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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

13th Post-ECTRIMS Meeting: review of the new developments presented at the 2020 ECTRIMS Congress (I)

INTRODUCTION

For more than a decade, following the ECTRIMS Congress, the Post-ECTRIMS Meeting has been held in Spain, where neurologists with expertise in multiple sclerosis (MS) from all over the country meet to review the most relevant latest developments presented at the ECTRIMS congress (on this occasion held together with ACTRIMS).

AIM

This article, published in two parts, summarises the presentations that took place at the Post-ECTRIMS Meeting, held online on 16 and 17 October 2020.

DEVELOPMENT

This first part includes the latest results regarding the impact of the environment and lifestyle on risk of MS and its clinical course, and the role of epigenetics and genetic factors on these processes. Findings from preclinical and clinical research on the lymphocyte subtypes identified and the involvement of lymphoid follicles and meningeal involvement in the disease are discussed. Changes in brain structure are addressed at the microscopic and macroscopic levels, including results from high-resolution imaging techniques. The latest advances on biomarkers for the diagnosis and prognosis of MS, and on the involvement of the microbiome in these patients are also reported. Finally, results from patient registries on the impact of COVID-19 in MS patients are outlined.

CONCLUSIONS

There have been new data on MS risk factors, the impact of MS at the cellular and structural level, the role of the microbiome in the disease, biomarkers, and the relationship between COVID-19 and MS.

POS0168 BONE MINERAL DENSITY IN PATIENTS WITH MULTIPLE SCLEROSIS. A DESCRIPTIVE STUDY FROM A UNIQUE CENTER FROM THE EAST OF SPAIN

Background:

Several studies have suggested that multiple sclerosis (MS) patients have low bone mineral density (LBMD) compared to healthy adults of same age. This fact, combined with the functional impairment of the disease, increases the risk of fractures. However, information about the prevalence and the risk factors of LBMD in Spanish patients with MS is still quite limited1–3.

Objectives:

To evaluate the prevalence of LBMD and low vitamin D in patients with MS from a unique center from the east of Spain, describing the clinical features of these patients.

Methods:

Type of study: observational, cross-sectional, descriptive. Patients with MS from a local cohort have been consecutively recruited for this study since Apr-2020. A cross-sectional visit which included a clinical interview, analytic test (blood and urine) and a dual-energy X-ray absorptiometry (DXA) was performed. We defined LBMD as T score ≤-1SD in postmenopausal women and men over 50 years and a Z score ≤-2SD in premenopausal women and men under 50 years. Low levels of vitamin D were defined as < 20ng/mL. A descriptive and associative analysis of these data was carried out using the SPSS software.

Results:

From a cohort of 288 MS patients, due to the COVID-19 pandemia, we have only been able to assess 60 patients, and only 48 out of them have undergone all the tests required. These were 30 women and 18 men, with a mean age of 49 (SD 11,6) years. The main type of MS was relapsing-remiting (77,1%) and 25% of them were not taking any maintenance treatment. Some of the classical factors related to a LBMD are shown in table a1. A 43,8% of the patients had a LBMD and 40,5% had low levels of vitamin D. Despite these results, as far as 89% of patients had never received any specific treatment, not even calcium and/or vitamin D supplementation. Furthermore, 13 patients (27,1%) must have received specific treatment, according to latest guidelines4, and only 4 of them (8,5%) were being adequately treated.

Table 1.Women/Men (n)30/18Mean age; SD (years)49; 11,6Non smokers/Smokers (%)58,4/41,7Alcohol abuse (%)8,3Personal history of fracture (%)10,4Personal history of nephrolithiasis (%)14,6Normal/Reduced mobility (%)77,1/22,9Sedentary lifestyle (%)66,7

Conclusion:

These preliminary results show that almost half of the MS patients have LBMD and a low vitamin D, most of them without taking any specific treatment. Taking this in mind, it is necessary to integrate the early diagnosis of LBMD in MS patients, working together with neurologists, to prevent the appearance of fractures and protect the quality of life of these patients. An analysis of our whole cohort of MS patients will help us in correctly assessing the magnitude of this problem.

