Andrea Harrer

Tumefactive MS lesions under fingolimod: a case report and literature review.

Objective: To report about a possible association between fingolimod treatment and tumefactive demyelinating lesions (TDL) as seen in a patient developing repeated TDL on continued fingolimod therapy. Methods: We performed serial clinical and radiologic assessments and immunophenotyping of blood and CSF immune cells. We also present a literature review about recent similar cases. Results: Clinical course and radiologic findings were consistent with diagnosis of TDL. Immune cell phenotyping showed pronounced shifts in the immune cell composition related to fingolimod treatment. In addition, we observed a subset of highly differentiated effector cells (CD45R0negCCR7neg) within the CD8+ T-cell population, which was about 2-fold enriched in the CSF compared to the peripheral blood. Conclusion: Our observations add further evidence for the development of atypical demyelinating lesions in some patients receiving fingolimod. These might be related to a treatment-associated shift in the immunopathology of specifically susceptible individuals.

Current therapies in ischemic stroke. Part A. Recent developments in acute stroke treatment and in stroke prevention.

Stroke is the third leading cause of death with an increasing prevalence. In previous years many important achievements and new therapeutic strategies have been established. This article provides an overview on recent developments and is an update to the article of Green et al. that was published in 2004. As this article is a comprehensive review we divided it in two parts. In this Part A of our review, recent developments in acute stroke treatment and in stroke prevention are described. In Part B we will reflect on neuroprotection.

Natalizumab therapy decreases surface expression of both VLA-heterodimer subunits on peripheral blood mononuclear cells

Natalizumab interferes with immune cell migration into the central nervous system via blocking the alpha-4 subunit of very-late activation antigen-4 (VLA-4). Occurrence of rare but serious progressive multifocal leukoencephalopathy during prolonged natalizumab therapy of multiple sclerosis (MS) calls for a more detailed understanding of potential coeffects. We longitudinally studied alpha-4 and beta-1 surface levels on blood cells from 18 MS patients by flow cytometry. Expectedly, detectability of natalizumab-blocked alpha-4 was diminished on all investigated cell subsets. In addition, we report a concurrent and significant decrease of beta-1 surface levels on T-cells, B-cells, natural killer cells, and natural killer T cells, but not on monocytes. Uncovering secondary effects of natalizumab is mandatory to increase safety in MS therapy.

Current therapies in ischemic stroke. Part B. Future candidates in stroke therapy and experimental studies

Stroke still remains a major healthcare problem. The growing understanding of the mechanism of cell death in ischemia leads to new approaches in stroke treatment. The aim of neuroprotection is to reduce the post-stroke impairment and the overall costs that are accompanied in patients with severe disability. Despite encouraging data from experimental animal models, almost all neuroprotective therapies have, to date, not been established in clinical routine. In this part B of our review on stroke therapies we provide an overview on future candidates in stroke therapy and neuroprotective agents that are under investigation.

Importance of cerebrospinal fluid analysis in the era of McDonald 2010 criteria: a German–Austrian retrospective multicenter study in patients with a clinically isolated syndrome

The majority of patients presenting with a first clinical symptom suggestive of multiple sclerosis (MS) do not fulfill the MRI criteria for dissemination in space and time according to the 2010 revision of the McDonald diagnostic criteria for MS and are thus classified as clinically isolated syndrome (CIS). To re-evaluate the utility of cerebrospinal fluid (CSF) analysis in the context of the revised McDonald criteria from 2010, we conducted a retrospective multicenter study aimed at determining the prevalence and predictive value of oligoclonal IgG bands (OCBs) in patients with CIS. Patients were recruited from ten specialized MS centers in Germany and Austria. We collected data from 406 patients; at disease onset, 44/406 (11xa0%) fulfilled the McDonald 2010 criteria for MS. Intrathecal IgG OCBs were detected in 310/362 (86xa0%) of CIS patients. Those patients were twice as likely to convert to MS according to McDonald 2010 criteria as OCB-negative individuals (hazard ratioxa0=xa02.1, pxa0=xa00.0014) and in a shorter time period of 25xa0months (95xa0% CI 21–34) compared to 47xa0months in OCB-negative individuals (95xa0% CI 36–85). In patients without brain lesions at first attack and presence of intrathecal OCBs (30/44), conversion rate to MS was 60xa0% (18/30), whereas it was only 21xa0% (3/14) in those without OCBs. Our data confirm that in patients with CIS the risk of conversion to MS substantially increases if OCBs are present at onset. CSF analysis definitely helps to evaluate the prognosis in patients who do not have MS according to the revised McDonald criteria.

