Geoffrey Keir

Cerebrospinal fluid in the diagnosis of multiple sclerosis: a consensus report.

The Committee of the European Concerted Action for Multiple Sclerosis (Charcot Foundation) organised five workshops to discuss CSF analytical standards in the diagnosis of multiple sclerosis. This consensus report from 12 European countries summarises the results of those workshops. It is hoped that neurologists will confer with their colleagues in clinical chemistry to arrange the best possible local practice. The most sensitive method for the detection of oligoclonal immunoglobulin bands is isoelectric focusing. The same amounts of IgG in parallel CSF and serum samples are used and oligoclonal bands are revealed with IgG specific antibody staining. All laboratories performing isoelectric focusing should check their technique at least annually using “blind” standards for the five different CSF and serum patterns. Quantitative measurements of IgG production in the CNS are less sensitive than isoelectric focusing. The preferred method for detection of blood-CSF barrier dysfunction is the albumin quotient. The CSF albumin or total protein concentrations are less satisfactory. These results must be interpreted with reference to the age of the patient and the local method of determination. Cells should be counted. The normal value is no more than 4 cells/microliters. Among evolving optional tests, measurement of the combined local synthesis of antibodies against measles, rubella, and/or varicella zoster could represent a significant advance if it offers higher specificity (not sensitivity) for identifying chronic rather than acute inflammation. Other tests that may have useful correlations with clinical indices include those for oligoclonal free light chains, IgM, IgA, or myelin basic protein concentrations.

Adaptation of the nitrate reductase and Griess reaction methods for the measurement of serum nitrate plus nitrite levels

Nitrite and nitrate determinations in biological fluids are increasingly being used as markers of nitric oxide production. We have modified a nitrate reductase and Griess reaction method for the measurement of serum nitrate and nitrite in ultrafiltrated samples using a microtitre plate. The recoveries of nitrate and nitrite were 95% (range = 86–113%) and 100% (range = 92–109%), respectively. The intra and inter assay coefficients of variation for nitrate plus nitrite in the concentration range 40–50μM were 9·1% and 7·8%, and in the concentration range of 2·5–10μM 23·4% and 25·5%, respectively. At its lower limit the assay is able to detect 125 pmoles of nitrate plus nitrite in 50μL of sample (2·5μmol/L). A mean serum nitrate plus nitrite level of 32·8μmol/L (SD 12·3) was measured in 24 healthy adult volunteers (12 men and 12 women), no age or sex differences were noted.

A specific ELISA for measuring neurofilament heavy chain phosphoforms

Neurofilaments (Nf) are the major constitutents of the axoskeleton and body fluid Nf levels are an important tool for estimating axonal degeneration in vivo. This paper presents a new sandwich ELISA allowing quantification of the NfH(SMI35) phosphoform from CSF, brain tissue and cell culture homogenates. The sensitivity of the NfH(SMI35) ELISA is 0.2 ng/ml with a recovery of 119% and a mean within- and between-batch precision of 10.6% and 23%, respectively. CSF NfH(SMI35) was stable at 4 degrees C, is not influenced by freeze-thaw cycles, and proteolysis present at room temperature could be prevented by adding protease inhibitors. Aggregate formation was observed for HPLC-purified bovine NfH and could be resolved by sonication. The upper reference value for CSF NfH(SMI35) levels (0.73 ng/ml) was defined as the 95% cumulative frequency from 416 CSF samples. Based on this cutoff, a significantly higher proportion of patients with amyotrophic lateral sclerosis, space-occupying lesions, disc prolapse and subarachnoid haemorrhage had pathologically elevated NfH(SMI35) levels compared to patients with cluster headache or demyelinating disease.A new nomenclature is proposed to facilitate the comparison between ELISA, immunoblotting and immunocytochemistry.

Axonal damage accumulates in the progressive phase of multiple sclerosis: three year follow up study

Background: Neurofilament phosphoforms (Nf) are principal components of the axoskeleton released during axonal injury. Cerebrospinal fluid (CSF) levels of Nf phosphoforms might be useful surrogate markers for disability in multiple sclerosis (MS), aid in distinguishing clinical subtypes, and provide valuable prognostic information. Method: Thirty four patients with MS were included in a three year follow up study along with 318 controls with other non-inflammatory neurological diseases. CSF levels of two Nf heavy chain (NfH) phosphoforms (NfHSMI35, NfHSMI34) were quantified at baseline and three year follow up using new ELISA techniques. Levels of NfH phosphoforms, the degree of phosphorylation (NfHSMI34:NfHSMI35 ratio), and changes in NfH levels between baseline and follow up (ΔNfH) were related to the clinical phenotype (RR or SP/PP), to three clinical scales (Kurtzke’s EDSS, ambulation index (AI), and nine hole peg test (9HPT)), and to progression of disability. Results: A significantly higher proportion (59%) of patients with SP/PPMS experienced an increase in NfHSMI35 levels between baseline and follow up compared with those with RRMS (14%, p<0.05). CSF NfHSMI34 levels at baseline were higher in patients with SP/PP (11 pg/ml) compared with RR (7 pg/ml, p<0.05) and NfHSMI35 levels were higher at follow up in SP/PP (129 pg/ml) compared with levels below assay sensitivity in RR (p<0.05). NfHSMI35 correlated with the EDSS (rs = 0.54, p<0.01), the AI (rs = 0.42, p<0.05), and the 9HPT (rs = 0.59, p<0.01) at follow up. Conclusion: The increase in NfH during the progressive phase of the disease together with the correlation of NfHSMI35 with all clinical scales at follow up suggests that cumulative axonal loss is responsible for sustained disability and that high NfHSMI35 levels are a poor prognostic sign.

