Heidi Beadnall

Exosomal microRNA signatures in multiple sclerosis reflect disease status

Multiple Sclerosis (MS) is a chronic inflammatory demyelinating disease of the central nervous system (CNS). There is currently no single definitive test for MS. Circulating exosomes represent promising candidate biomarkers for a host of human diseases. Exosomes contain RNA, DNA, and proteins, can cross the blood-brain barrier, and are secreted from almost all cell types including cells of the CNS. We hypothesized that serum exosomal miRNAs could present a useful blood-based assay for MS disease detection and monitoring. Exosome-associated microRNAs in serum samples from MS patients (n = 25) and matched healthy controls (n = 11) were profiled using small RNA next generation sequencing. We identified differentially expressed exosomal miRNAs in both relapsing-remitting MS (RRMS) (miR-15b-5p, miR-451a, miR-30b-5p, miR-342-3p) and progressive MS patient sera (miR-127-3p, miR-370-3p, miR-409-3p, miR-432-5p) in relation to controls. Critically, we identified a group of nine miRNAs (miR-15b-5p, miR-23a-3p, miR-223-3p, miR-374a-5p, miR-30b-5p, miR-433-3p, miR-485-3p, miR-342-3p, miR-432-5p) that distinguished relapsing-remitting from progressive disease. Eight out of nine miRNAs were validated in an independent group (n = 11) of progressive MS cases. This is the first demonstration that microRNAs associated with circulating exosomes are informative biomarkers not only for the diagnosis of MS, but in predicting disease subtype with a high degree of accuracy.

Automated brain volumetrics in multiple sclerosis: a step closer to clinical application

Background Whole brain volume (WBV) estimates in patients with multiple sclerosis (MS) correlate more robustly with clinical disability than traditional, lesion-based metrics. Numerous algorithms to measure WBV have been developed over the past two decades. We compare Structural Image Evaluation using Normalisation of Atrophy-Cross-sectional (SIENAX) to NeuroQuant and MSmetrix, for assessment of cross-sectional WBV in patients with MS. Methods MRIs from 61 patients with relapsing-remitting MS and 2 patients with clinically isolated syndrome were analysed. WBV measurements were calculated using SIENAX, NeuroQuant and MSmetrix. Statistical agreement between the methods was evaluated using linear regression and Bland-Altman plots. Precision and accuracy of WBV measurement was calculated for (1) NeuroQuant versus SIENAX and (2) MSmetrix versus SIENAX. Results Precision (Pearsons r) of WBV estimation for NeuroQuant and MSmetrix versus SIENAX was 0.983 and 0.992, respectively. Accuracy (Cb) was 0.871 and 0.994, respectively. NeuroQuant and MSmetrix showed a 5.5% and 1.0% volume difference compared with SIENAX, respectively, that was consistent across low and high values. Conclusions In the analysed population, NeuroQuant and MSmetrix both quantified cross-sectional WBV with comparable statistical agreement to SIENAX, a well-validated cross-sectional tool that has been used extensively in MS clinical studies.

Baló's concentric sclerosis and tumefactive demyelination: A shared immunopathogenesis?

Balós concentric sclerosis (BCS) and tumefactive demyelination (TD) are considered atypical forms of multiple sclerosis (MS). Baló lesions are characterized by concentric rings corresponding to alternating bands of demyelination and relatively preserved myelin (Hu and Lucchinetti, 2009). Tumefactive lesions are pseudotumoural demyelinating lesions of >2 cm and may have an open ring-enhancing magnetic resonance imaging appearance (Hu and Lucchinetti, 2009; Lucchinetti et al., 2008; Altintas et al., 2012). We present a patient who developed limb weakness and focal seizures secondary to a lesion radiologically and histopathologically consistent with BCS who, six months later, developed a tumefactive demyelinating lesion. This is the first description of BCS and TD occurring in the same patient and is particularly notable because of the lack of any other more typical demyelinating lesions on the MRIs. The nature of BCS and TD in relation to more typical multiple sclerosis is discussed.

Virus-related Merkel cell carcinoma complicating fingolimod treatment for multiple sclerosis.

Idiopathic REM sleep behavior disorder (iRBD) is a rare disease (0.0038%–0.005%).1 In patients with narcolepsy type 1 (NT1), symptomatic RBD is a frequent, comorbid disease, ranging from 45% to 61%.2 iRBD is a premotor stage of neurodegenerative disease. Few patients with narcolepsy develop Alzheimer disease or Parkinson disease.3 Treatment studies in patients with RBD are rare and have small sample sizes and heterogeneous populations and methods.4 Sodium oxybate (SO) has been efficacious in 2 patients with iRBD.5,6

Tablet-based screening improves continence management in multiple sclerosis.

To investigate whether electronic continence questionnaires aid early identification and optimizes management of sphincter dysfunction in a multiple sclerosis clinic.

Successful implementation of an automated electronic support system for patient safety monitoring: The alemtuzumab in multiple sclerosis safety systems (AMS3) study:

Background: Alemtuzumab is a highly effective treatment for relapsing-remitting multiple sclerosis (MS) but requires ongoing pathology monitoring for autoimmune adverse effects. The Alemtuzumab in MS Safety Systems (AMS3) study evaluated the implementation of an automated pathology-monitoring system. Objectives: To develop an efficient automated clinical decision support system (CDSS) to electronically prompt and track pathology collection and to provide prescribers and patients with customised alerts of abnormal results for identified risks. Methods: A total of 10 patients with relapsing-remitting MS treated with alemtuzumab were enrolled to test the system. Standard care laboratory monitoring was performed and compared to the performance of the CDSS. Results: The automated CDSS, an integrated patient smartphone application and an additional pre-screening tool were all successfully developed. Compliance with pathology monitoring was 96.7%. The automated analysis of pathology results was significantly faster than standard care neurologist review (p < 0.001). The system correctly identified and alerted abnormalities, including one case of immune thrombocytopenia (ITP) while the treating neurologist was on leave, enabling prompt treatment of serious adverse events. During the course of the study, the CDSS was deployed throughout Australia. Conclusion: We successfully developed automated pathology monitoring with a CDSS, demonstrating real-world benefits of high compliance and timely alerting of important results.