References:

[1]López Méndez P, Sosa Henríquez M. Vitamin D and multiple sclerosis. Prevalence of hypovitaminosis D. Rev Osteoporos y Metab Miner. 2015;7(2):71-78.

[2]Gupta S, Ahsan I, Mahfooz N, Abdelhamid N, Ramanathan M, Weinstock-Guttman B. Osteoporosis and multiple sclerosis: Risk factors, pathophysiology, and therapeutic interventions. CNS Drugs. 2014;28(8):731-742.

[3]Moen S, E.Celius, L S, L N, E E, T H. Low bone mass in newly diagnosed multiple sclerosis and clinically isolated syndrome. Neurology. 2011;77(2):151-157.

[4]Lems WF, Dreinhöfer KE, Bischoff-Ferrari H, et al. EULAR/EFORT recommendations for management of patients older than 50 years with a fragility fracture and prevention of subsequent fractures. Ann Rheum Dis. 2017;76(5):802-810.

Disclosure of Interests:

None declared

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

13th Post-ECTRIMS Meeting: review of the new developments presented at the 2020 ECTRIMS Congress (II)

INTRODUCTION

For more than a decade, after the ECTRIMS Congress, Spain has hosted the Post-ECTRIMS meeting, where neurologists with expertise in multiple sclerosis (MS) meet to review the new developments presented at the ECTRIMS.

AIM

This article, published in two parts, summarises the presentations of the post-ECTRIMS meeting, held online on 16 and 17 October 2020.

DEVELOPMENT

This second part highlights the importance of gender and age in understanding the pathology of the disease and optimising its management. The advances made in paediatric MS, from a neuropsychological and neuroimaging point of view, are presented. In turn, special attention is paid to the findings that contribute to a more personalised approach to therapy and to choosing the best treatment strategy (pharmacological and non-pharmacological) for each patient. Similarly, results related to possible strategies to promote remyelination are addressed. Although there are no major advances in the treatment of progressive forms, some quantitative methods for the classification of these patients are highlighted. In addition, the study also includes results on potential tools for assessment and treatment of cognitive deficits, and some relevant aspects observed in the spectrum of neuromyelitis optica disorders. Finally, the results of the papers considered as breaking news at the ECTRIMS-ACTRIMS are detailed.

CONCLUSIONS

Most of the advances presented were related to the knowledge of paediatric MS, remyelination strategies and cognitive assessment in MS.

High clinical inflammatory activity prior to the development of secondary progression: a prospective 5-year follow-up study

Objective: To study if there are different patterns of clinical activity - measured by the annual exacerbation rate (AER) - among relapsing-remitting multiple sclerosis (RRMS), "early" secondary multiple sclerosis (SPMS) and "late" SPMS. Methods: A prospective 5-year follow-up study in 80 MS patients has been carried out, calculating the AER and the mean expanded disability status scale (EDSS) change rate (MCR). Results: A significant difference on the AER, among RRMS, early SPMS and late SPMS, has been found. Conclusions: The SPMS has a high clinical inflammatory activity before and during its transformation from a RRMS. Multiple Sclerosis (2002) 8, 59-63

Early diffuse demyelinating lesion in the cervical spinal cord predicts a worse prognosis in relapsing—remitting multiple sclerosis

Objective: To study the long-term outcome and persistence of two patterns of cervical spinal cord abnormality in early relapsing—remitting multiple sclerosis (RRMS).

Methods: RRMS patients with a spinal cord MRI performed during the first 3 years of the disease, a control MRI 5 years later and who have been followed up at least 10 years were included. Patients were grouped according the T2 spinal cord MRI into: (A) nodular pattern, if one or more focal lesions were present; and (B) diffuse pattern, defined as a poorly demarcated high signal area. The end point was defined as the time to reach an Expanded Disability Status Score (EDSS) of 4.0.

