| | - Claudia Chien
- Experimental and Clinical Research Center, a cooperation between the Max Delbrück Center for Molecular Medicine and the Helmholtz Association, Charité - University Medicine Berlin, Berlin, Germany
- Experimental and Clinical Research Center, Charité - University Medicine Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
| | - Achim Berthele
- Department of Neurology, Klinikum rechts der Isar, TUM School of Medicine, Technical University of Munich, Munich, Germany
| | - Alexander U Brandt
- Experimental and Clinical Research Center, a cooperation between the Max Delbrück Center for Molecular Medicine and the Helmholtz Association, Charité - University Medicine Berlin, Berlin, Germany
- Experimental and Clinical Research Center, Charité - University Medicine Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
- Department of Neurology, Charité - University Medicine Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Neurology, University of California, Irvine, Irvine, California, USA
| | - Thomas Korn
- Department of Neurology, Klinikum rechts der Isar, TUM School of Medicine, Technical University of Munich, Munich, Germany
- Institute for Experimental Neuroimmunology, Technical University of Munich, Munich, Germany
- Munich Cluster of Systems Neurology (SyNergy), Munich, Germany
| | - Friedemann Paul
- Experimental and Clinical Research Center, a cooperation between the Max Delbrück Center for Molecular Medicine and the Helmholtz Association, Charité - University Medicine Berlin, Berlin, Germany
- Experimental and Clinical Research Center, Charité - University Medicine Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
- Department of Neurology, Charité - University Medicine Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Bernhard Hemmer
- Department of Neurology, Klinikum rechts der Isar, TUM School of Medicine, Technical University of Munich, Munich, Germany
- Munich Cluster of Systems Neurology (SyNergy), Munich, Germany
| | - Hanna G Zimmermann
- Experimental and Clinical Research Center, a cooperation between the Max Delbrück Center for Molecular Medicine and the Helmholtz Association, Charité - University Medicine Berlin, Berlin, Germany
- Experimental and Clinical Research Center, Charité - University Medicine Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
| | - Benjamin Knier
- Department of Neurology, Klinikum rechts der Isar, TUM School of Medicine, Technical University of Munich, Munich, Germany
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Recent Progress in the Identification of Early Transition Biomarkers from Relapsing-Remitting to Progressive Multiple Sclerosis. Int J Mol Sci 2023; 24:ijms24054375. [PMID: 36901807 PMCID: PMC10002756 DOI: 10.3390/ijms24054375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 02/12/2023] [Accepted: 02/15/2023] [Indexed: 02/25/2023] Open
Abstract
Despite extensive research into the pathophysiology of multiple sclerosis (MS) and recent developments in potent disease-modifying therapies (DMTs), two-thirds of relapsing-remitting MS patients transition to progressive MS (PMS). The main pathogenic mechanism in PMS is represented not by inflammation but by neurodegeneration, which leads to irreversible neurological disability. For this reason, this transition represents a critical factor for the long-term prognosis. Currently, the diagnosis of PMS can only be established retrospectively based on the progressive worsening of the disability over a period of at least 6 months. In some cases, the diagnosis of PMS is delayed for up to 3 years. With the approval of highly effective DMTs, some with proven effects on neurodegeneration, there is an urgent need for reliable biomarkers to identify this transition phase early and to select patients at a high risk of conversion to PMS. The purpose of this review is to discuss the progress made in the last decade in an attempt to find such a biomarker in the molecular field (serum and cerebrospinal fluid) between the magnetic resonance imaging parameters and optical coherence tomography measures.