Recent developments in approved and oral multiple sclerosis treatment and an update on future treatment options

Multiple sclerosis (MS) is the most common chronic neurological disease in young adults in the western world. There was no specific treatment available for this serious disorder until the introduction of the immunomodulatory drug interferon-β in the mid-1990s. Since then, the number of agents and treatment strategies for MS has increased rapidly. Deeper knowledge on the heterogeneous nature of MS cleared the way for several more specific, more effective and more comfortable therapies. Here, because of the exciting recent developments concerning oral treatment forms for MS, we summarize the current state of approved and future therapy options. In particular, we highlight oral treatment options in MS.

Flow-cytometry and the detection of anti-natalizumab NAB in multiple sclerosis

WCN 2013 No: 2028 Topic: 6 — MS & Demyelinating Diseases Reduced intrathecal IgG synthesis in the cerebrospinal fluid from natalizumab-treated patients with active multiple sclerosis A. Harrer, G. Pilz, P. Wipfler, K. Oppermann, B. Holl, W. Hitzl, S. Afazel, E. Haschke-Becher, E. Trinka, J. Kraus. Department of Neurology, Paracelsus Medical University, Christian-Doppler-Klinik, Salzburg, Austria; Research Office, Biostatistics, Paracelsus Medical University, Salzburg, Austria; Central Laboratory, Paracelsus Medical University, Christian-Doppler-Klinik, Salzburg, Austria Oligoclonal bands (OCB) have been reported to disappear from the cerebrospinal fluid (CSF) in natalizumab (NZB)-treated patients with multiple sclerosis (MS) although OCB are considered to persist in MS. Detection of OCB is qualitative evidence of intrathecally produced IgG. We investigated if this NZB-effect on intrathecal IgG synthesis can be quantitatively assessed by analyzing the fraction of intrathecally produced IgG (IgGIF). We included 31 MS patients, 17 were untreated (first diagnosis) and from 14 patients CSF was collected to rule out progressive multifocal leukoencephalopathy (PML) during NZB treatment. From 6 of the 14 NZB-treated patients CSF data from the first diagnosis were also available. IgG and albumin concentrations of CSF and serum samples were measured by immunonephelometry and used to calculate the CSF/serum quotients and IgGIF (in %) according to Reiber (1998). Quantification of intrathecal IgG synthesis showed a reduced IgGIF in NZB-treated patients compared to untreatedMS patients (p= 0.0026). Intraindividual comparisons of baseline and follow-up data in the NZBtreated group of 6 showed disappearance of intrathecal IgG production in 2 and an overall reduction of the IgGIF (p= 0.018). Quantifying intrathecal IgG synthesis revealed a pronouncedly reduced IgGIF in NZB-treated MS patients. This corroborates previous reports about disappearing OCB and suggests effectiveness of NZB therapy on intrathecal IgG production. Since lumbar punctures were performed to rule out PML this observation is limited to NZB-treated patients with active disease. Clarification of the underlying mechanisms will provide important knowledge about the clinical relevance of this finding and the pathogenesis of NZB-associated PML. doi:10.1016/j.jns.2013.07.1410 Abstract — WCN 2013 No: 2004 Topic: 6 — MS & Demyelinating Diseases Incidence of multiple sclerosis in the region of Sarajevo before and after the war events WCN 2013 No: 2004 Topic: 6 — MS & Demyelinating Diseases Incidence of multiple sclerosis in the region of Sarajevo before and after the war events J. Djelilovic-Vranic, A. Alajbegovic, M. Tiric-Campara, S. Salcic, E. Djozic, E. Eljubovic. Neurology Clinic, Clinical Center of Sarajevo University, Sarajevo, Bosnia and Herzegovina Introduction: Multiple sclerosis is an autoimmune demyelinating disease and degeneration of axons, in the appearance of which stress has an important role. The goal is to determine the incidence of multiple sclerosis in the region of Sarajevo in the period before and after the war (1986–2012). Material andmethods:We analyzed all new