Results: Twenty-five patients were included; 12 in group A and 13 in group B. Three patients in group A and 9 in group B reached EDSS 4, in a mean time of 11 years in group A and 7 years in group B (log rank 10.3, p = 0.001). Multivariate Cox regression analysis assessing the risk of EDSS 4.0 including sex, age, number of relapses in the first 2 years, number of T2 brain lesions and spinal cord pattern showed higher risk for the diffuse pattern (hazard ratio 7.2, 95% confidence interval 1.4—36.4). Control MRI showed the persistence of the diffuse pattern in all patients, and the development of diffuse pattern in two patients with basal nodular lesions.

Conclusions: The diffuse abnormality in cervical spinal cord at the beginning of the disease is persistent and predicts a worse prognosis in RRMS patients.

Effect of relapses over early progression of disability in multiple sclerosis patients treated with beta-interferon

Observational study designed to explore the effect of demographical variables and number of relapses over the disability progression in the two first years of beta-interferon treatment for multiple sclerosis. One hundred and sixty two patients treated with beta-interferon for at least two years were included, 70.9% females, mean age 33.4 years, mean disease duration 75.1 months, mean EDSS 2.4, previous year relapse rate 1.3. Main end-point was defined as a sustained EDSS increase (1.5 if previous EDSS 0-2.0; 1.0 if previous EDSS 2.5-4.0; 0.5 if previous EDSS 4.5 or higher). 62.3% of patients presented one or more relapses and 32.7% patients reached sustained disability increase. The univariate and multivariate Cox regression analysis only showed statistical significance for the relapses in the two first years after the treatment (HR 1 relapse: 3.4, p = 0.05; HR ≥ 2 relapses: 4.3, p < 0.001). The Kaplan-Meier survival analysis showed a higher probability of EDSS progression for patients with one relapse (log rank 10.9, p = 0.02) and with ≥ 2 relapses (log rank 17.7, p < 0.001), with no differences between them ( p = 0.38). In conclusion, patients with one or more relapses in the first two years of interferon treatment developed an earlier sustained progression of the disability.

High clinical inflammatory activity prior to the development of secondary progression: a prospective 5-year follow-up study

OBJECTIVE

To study if there are different patterns of clinical activity--measured by the annual exacerbation rate (AER)--among relapsing-remitting multiple sderosis (RRMS), "early" secondary multiple sclerosis (SPMS) and "late" SPMS.

METHODS

A prospective 5-year follow-up study in 80 MS patients has been carried out, calculating the AER and the mean expanded disability status scale (EDSS) change rate (MCR).

RESULTS

A significant difference on the AER, among RRMS, early SPMS and late SPMS, has been found.

CONCLUSIONS

The SPMS has a high clinical inflammatory activity before and during its transformation from a RRMS.

[Cognitive impairment, clinic forms and progression in multiple sclerosis]

INTRODUCTION

Multiple sclerosis-related cognitive impairment is an important clinical dimension of the disease by virtue of its prevalence and its functional significance. It is directly related to cerebral multiple sclerosis pathology, but relatively independent of physical impairment.

DEVELOPMENT

Thus, the assessment of neuropsychologic outcomes complements the assessment of physical outcomes in multiples sclerosis clinical trials. Neuropsychologic measures fulfill most of the criteria identified for an optimal multiple sclerosis clinical outcome measure. Major drawbacks to their current use in assessing clinical trial outcomes are the heterogeneity inherent in neuropsychological test performance(both cross-sectionally and longitudinally), and limitations in our knowledge about the evolution of multiple sclerosis- related cognitive impairment and the psychometric properties of specific measures over time. At this point in time, we cannot identify the single "best" measure for assessing neuropsychologic change in multiple sclerosis patients, and we cannot specify what constitutes clinically significant change. Analyses of neuropsychologic data from recently completed trial will soon provide an empirical basis for selecting measures to use in future multiple sclerosis clinical trials and specifying criteria for clinically significant change on these measures.

[A study of various scales of fatigue and impact on the quality of life among patients with multiple sclerosis]

OBJECTIVES

To explore fatigue in multiple sclerosis and evaluate the specificity of three fatigue scales in this condition: the fatigue severity scale, the specific fatigue scale and the fatigue impact scale.