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Wang L, Tan H, Yu J, ZhangBao J, Huang W, Chang X, Zhou L, Lu C, Xiao Y, Lu J, Zhao C, Wang M, Wu X, Wu M, Dong Q, Ngew KY, Quan C. Baseline retinal nerve fiber layer thickness as a predictor of multiple sclerosis progression: New insights from the FREEDOMS II study. Eur J Neurol 2023; 30:443-452. [PMID: 36286605 DOI: 10.1111/ene.15612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/13/2022] [Accepted: 10/20/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND PURPOSE The aim was to evaluate the potential of retinal nerve fiber layer thickness (RNFLT) measured with optical coherence tomography in predicting disease progression in relapsing-remitting multiple sclerosis (RRMS). METHODS Analyses were conducted post hoc of this 24-month, phase III, double-blind study, in which RRMS patients were randomized (1:1:1) to once daily oral fingolimod 0.5 mg, 1.25 mg or placebo. The key outcomes were the association between baseline RNFLT and baseline clinical characteristics and clinical/imaging outcomes up to 24 months. Change of RNFLT with fingolimod versus placebo within 24 months and time to retinal nerve fiber layer (RNFL) thinning were evaluated. RESULTS Altogether 885 patients were included. At baseline, lower RNFLT was correlated with higher Expanded Disability Status Scale score (r = -1.085, p = 0.018), lower brain volume (r = 0.025, p = 0.006) and deep gray matter volume (r = 0.731, p < 0.0001), worse visual acuity (r = -19.846, p < 0.0001) and longer duration since diagnosis (r = -0.258, p = 0.018). At month 12, low baseline RNFLT (<86 μm) versus high baseline RNFLT (≥99 μm) was associated with a greater brain volume loss (percentage change -0.605% vs. -0.315%, p = 0.035) in patients without optic neuritis history. At month 24, low baseline RNFLT versus high baseline RNFLT was associated with a higher number of new or newly enlarged T2 lesions (mean number 4.0 vs. 2.8, p = 0.014) and a higher risk of subsequent RNFL thinning (hazard ratio 2.55; 95% confidence interval 1.84-3.53; p < 0.001). The atrophy of the RNFL in the inferior quadrant was alleviated with fingolimod 0.5 mg versus placebo at month 24 (Δ(least squares mean) = 1.8, p = 0.047). CONCLUSION Retinal nerve fiber layer thickness could predict disease progression in RRMS. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT00355134, https://clinicaltrials.gov/ct2/show/NCT00355134.
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Affiliation(s)
- Liang Wang
- Department of Neurology and Rare Disease Center, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Hongmei Tan
- Department of Neurology and Rare Disease Center, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Jian Yu
- Department of Ophthalmology and Vision Science, Eye and ENT Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jingzi ZhangBao
- Department of Neurology and Rare Disease Center, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Wenjuan Huang
- Department of Neurology and Rare Disease Center, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Xuechun Chang
- Department of Neurology and Rare Disease Center, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Lei Zhou
- Department of Neurology and Rare Disease Center, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Chuanzhen Lu
- Department of Neurology and Rare Disease Center, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Institute of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yiqin Xiao
- Department of Ophthalmology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jiahong Lu
- Department of Neurology and Rare Disease Center, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Institute of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Chongbo Zhao
- Department of Neurology and Rare Disease Center, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Institute of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Min Wang
- Department of Ophthalmology and Vision Science, Eye and ENT Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xue Wu
- Novartis Pharmaceuticals, Shanghai, China
| | - Mengyun Wu
- Novartis Pharmaceuticals, Shanghai, China
| | - Qiang Dong
- Department of Neurology and Rare Disease Center, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Institute of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Kok Yew Ngew
- Novartis Corporation (Malaysia) Sdn. Bhd., Petaling Jaya, Malaysia
| | - Chao Quan
- Department of Neurology and Rare Disease Center, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Institute of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