cases of multiple sclerosis in the region of Sarajevo in the period January 1986–December 2012. Diagnostic criteria included anamnesis, clinical presentation, MRI findings and evaluation of the spine, evoked potentials-visual and cerebrospinal fluid examination. Results:During the period 1986–1990, therewere 45 new cases ofMS, in the period 1991–1995, there were 27 new MS cases, from 1996 to 2000 107 new cases were registered of MS, and from 2001–2005 there were 150 new cases ofMS. In the period 2006–2010, therewere 174 new cases of MS. In 2011 there were 34 new cases of MS and during the 2012, 41 new cases. Stress as provoking factor was present in the first five-year period at 11.1% in the second at 18.5%, in the third with 19.6%, in the fourth five-year period at 36.5% of cases and in the final at 43.8% of cases. Conclusions: In the period after the war, the MS in the region of Sarajevo has increased in incidence. Multiple sclerosis in the region of Sarajevo is more frequent in women than in men, most frequently in the age 20–40 years. But it also tends to occur in a relatively advanced age, after 50 years. doi:10.1016/j.jns.2013.07.1411 Abstract — WCN 2013 No: 1996 Topic: 6 — MS & Demyelinating Diseases Multiple sclerosis prevalence study: The comparison of two coastal cities, located in the Black Sea and the Mediterranean Sea in Turkey WCN 2013 No: 1996 Topic: 6 — MS & Demyelinating Diseases Multiple sclerosis prevalence study: The comparison of two coastal cities, located in the Black Sea and the Mediterranean Sea in Turkey U. Turk Boru, A. Duman, A.Ş. Kulualp, N. Guler, M. Tasdemir. Neurology, Dr. Lutfi Kirdar Kartal Training and Research Hospital, Istanbul, Turkey; Neurology, Artvin State Hospital, Marmara University, Istanbul, Turkey; Public Health, Marmara University, Istanbul, Turkey Background: The studies about Multiple Sclerosis (MS) epidemiology have increased in the last years. The studies, we conducted in Turkey, which have been compared with new studies were made in Turkey. These studies show that there are also distinct variations between the same geographical areas. Objective: We carried out this study in order to determine the prevalence and to compare the difference between Mediterranean and Black Sea regions. Patients and metods: This descriptive, cross-sectional, door-to-door survey was carried out in the Mediterranean coastal city Gazipasa and the Black Sea coastal city Artvin in 2012. All people, who live in the city, were visited and interviewed in their houses. The center town of Artvin andGazipasa had been screened by door to door. A population of 16.116 people was screened in Artvin and 13.451 of the people were screened in Gazipasa. Poser criteria were used as diagnostic criteria in the study. Results: Seven patients were diagnosed as clinically definitive MS with the definitive anamnesis and MR investigation. Female to male ratio was 1.33. The prevalence of MS was found to be 52.0/100.000 in Gazipasa. Three female patients were diagnosed as clinically definitive MS. The prevalence of MS was found to be 18.6/100.000 in Artvin. Conclusion: According to the results, the countries in the Mediterranean area is also now in the high MS prevalence zone. More than 2 times of the difference was found between prevalences of Artvin and Gazipasa. Our recent studies, conducted in Turkey, provide evidence that the latitude gradient in the distribution of MS is disappearing. doi:10.1016/j.jns.2013.07.1412 Abstract — WCN 2013 No: 2019 Topic: 6 — MS & Demyelinating Diseases Flow-cytometry and the detection of anti-natalizumab NAB in multiple sclerosis WCN 2013 No: 2019 Topic: 6 — MS & Demyelinating Diseases Flow-cytometry and the detection of anti-natalizumab NAB in multiple sclerosis K. Oppermann, A. Harrer, G. Pilz, P. Wipfler, B. Holl, F. Deisenhammer, S. Afazel, E. Haschke-Becher, E. Trinka, J. Kraus. Abstracts / Journal of the Neurological Sciences 333 (2013) e358–e421 e389

Reduced intrathecal IgG synthesis in the cerebrospinal fluid from natalizumab-treated patients with active multiple sclerosis