MATERIAL AND METHODS

We sent out 60 questionnaires with the three scales and the quality of life scale, the Nottingham Health Profile, to patients with multiple sclerosis as clinically defined by Poser's criteria. Answers were received to 58 questionnaires and the data correlated by Sperman's correlation and the Student t test, with demographic variables (age, age of onset and sex) and clinical variables (clinical form, time the disease was present, period of time since the previous episode and Kurtzke scale (EDSS).

RESULTS

Fatigue was present in 78% of the patients. There was correlation between fatigue severity scale and EDSS, pyramidal function, cerebellar function, the period of time the illness was present and the clinical form. We found that the specific fatigue scale is independent of EDSS. The fatigue impact scale was correlated with the EDSS apart from the questions concerning cognitive function.

CONCLUSIONS

Fatigue is a common symptom of multiple sclerosis which has an independent effect on cognitive function. It is also related to involvement of the pyramidal and cerebellar systems, and depends on the degree of disability and time the disease has been present. The specific fatigue scale is a good tool for exploration of this symptom of multiple sclerosis.

[Axonal involvement in multiple sclerosis. Current concepts]

INTRODUCTION

Axon pathology in multiple sclerosis is an emerging concept, not because it is unknown but because it has been forgotten. However, clinical, functional and pathological aspects have clearly shown that it is damaged at a very early stage in development of the plaque of demyelination. There is sufficient clinical, radiological and pathological evidence to permit definition of axonal damage as the central element of the pathology and clinical features of multiple sclerosis.

DEVELOPMENT AND CONCLUSIONS

Throughout this article we will see how the axon is affected in multiple sclerosis, how this affects the inflammatory response and which parameters allow us to measure axonal damage and its relation to disability. Finally we will see how a new physiopathogenic concept of multiple sclerosis appears, based on the axonal lesion, and how this fits current clinico-pathological concepts better.

[Sjögren syndrome and subacute demyelinating polyradiculopathy: an unusual association]

INTRODUCTION

Sjögren's syndrome is a chronic inflammatory condition of unknown aetiology and autoimmune pathology. The defining feature is the dry syndrome, expressed as xerophthalmia and xerostomia. Extra-glandular involvement at many other levels may also occur. Neurological involvement is not unusual. The peripheral nervous system is most frequently involved, and a predominantly sensitive symmetrical distal polyneuropathy may be the first sign of the condition. Other patterns of peripheral involvement are also associated with the syndrome. We present a case of subacute demyelinating polyradiculopathy associated with primary Sjögren's syndrome.

CLINICAL CASE

A 28 year old woman with dry syndrome presented with paraesthesia in her hands and feet, distal weakness, which had progressed proximally in the muscles of her arms and legs, and bilateral facial weakness. The condition progressed for eight weeks. When complementary tests were done, alterations typical of this condition (FR, ANA, anti-Ro and anti-La) were seen and also others typical of the dry syndrome (Schirmer's test). Therefore, in view of these findings and the clinical features, after other conditions had been ruled out, a diagnosis of primary Sjögren's syndrome was made. The type of neuropathy was determined by the clinical features, electromyography and CSF findings. Treatment with corticosteroids gave good results.

CONCLUSIONS

Demyelinating polyradiculopathy is a form of peripheral nervous system involvement which is rarely seen in this disorder. In the differential diagnosis Sjögren's syndrome should be considered, an orientative history taken, autoantibodies determined and an ophthalmological examination made.

[Lacunar infarct and deep cerebral hemorrhage: a comparison of the risk factors]

INTRODUCTION

Lacunar infarcts (LI) and deep cerebral hemorrhages (DCH) have the same localization and a vasculopathy which appears to be similar, at the level of the small perforating arteries, classically attributed to arterial hypertension (AHT).

OBJECTIVES

To compare the vascular risk factors of patients with lacunar ictus (LIc) and those with DCH, to try to determine how these may affect the appearance of one type of stroke or another.

PATIENTS AND METHODS

We analyzed a prospective consecutive series of patients with cerebral vascular accidents (CVA), selecting 1,540 patients in the first 1,155 with a first CVA. We recorded demographic data and the following risk factors: previous transient ischemic accident (TIA), AHT, diabetes mellitus (DM), hypercholesterolemia, ischemic cardiopathy, atrial fibrillation and the presence of silent infarcts on CT.