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Tur C, Carbonell-Mirabent P, Cobo-Calvo Á, Otero-Romero S, Arrambide G, Midaglia L, Castilló J, Vidal-Jordana Á, Rodríguez-Acevedo B, Zabalza A, Galán I, Nos C, Salerno A, Auger C, Pareto D, Comabella M, Río J, Sastre-Garriga J, Rovira À, Tintoré M, Montalban X. Association of Early Progression Independent of Relapse Activity With Long-term Disability After a First Demyelinating Event in Multiple Sclerosis. JAMA Neurol 2023; 80:151-160. [PMID: 36534392 PMCID: PMC9856884 DOI: 10.1001/jamaneurol.2022.4655] [Citation(s) in RCA: 38] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Importance Progression independent of relapse activity (PIRA) is the main event responsible for irreversible disability accumulation in relapsing multiple sclerosis (MS). Objective To investigate clinical and neuroimaging predictors of PIRA at the time of the first demyelinating attack and factors associated with long-term clinical outcomes of people who present with PIRA. Design, Setting, and Participants This cohort study, conducted from January 1, 1994, to July 31, 2021, included patients with a first demyelinating attack from multiple sclerosis; patients were recruited from 1 study center in Spain. Patients were excluded if they refused to participate, had alternative diagnoses, did not meet protocol requirements, had inconsistent demographic information, or had less than 3 clinical assessments. Exposures Exposures included (1) clinical and neuroimaging features at the first demyelinating attack and (2) presenting PIRA, ie, confirmed disability accumulation (CDA) in a free-relapse period at any time after symptom onset, within (vs after) the first 5 years of the disease (ie, early/late PIRA), and in the presence (vs absence) of new T2 lesions in the previous 2 years (ie, active/nonactive PIRA). Main Outcomes and Measures Expanded Disability Status Scale (EDSS) yearly increase rates since the first attack and adjusted hazard ratios (HRs) for predictors of time to PIRA and time to EDSS 6.0. Results Of the 1128 patients (mean [SD] age, 32.1 [8.3] years; 781 female individuals [69.2%]) included in the study, 277 (25%) developed 1 or more PIRA events at a median (IQR) follow-up time of 7.2 (4.6-12.4) years (for first PIRA). Of all patients with PIRA, 86 of 277 (31%) developed early PIRA, and 73 of 144 (51%) developed active PIRA. Patients with PIRA were slightly older, had more brain lesions, and were more likely to have oligoclonal bands than those without PIRA. Older age at the first attack was the only predictor of PIRA (HR, 1.43; 95% CI, 1.23-1.65; P < .001 for each older decade). Patients with PIRA had steeper EDSS yearly increase rates (0.18; 95% CI, 0.16-0.20 vs 0.04; 95% CI, 0.02-0.05; P < .001) and an 8-fold greater risk of reaching EDSS 6.0 (HR, 7.93; 95% CI, 2.25-27.96; P = .001) than those without PIRA. Early PIRA had steeper EDSS yearly increase rates than late PIRA (0.31; 95% CI, 0.26-0.35 vs 0.13; 95% CI, 0.10-0.16; P < .001) and a 26-fold greater risk of reaching EDSS 6.0 from the first attack (HR, 26.21; 95% CI, 2.26-303.95; P = .009). Conclusions and Relevance Results of this cohort study suggest that for patients with multiple sclerosis, presenting with PIRA after a first demyelinating event was not uncommon and suggests an unfavorable long-term prognosis, especially if it occurs early in the disease course.
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Affiliation(s)
- Carmen Tur
- Multiple Sclerosis Centre of Catalonia, Department of Neurology/Neuroimmunology, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Pere Carbonell-Mirabent
- Multiple Sclerosis Centre of Catalonia, Department of Neurology/Neuroimmunology, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Álvaro Cobo-Calvo
- Multiple Sclerosis Centre of Catalonia, Department of Neurology/Neuroimmunology, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Susana Otero-Romero
- Multiple Sclerosis Centre of Catalonia, Department of Neurology/Neuroimmunology, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Georgina Arrambide
- Multiple Sclerosis Centre of Catalonia, Department of Neurology/Neuroimmunology, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Luciana Midaglia
- Multiple Sclerosis Centre of Catalonia, Department of Neurology/Neuroimmunology, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Joaquín Castilló
- Multiple Sclerosis Centre of Catalonia, Department of Neurology/Neuroimmunology, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ángela Vidal-Jordana
- Multiple Sclerosis Centre of Catalonia, Department of Neurology/Neuroimmunology, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Breogán Rodríguez-Acevedo
- Multiple Sclerosis Centre of Catalonia, Department of Neurology/Neuroimmunology, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ana Zabalza
- Multiple Sclerosis Centre of Catalonia, Department of Neurology/Neuroimmunology, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ingrid Galán
- Multiple Sclerosis Centre of Catalonia, Department of Neurology/Neuroimmunology, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Carlos Nos
- Multiple Sclerosis Centre of Catalonia, Department of Neurology/Neuroimmunology, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Annalaura Salerno
- Section of Neuroradiology, Department of Radiology, Vall d’Hebron University Hospital, Spain. Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Cristina Auger