OBJECTIVE: Here, we investigated if this NZB-effect on CNS-restricted humoral immune activities can be quantitatively assessed by analyzing the fraction of intrathecally produced IgG (IgGIF). BACKGROUND: Evidence of oligoclonal bands (OCB) disappearing from the cerebrospinal fluid (CSF) in natalizumab (NZB)-treated patients with multiple sclerosis (MS) is accumulating. OCB are only qualitative but not quantitative evidence of an intrathecal IgG production and considered to persist in MS. DESIGN/METHODS: We included 31 MS patients, 17 were untreated and in 14 CSF was investigated to rule out progressive multifocal leukoencephalopathy (PML) during NZB treatment. From 6 patients of the NZB-treated group IgGIF results of the lumbar punctures at first diagnosis were available. IgG and albumin concentrations of CSF and serum samples were measured by immunonephelometry and used to calculate the CSF/serum quotients and IgGIF (in %) according to Reiber (1998). RESULTS: Quantification of CNS-restricted IgG showed a reduced IgGIF in NZB-treated patients compared to untreated MS patients (p=0.0026). Likewise, intraindividual comparisons of baseline and follow-up data in the natalizumab-treated group of 6 showed disappearance of local IgG production in 2 and an overall significant reduction of the IgGIF (p=0.018). CONCLUSIONS: Quantifying intrathecal IgG synthesis revealed a pronouncedly reduced IgGIF in natalizumab-treated MS patients of both, inter- and intraindividual group comparisons. This corroborates previous reports about disappearing OCB and strongly suggests effectiveness of NZB therapy on intrathecal IgG production. Since lumbar punctures were performed to rule out PML this observation is limited to natalizumab-treated patients with active disease. Clarification of the underlying mechanisms will provide important knowledge about the clinical relevance of this finding and the potential pathogenesis of opportunistic CNS infections during NZB therapy. Disclosure: Dr. Kraus has received personal compensation for activities with Allmirall, Bayer, Biogen Idec, Genzyme, Medtronic, Merck Serono, Novartis, and Sanofi-Aventis. Dr. Kraus has received research support from Bayer, Biogen Idec, Merck Serono, Novartis, and Sanofi-Aventis. Dr. Pilz has received personal compensation for activities with Biogen Idec and Merck Serono. Dr. Wipfler has received personal compensation for activities with Merck Serono. Dr. Oppermann has received research support from Biogen Idec. Dr. Holl has received personal compensation for activities with Biogen Idec and Merck Serono. Dr. Hitzl has nothing to disclose. Dr. Afazel has nothing to disclose. Dr. Haschke-Becher has received research support from Abbott and Roche. Dr. Trinka has received personal compensation for activities with UCB Pharma, Eisai Inc., Sepracor, Medtronic, Inc., Pfizer, and Ever-Neuropharma. Dr. Trinka has received research support from UCB Pharma. Dr. Harrer has received personal compensation for activities with Merck Serono.

Zukünftiger Stellenwert von Liquor-Biomarker in der modernen MS-Therapie/Future relevance of CSF biomarkers in modern MS treatment

Zusammenfassung In den letzten Jahren wurde die Therapie der Multiplen Sklerose (MS) durch neue, immunologisch selektivere und wirksamere Medikamente erweitert. Untersuchungen des Liquors cerebrospinalis (CSF) zeigten, dass diese Medikamente auch einschneidende immunologische Veränderungen hinter der Blut-CSF-Schranke induzieren. Dadurch kann einerseits die gute Wirksamkeit erklärt werden, andererseits wird aber auch das Risiko opportunistischer Infektionen im ZNS, wie z.B. das Auftreten einer progressiven multifokalen Leukenzephalopathie (PML), begünstigt. In dieser Übersichtsarbeit wird auf die bis jetzt bekannten immunologischen Veränderungen, die durch die beiden in der Behandlung der hochaktiven MS zugelassenen Medikamente-Natalizumab und Fingolimod-ausgelöst werden, eingegangen. Die Untersuchung des CSF bietet ein sehr interessantes Forschungsfeld, um zukünftig mehr über die immunologischen Veränderungen bei MS hinter der Blut-Hirn-Schranke unter Therapie herauszufinden. Abstract During the past years treatment of multiple sclerosis (MS) has critically improved with the introduction of new and very effective drugs. These modern MS therapeutics selectively interfere with immune cell trafficking resulting in substantial shifts in leukocyte counts in peripheral blood. Strikingly, investigations of cerebrospinal fluid (CSF) also revealed immunological changes behind the blood-CSF barrier which might contribute to the increased effectiveness of these drugs. By contrast, these changes might account for a reduced immune surveillance of the central nervous system (CNS) and favor the occurrence of opportunistic infections such as progressive multifocal leukoencephalopathy. In this review, we focus on immunological changes induced by two approved agents in the treatment of highly active MS, natalizumab and fingolimod, and outline the current knowledge about their impact in the CSF compartment of the CNS. Further investigations and monitoring of immunological changes in CSF under MS therapy might help to provide further information about immunological changes.