RESULTS

Two hundred and four patients had LIc and 163 had DCH. There was a significant dissociation between LIc and a history of TIA, DM, hypercholesterolemia and the presence of silent lacunar-type infarcts on CT. However, after multivariant analysis, DM did not continue to be an independent variable. Arterial blood pressure was found to be greater in the DCH group.

CONCLUSIONS

The presence of different risk factors for LIc and DCH may be the key to understanding the mechanism which leads to one type or other of CVA.

Circadian variation in acute ischemic stroke: a hospital-based study

BACKGROUND AND PURPOSE

We investigated circadian rhythm in ischemic stroke onset and its subtypes, differentiating between first-ever stroke and recurrent stroke.

METHODS

A consecutive series of 1223 patients with ischemic stroke was admitted at 2 reference hospitals; the time of onset of symptoms was obtained, differentiating between onset while asleep and awake. We compared circadian rhythm between stroke types and between first-ever and recurrent stroke.

RESULTS

The onset time was known in 914 patients; 25.6% experienced onset on awakening [higher incidence in thrombotic and lacunar stroke (28.9% and 28.4%, respectively) than in embolic stroke (18.8%)]. For all stroke subtypes, there was a significant diurnal variation, with a morning peak between 6 AM and noon; after redistributing the hour of onset of patients awakening with stroke, the morning peak was minimal in all types of stroke. There were no differences in circadian rhythm between patients with first-ever and recurrent stroke.

CONCLUSIONS

Only hospitalized patients were studied. There is a circadian rhythm in all types of stroke, with higher frequency during the day and lower frequency in the last hours in the evening. The highest incidence in the early hours of the morning can be overestimated, due to patients who awaken with stroke. There is no difference in circadian rhythm between first-ever stroke and recurrent stroke.

[Familial multiple sclerosis: a study of six families]

INTRODUCTION

Multiple sclerosis (MS) is a demyelinating disorder of the CNS, of autoimmune pathology and unknown aetiology. Several theories regarding its aetiology have been suggested, although none seems to be completely convincing. Genetically predisposed persons are affected, therefore groups of MS are seen in certain families.

OBJECTIVES

To describe the family links, type of illness and evolution of 12 patients from six families with two or more members diagnosed as having MS, and to evaluate any differences from the other cases recorded in our data base.

PATIENTS AND METHODS

We studied 12 patients diagnosed on the criteria of Poser, and with at least one first or second degree relation with MS. We compared clinical data, form of presentation and course with 127 patients recorded in the data base.

RESULTS

We describe six families: two homozygotic twins, two families in which transmission was from father to child and three families with first degree cousins affected. We found no clinical variation in the presentation, number of attacks or evolution, as compared with the other patients. Nor was there homogeneity between the familial forms of MS.

CONCLUSIONS

Familial forms make up approximately 10% of the series. We do not have any data available for early diagnosis nor for prognostic significance of familial MS.

[Partial simple vegetative crisis: importance of electroencephalographic findings]

INTRODUCTION

50% of the patients with cerebral tumours present with epileptic crises, which may be partial or generalized. The commonest partial crises have motor symptoms. These make up 30% of the simple partial crises. Partial simple crises with purely vegetative-type symptoms are very uncommon (less than 5%). They are considered to be caused by discharges in the internal regions of the temporal lobes, mainly in the limbic system. This means that it is very difficult to identify them using techniques of surface EEG.

CLINICAL CASE

We describe the case of a patient with a cerebral tumour. The initial clinical features were short episodes of generalized coldness and sweating which had been present for the previous two weeks, without any other symptoms. During a routine EEG, focal critical paroxystic activity was recorded in the right temporal region. This coincided with a clinical episode similar to those described.

CONCLUSIONS

The episodes were labelled partial simple vegetative crises. In this case the EEG was crucial for diagnosis and subsequently to recommend suitable treatment. However, difficulty in recording this type of crisis with a surface EEG makes correct diagnosis of these patients very difficult, since the epileptogenic focus is deeply situated.