Isoelectric focusing of cerebrospinal fluid immunoglobulin G: an annotated update

A revised agarose isoelectric focusing method for detecting oligoclonal IgG in unconcentrated cerebrospinal fluid is presented. The technique is shown to be robust and reproducible and suitable for the detection of intrathecal IgG synthesis.

Cerebrospinal fluid (CSF) and serum S100B: release and wash-out pattern.

S100B is an important brain specific protein for monitoring damage and activation of astrocytes. Using a straight forward, non-resource demanding in-house ELISA technique we measured S100B in cerebrospinal fluid (CSF) and serum in patients with traumatic brain injury (TBI) (serum), subarachnoid hemorrhage (SAH) (CSF, serum), intracranial hemorrhage (ICH) (CSF, serum), normal controls (NC) (serum) and a reference population (CSF, N=409). The release and wash-out pattern found in CSF and serum are discussed in relation to the three main determinants for increased brain specific protein levels in body fluids: (i) total mass effect; (ii) pathology; and (iii) time effect.

Anti-myelin antibodies do not allow earlier diagnosis of multiple sclerosis.

This study investigates whether the presence of serum and plasma anti-myelin oligodendrocyte glycoprotein (MOG) and anti-myelin basic protein (MBP) in patients presenting with a clinically isolated syndrome compatible with demyelination (CIS) predicts early conversion to multiple sclerosis (MS). Forty-seven patients with CIS (46 with optic neuritis) had anti-MOG and anti-MBP antibodies analysed at baseline, and clinical and magnetic resonance imaging assessments. There was no evidence that the MS status based on either the McDonald or Poser criteria relates to the antibody status.

Cerebrospinal fluid S100B correlates with brain atrophy in Alzheimer's disease.

S100B is a predominantly astrocytic protein with dose-dependent cytotoxic and neurotrophic properties encoded on chromosome 21q22.3. Concentrations of S100B were measured in the cerebrospinal fluid (CSF) of 31 patients with Alzheimers disease (AD), 36 patients with frontotemporal lobe dementia (FTLD) and 49 patients with other non-inflammatory neurological diseases. Additional CSF S100B concentrations were correlated with normalised brain volume measurements in AD and FTLD. CSF S100B was significantly higher in AD (Mean+/-standard deviation=0.4+/-0.2 ng/ml) and FTLD (0.42+/-0.19 ng/ml) patients when compared with control subjects (0.25+/-0.08, P<0.001). In patients with AD, S100B correlated negatively with normalised brain volume (R(S)=-0.53, P<0.001). No such correlation was found for FTLD patients. This study supports the concept that S100B is of pathological relevance for degeneration of the central nervous system in AD.

A rapid method for detecting oligoclonal IgG in unconcentrated CSF, by agarose isoelectric focusing, transfer to cellulose nitrate and immunoperoxidase staining

Abstract A method has been developed for determining the electrophoretic distribution of IgG in unconcentrated cerebrospinal fluid by agarose isoelectric focusing, followed by transfer of focused protein from the agarose on to cellulose nitrate membranes. A double antibody immunoperoxidase staining technique is used, which is both rapid and sensitive.

Increase of uric acid and purine compounds in biological fluids of multiple sclerosis patients

OBJECTIVES In this study, the concentrations of uric acid, purine profile and creatinine in samples of cerebrospinal fluid and serum of multiple sclerosis (MS) patients were measured by HPLC and compared with corresponding values recorded in patients without MS (cerebrospinal fluid) and healthy subjects (serum). DESIGN AND METHODS All samples were deproteinized with ultrafiltration (which ensures minimal sample manipulation and efficient protein removal) and then assayed for the synchronous HPLC separation of uric acid, hypoxanthine, xanthine, inosine, adenosine, guanosine and creatinine. RESULTS The values of all compounds assayed were significantly higher in both biological fluids of MS patients with respect to values measured in controls. In particular, serum hypoxanthine, xanthine, uric acid and sum of oxypurines were, respectively, 3.17, 3.11, 1.23 and 1.27-fold higher in these patients than corresponding values recorded in controls (p<0.001). CONCLUSIONS Differently from what previously reported, we here demonstrate that all purine compounds, including uric acid, are elevated in biological fluids of MS patients. Reinforced by the trend observed for creatinine, this corroborates the notion of sustained purine catabolism, possibly due to imbalance in ATP homeostasis, under these pathological conditions. These results cast doubt on the hypothesis that uric acid is depleted in MS because of increased oxidative stress, rather suggesting that this disease causes a generalized increase in purine catabolism. As observed in other pathological states, uric acid, purine compounds and creatinine, can be considered markers of metabolic energy imbalance rather than of reactive oxygen species, even in MS.