- Section of Neuroradiology, Department of Radiology, Vall d’Hebron University Hospital, Spain. Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Deborah Pareto
- Section of Neuroradiology, Department of Radiology, Vall d’Hebron University Hospital, Spain. Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Manuel Comabella
- Multiple Sclerosis Centre of Catalonia, Department of Neurology/Neuroimmunology, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jordi Río
- Multiple Sclerosis Centre of Catalonia, Department of Neurology/Neuroimmunology, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jaume Sastre-Garriga
- Multiple Sclerosis Centre of Catalonia, Department of Neurology/Neuroimmunology, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Àlex Rovira
- Section of Neuroradiology, Department of Radiology, Vall d’Hebron University Hospital, Spain. Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mar Tintoré
- Multiple Sclerosis Centre of Catalonia, Department of Neurology/Neuroimmunology, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Xavier Montalban
- Multiple Sclerosis Centre of Catalonia, Department of Neurology/Neuroimmunology, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
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Camara-Lemarroy C, Silva C, Gohill J, Yong VW, Koch M. Serum neurofilament-light and glial fibrillary acidic protein levels in hydroxychloroquine-treated primary progressive multiple sclerosis. Eur J Neurol 2023; 30:187-194. [PMID: 36214614 DOI: 10.1111/ene.15588] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 08/02/2022] [Accepted: 09/29/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND In a recent trial, hydroxychloroquine (HCQ) treatment reduced the expected rate of disability worsening at 18 months in primary progressive multiple sclerosis (PPMS). Neurofilament light chain (NfL) and glial fibrillary acidic protein (GFAP) are emerging biomarkers in multiple sclerosis. METHODS We measured NfL and GFAP levels in serum samples from 39 patients with inactive PPMS included in a phase II clinical trial of HCQ treatment in PPMS at multiple time points over 18 months, and investigated the association of these biomarkers with clinical disability at screening and during follow-up. Screening and 12-month retinal nerve fiber layer (RNFL) thickness was also recorded and analyzed. RESULTS NfL and GFAP levels increased over time, but only significantly from screening to month 6. NfL and GFAP levels did not significantly increase from month 6 up to month 18. At screening, NfL and GFAP levels did not correlate with the Expanded Disability Status Scale (EDSS), and GFAP but not NfL modestly correlated with Timed 25-Foot Walk test (T25FW). Screening NfL and GFAP levels did not predict disability worsening (≥20% worsening on the T25FW) at month 18. RNFL thickness decreased significantly from screening to month 12 and independently predicted disability worsening. CONCLUSIONS In this cohort of people with inactive PPMS, HCQ treatment attenuated the increase of NfL and GFAP after 6 months of treatment and up to 18 months of follow-up, suggesting a treatment effect of HCQ over these biomarkers. RNFL thickness, a marker of neuroaxonal atrophy, was associated with disability worsening, and should be explored further as a prognostic marker in this population.
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Affiliation(s)
- Carlos Camara-Lemarroy
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,UANL School of Medicine, Monterrey, Mexico
| | - Claudia Silva
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Jit Gohill
- Section of Ophthalmology, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - V Wee Yong
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Marcus Koch
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Olbert E, Struhal W. Retinal imaging with optical coherence tomography in multiple sclerosis: novel aspects. Wien Med Wochenschr 2022; 172:329-336. [PMID: 35347500 PMCID: PMC9606096 DOI: 10.1007/s10354-022-00925-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 02/21/2022] [Indexed: 11/30/2022]
Abstract
Optical coherence tomography (OCT) is of increasing interest in the clinical assessment of multiple sclerosis (MS) patients beyond the scope of clinical studies. In this narrative review, we discuss novel changes of OCT parameters during acute optic neuritis and the disease course of MS patients. OCT images document the changes of retinal layers during an episode of acute optic neuritis and can therefore provide valuable insights into the pathophysiology. Moreover, MS patients show progredient thinning of retinal layers throughout the disease. The thinning is accelerated through relapses as well as disease progression without relapse. The OCT parameters are also associated with clinical outcome parameters, including disability, cognitive function, and brain atrophy. The impact of disease-modifying therapies on OCT parameters is the subject of ongoing research and depends on the agent used. Additional data are still necessary before OCT parameters can be implemented in the clinical standard of care of MS patients.