Therapeutisches Drug-Monitoring der Natalizumab-Sättigung von Immunzellen mittels Durchflusszytometrie bei Multipler Sklerose/Flow cytometry and drug monitoring of natalizumab saturation of immune cells in multiple sclerosis

Zusammenfassung Einleitung: Natalizumab (Tysabri) kann in seiner Eigenschaft als blockierender Antikörper des alpha-4-Integrins auf der Oberfläche von Immunzellen mittels Durchflusszytometrie nachgewiesen werden. Wir untersuchten, ob sich der Sättigungsgrad von Immunzellen mit Natalizumab als Biomarker für ein Therapieansprechen bei Multipler Sklerose (MS) eignet. Methode: Bei 11 MS-PatientInnen wurde vor Therapiebeginn und nach 4, 8 und 12 Wochen die Natalizumab-Sättigung von T-Zellen (CD3+) und wichtigen T-Zell Subpopulationen (naive (CD45RA+)/memory (CD45R0+) CD4+ und CD8+) mittels Durchflusszytometrie untersucht. Ergebnisse: Jeweils vier Wochen nach den ersten drei Infusionen war der mittlere Natalizumab-Sättigungsgrad (n=9) von T-Zellen jeweils knapp unter 80%. Eine Patientin mit neutralisierenden Antikörpern (NAB) gegen Natalizumab und ein Patient mit zu langen Infusionsintervallen wurden aufgrund von Auffälligkeiten im Natalizumab-Sättigungsgrad der Immunzellen identifiziert. Die unterschiedlich hohen alpha-4 Expressionswerte der einzelnen T-Zellsubpopulationen hatten keinen Einfluss auf den Sättigungsgrad mit Natalizumab. Schlussfolgerung: Wir konnten zeigen, dass ein Monitoring der Natalizumab-Sättigung von T-Lymphozyten mittels Durchflusszytometrie eine Routine-taugliche Methode ist, um PatientInnen mit einem möglichen suboptimalen Therapieerfolg aufgrund von NAB oder unregelmäßigen Infusionsintervallen zu identifizieren. Weiterführende Studien zur Bestimmung eines Schwellenwertes für eine unzureichende Nalizumab-Sättigung eröffnen die Möglichkeit für individualisierte Therapieschemata. Dies ist im Hinblick auf das Risiko opportunistischer Infektionen wichtig, um die Sicherheit dieses so hochwirksamen Therapeutikums für die Langzeitbehandlung in der MS zu erhöhen. Abstract Background: Natalizumab (Tysabri) is a blocking antibody specific for the α-4 integrin subunit and can be detected on the surface of immune cells by flow cytometry. We investigated if determination of natalizumab saturation of immune cells has the potential to act as a biomarker for treatment effectiveness in multiple sclerosis (MS). Methods: Natalizumab saturation of immune cells from 11 patients was measured before the start of treatment and after 4, 8, and 12 weeks of natalizumab therapy on T cells (CD3+) and T cell subsets [naive (CD45RA+/memory (CD45R0+) CD4+ and CD8+] by flow cytometry. Results: At weeks 4, 8, and 12 the average (n=9) natalizumab saturation of T cells approximated 80%. One patient with natalizumab neutralizing antibodies (NABs) and another patient with irregular infusion intervals were identified by abnormalities in the natalizumab saturation of cells. Different α-4 expression levels of T cell subpopulations were irrelevant to measuring cellular natalizumab saturation. Conclusions: We show that monitoring natalizumab saturation of T cells by flow cytometry is a useful and routine-qualified method to identify patients with a reduced treatment effect due to NABs or irregular infusion intervals. Further studies to determine a cut-off value for suboptimal natalizumab saturation of immune cells will also show the potential of this parameter concerning more individualized treatment schedules. Considering the risk of opportunistic infections, it is very important to increase the safety of this highly effective MS therapy.