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Affiliation(s)
- Elisabeth Olbert
- Department of Neurology, University Hospital Tulln, Alter Ziegelweg 10, 3430, Tulln an der Donau, Austria. .,Karl Landsteiner University of Health Sciences, Tulln, Austria.
| | - Walter Struhal
- Department of Neurology, University Hospital Tulln, Alter Ziegelweg 10, 3430, Tulln an der Donau, Austria.,Karl Landsteiner University of Health Sciences, Tulln, Austria
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Krajnc N, Altmann P, Riedl K, Mitsch C, Berger T, Leutmezer F, Rommer P, Pemp B, Bsteh G. Association of Cerebrospinal Fluid Parameters and Neurofilament Light Chain With Retinal Nerve Fiber Layer Thickness in Multiple Sclerosis. Front Neurol 2022; 13:814734. [PMID: 35321514 PMCID: PMC8936502 DOI: 10.3389/fneur.2022.814734] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 01/31/2022] [Indexed: 01/04/2023] Open
Abstract
Introduction Multiple sclerosis (MS) pathophysiology comprises both inflammatory and neurodegenerative characteristics. Cerebrospinal fluid (CSF) analysis allows for assessment of inflammation while neurofilament light chain can indicate neuroaxonal damage. Retinal thinning is a robust prognostic biomarker for neurodegeneration in MS. To date, an association between CSF parameters upon MS diagnosis and retinal thinning has not been investigated. Aims and Objectives We aimed to determine whether CSF parameters are associated with the evolution of retinal layer thinning in people with MS (pwMS). Methods For this longitudinal observational study, we investigated pwMS from the Vienna MS database (VMSD), who had undergone (1) a diagnostic lumbar puncture (LP) between 2015 and 2020, and (2) simultaneous optical coherence tomography (OCT) and/or (3) a follow-up OCT scan. Linear stepwise regression models were calculated with OCT parameters (peripapillary retinal nerve fiber layer [pRNFL] thickness at LP and at follow-up, annualized loss of pRNFL thickness [aLpRNFL]) as a dependent variable, and CSF parameters (white blood cell [WBC] count, total protein [CSFTP], CSF/serum albumin ratio [Qalb], intrathecal synthesis of immunoglobulins, neurofilament light chain [NfL] in both CSF and serum [CSFNfL/sNfL]) as independent variables adjusted for age, sex, and disease duration. Results We analyzed 61 pwMS (median age 30.0 years [interquartile range 25.5–35.0], 57.4% female, median disease duration 1.0 month [IQR 0–2.0] before LP, median follow-up 1.9 years [IQR 1.1–3.5]). CSFNfL and sNfL measurements were available in 26 and 31 pwMS, respectively. pRNFL thickness at LP was inversely associated with the CSF WBC count (β = −0.36; 95% CI −0.51, −0.08; p = 0.008). We did not find any association between other CSF parameters, including CSFNfL, sNfL, and aLpRNFL. Conclusions Increased WBC count as an indicator of acute inflammation and blood-brain-barrier breakdown seems to be associated with the amount of retinal thickness already lost at the time of LP. However, neither routine CSF parameters nor a singular NfL measurement allows the prediction of future retinal thinning.
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Affiliation(s)
- Nik Krajnc
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Patrick Altmann
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Katharina Riedl
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Christoph Mitsch
- Department of Ophthalmology, Medical University of Vienna, Vienna, Austria
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Fritz Leutmezer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Paulus Rommer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Berthold Pemp
- Department of Ophthalmology, Medical University of Vienna, Vienna, Austria
| | - Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- *Correspondence: Gabriel Bsteh
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Siger M, Owidzka M, Świderek-Matysiak M, Omulecki W, Stasiołek M. Optical Coherence Tomography in the Differential Diagnosis of Patients with Multiple Sclerosis and Patients with MRI Nonspecific White Matter Lesions. SENSORS 2021; 21:s21217127. [PMID: 34770434 PMCID: PMC8588219 DOI: 10.3390/s21217127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 10/18/2021] [Accepted: 10/21/2021] [Indexed: 11/16/2022]
Abstract
In the differential diagnosis of nonspecific white matter lesions (NSWMLs) detected on magnetic resonance imaging (MRI), multiple sclerosis (MS) should be taken into consideration. Optical coherence tomography (OCT) is a promising tool applied in the differential diagnostic process of MS. We tested whether OCT may be useful in distinguishing between MS and NSWMLs patients. In patients with MS (n = 41) and NSWMLs (n = 19), the following OCT parameters were measured: thickness of the peripapillary Retinal Nerve Fibre Layer (pRNFL) in superior, inferior, nasal, and temporal segments; thickness of the ganglion cell-inner plexiform layer (GCIPL); thickness of macular RNFL (mRNFL); and macular volume (MV). In MS patients, GCIPL was significantly lower than in NSWMLs patients (p = 0.024). Additionally, in MS patients, mRNFL was significantly lower than in NSWMLs patients (p = 0.030). The average segmental pRNFL and MV did not differ between MS and NSWMLs patients (p > 0.05). GCIPL and macular RNFL thinning significantly influenced the risk of MS (18.6% [95% CI 2.7%, 25.3%]; 27.4% [95% CI 4.5%, 62.3%]), and reduced GCIPL thickness appeared to be the best predictor of MS. We conclude that OCT may be helpful in the differential diagnosis of MS and NSWMLs patients in real-world settings.
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Affiliation(s)
- Małgorzata Siger
- Department of Neurology, Medical University of Lodz, 90-419 Lodz, Poland; (M.Ś.-M.); (M.S.)
- Correspondence:
| | - Marta Owidzka
- Department of Eye Disease, Medical University of Lodz, 90-419 Lodz, Poland; (M.O.); (W.O.)
| | | | - Wojciech Omulecki
- Department of Eye Disease, Medical University of Lodz, 90-419 Lodz, Poland; (M.O.); (W.O.)
| | - Mariusz Stasiołek
- Department of Neurology, Medical University of Lodz, 90-419 Lodz, Poland; (M.Ś.-M.); (M.S.)
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10
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Krajnc N, Bsteh G, Berger T. Clinical and Paraclinical Biomarkers and the Hitches to Assess Conversion to Secondary Progressive Multiple Sclerosis: A Systematic Review. Front Neurol 2021; 12:666868. [PMID: 34512500 PMCID: PMC8427301 DOI: 10.3389/fneur.2021.666868] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 07/06/2021] [Indexed: 12/11/2022] Open
Abstract
Conversion to secondary progressive (SP) course is the decisive factor for long-term prognosis in relapsing multiple sclerosis (MS), generally considered the clinical equivalent of progressive MS-associated neuroaxonal degeneration. Evidence is accumulating that both inflammation and neurodegeneration are present along a continuum of pathologic processes in all phases of MS. While inflammation is the prominent feature in early stages, its quality changes and relative importance to disease course decreases while neurodegenerative processes prevail with ongoing disease. Consequently, anti-inflammatory disease-modifying therapies successfully used in relapsing MS are ineffective in SPMS, whereas specific treatment for the latter is increasingly a focus of MS research. Therefore, the prevention, but also the (anticipatory) diagnosis of SPMS, is of crucial importance. The problem is that currently SPMS diagnosis is exclusively based on retrospectively assessing the increase of overt physical disability usually over the past 6–12 months. This inevitably results in a delay of diagnosis of up to 3 years resulting in periods of uncertainty and, thus, making early therapy adaptation to prevent SPMS conversion impossible. Hence, there is an urgent need for reliable and objective biomarkers to prospectively predict and define SPMS conversion. Here, we review current evidence on clinical parameters, magnetic resonance imaging and optical coherence tomography measures, and serum and cerebrospinal fluid biomarkers in the context of MS-associated neurodegeneration and SPMS conversion. Ultimately, we discuss the necessity of multimodal approaches in order to approach objective definition and prediction of conversion to SPMS.
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Affiliation(s)
- Nik Krajnc
- Department of Neurology, Medical University of Vienna, Vienna, Austria.,Department of Neurology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
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11
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Long-Term Disease Stability Assessed by the Expanded Disability Status Scale in Patients Treated with Cladribine Tablets 3.5 mg/kg for Relapsing Multiple Sclerosis: An Exploratory Post Hoc Analysis of the CLARITY and CLARITY Extension Studies. Adv Ther 2021; 38:4975-4985. [PMID: 34370275 PMCID: PMC8408069 DOI: 10.1007/s12325-021-01865-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 07/16/2021] [Indexed: 01/22/2023]
Abstract
INTRODUCTION In the Cladribine Tablets Treating Multiple Sclerosis Orally (CLARITY) study, cladribine tablets significantly reduced relapse rates and improved findings on magnetic resonance imaging versus placebo in patients with relapsing multiple sclerosis. In the CLARITY Extension study, treatment with cladribine tablets for 2 years followed by placebo for 2 years produced similar clinical benefits to 4 years of cladribine tablets. The objective of this exploratory post hoc analysis was to evaluate long-term disease stability (assessed by the Expanded Disability Status Scale [EDSS] score) after treatment with cladribine tablets. METHODS Patients enrolled into CLARITY Extension who were previously randomized to cladribine tablets 3.5 mg/kg in the CLARITY study were included in this post hoc analysis. Two treatment groups were investigated-patients randomized to cladribine tablets 3.5 mg/kg in CLARITY and thereafter randomized to placebo in CLARITY Extension (the CP3.5 group) or to cladribine tablets 3.5 mg/kg in CLARITY Extension (the CC7 group). In each treatment group, EDSS scores at 6-month intervals, EDSS score improvement/worsening each year, and time to 3- and 6-month confirmed EDSS progression were assessed from CLARITY baseline over 5 years of follow-up (including a variable bridging interval between studies). All analyses are descriptive, and no statistical comparisons were performed for between-treatment group differences. RESULTS The median (95% confidence interval [CI]) EDSS score for patients in the CP3.5 group at 5 years was 2.5 (2.0-3.5) compared with 3.0 (2.5-3.5) at baseline. In the CC7 group, median EDSS score (95% CI) at 5 years was 2.0 (2.0-3.0) compared with 2.5 (2.5-3.0) at baseline. During year 5 for the CP3.5 group, and based on changes in minimum score each year, EDSS score stability was observed in 53.9% of patients, improvement in 21.3%, and worsening in 24.7%. In the CC7 group, EDSS score remained stable in 66.1%, improved in 18.1%, and worsened in 15.8% of patients. Over 70% of patients in both treatment groups did not show 3- or 6-month confirmed EDSS progression at 5 years from CLARITY baseline. CONCLUSIONS These findings confirm long-term beneficial effects on disability afforded by either the recommended dose of cladribine tablets over 4 years (cumulative dose, 3.5 mg/kg) or a higher cumulative dose. TRIAL REGISTRATION ClinicalTrials.gov NCT00213135 (CLARITY); NCT00641537 (CLARITY Extension).
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12
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Guerrieri S, Comi G, Leocani L. Optical Coherence Tomography and Visual Evoked Potentials as Prognostic and Monitoring Tools in Progressive Multiple Sclerosis. Front Neurosci 2021; 15:692599. [PMID: 34421520 PMCID: PMC8374170 DOI: 10.3389/fnins.2021.692599] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 06/07/2021] [Indexed: 11/13/2022] Open
Abstract
Understanding the mechanisms underlying progression and developing new treatments for progressive multiple sclerosis (PMS) are among the major challenges in the field of central nervous system (CNS) demyelinating diseases. Over the last 10 years, also because of some technological advances, the visual pathways have emerged as a useful platform to study the processes of demyelination/remyelination and their relationship with axonal degeneration/protection. The wider availability and technological advances in optical coherence tomography (OCT) have allowed to add information on structural neuroretinal changes, in addition to functional information provided by visual evoked potentials (VEPs). The present review will address the role of the visual pathway as a platform to assess functional and structural damage in MS, focusing in particular on the role of VEPs and OCT, alone or in combination, in the prognosis and monitoring of PMS.
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Affiliation(s)
- Simone Guerrieri
- Experimental Neurophysiology Unit, San Raffaele Hospital, Institute of Experimental Neurology (INSPE), Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Giancarlo Comi
- Vita-Salute San Raffaele University, Milan, Italy.,Casa di Cura del Policlinico, Milan, Italy
| | - Letizia Leocani
- Experimental Neurophysiology Unit, San Raffaele Hospital, Institute of Experimental Neurology (INSPE), Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
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