005 Filling in the gaps: precision MRI reporting in multiple sclerosis clinical practice

Introduction Clinical multiple sclerosis (MS) magnetic resonance imaging (MRI) brain reports provide important information to neurologists. The quantitative data reported varies between centres and radiologists. Structured MRI reporting and formal quantitative MRI (QMRI) analysis may assist clinicians with patient management. The objective is to compare quantitative data derived from standard clinical reports, structured neuroradiologist reviews, local QMRI analyses and fully-automated MSmetrix QMRI analyses, in a longitudinal clinical MS cohort. Methods Clinical brain MRI scans separated by one-year minimum, from the same patient on the same scanner, were evaluated. Quantitative information was extracted from the clinical reports and structured neuroradiologist reviews. MRI scan-pairs were analysed locally by imaging-analysts and centrally by MSmetrix. Results 50 MS patients, baseline age 39.02 (9.06) years, disease duration 9.11 (6.88) years and Expanded Disability Status Scale score 1.91 (1.62), were included. Compared to clinical reports, structured neuroradiologist reviews provided increased semi-/quantitative data; baseline T2 and T1 lesion burden (50% vs 100%; 2% vs 100%), baseline brain volume-loss (BVL; 72% vs 100%), new T1 lesions (0% vs 100%), regional brain atrophy (BA; 20% vs 100%). Lesion and brain volumes were not provided in radiology reports/reviews. Comparison of local and central QMRI revealed moderate-strong Pearson correlations for most metrics; Intra-class correlations varied more widely. Statistical consistency existed across all methods in detecting new T2 lesions. Radiologist-identified baseline BVL was associated with lower quantitatively-measured brain volumes. Local QMRI longitudinal BA rates >0.4% and >0.8%, were 48% and 26% respectively. Neuroradiologist review identified BA in 12%. Conclusion Structured neuroradiology review provided additional quantitative information over standard clinical reports. Quantitative data measured using local and MSmetrix pipelines were generally well associated but are not interchangeable. Longitudinal whole brain and regional atrophy is not reliably identified by radiologists and QMRI analysis provides a clear advantage in this regard. Structured reporting, and formal QMRI analysis, provide additional quantitative MRI data that may assist clinical decision-making in MS.

The prognostic utility of no evidence of disease activity (neda)

Objectives To investigate NEDA-3 and NEDA-4 status over one year in a group of heterogeneously treated patients with relapsing-remitting multiple sclerosis (MS). To investigate the prognostic utility of NEDA-3 status at 3 months for NEDA-3 at 12 months. Methods Sixty-nine patients with relapsing-remitting MS were recruited from the MS Clinic, Brain and Mind Centre, Sydney. Patients underwent clinical assessments, including an Expanded Disability Scale Status (EDSS), and MRI at baseline, 3 and 12 months. NEDA-3 was defined as; i) the absence of clinical relapses, ii) no 3 month confirmed disability progression, and iii) no new/enlarging T2 lesions or gadolinium-enhancing lesions. NEDA-4, determined at 12 months was defined as NEDA-3 plus the inclusion of a fourth measure, iv) no annualised brain atrophy of >0.4%. Results Of the participants, 84.1% were female, mean (SD) age was 37.1 (9.1) years, mean EDSS score 1.9 (1.4), average disease duration 7.6 (7.1) years and all patients were on disease-modifying therapy (DMT). At 3 months, 47.83% of the cohort had NEDA-3. Between 3 and 12 months, 36.23% had NEDA-3. Between 0 and 12 months, 23.19% had NEDA-3% and 13.04% achieved NEDA-4 status. The positive predictive value of NEDA-3 status at 3 months for 12 months was 39% (95%CI 23 to 58). Negative predictive value was 67% (95%CI 49 to 81), sensitivity 52% (95%CI 31 to 72) and specificity 55% (95%CI 39 to 70). Conclusions NEDA-3 was achieved more frequently than NEDA-4, suggesting significant disease progression in a proportion of patients despite the absence of traditional clinical and MRI metrics of disease activity. In this heterogeneous cohort, NEDA-3 at 3 months was not useful in predicting those who would maintain NEDA-3 at 12 months, emphasising the need for regular clinical and radiological assessment in MS. In this real-world patient cohort, disease progression occurred despite DMT in most patients, emphasising the need for improved treatment escalation paradigms in MS.

Comparing magnetic resonance imaging brain atrophy measurement techniques in multiple sclerosis clinical practice: longitudinal assessment

Objectives To determine the annualised percentage whole brain volume change (PBVC) between two time-points using Structural Image Evaluation using Normalisation of Atrophy (SIENA), SIENA Cross-sectional (SIENAX), and MSmetrixTM-longitudinal (MSmetrix-long) in a real-world multiple sclerosis (MS) cohort. To compare the whole brain atrophy (WBA) measurements derived by two registration-based longitudinal software methods (SIENA, MSmetrix-long), and a cross-sectional, segmentation-based method (SIENAX). Methods Clinical MRI scans (1 mm3 3DT1 IR-FSPGR; GE 3.0T scanner) were acquired from 102 MS patients at baseline and approximately 12 months. WBA analysis was performed using SIENA, SIENAX and MSmetrix-long (fully automated) for each subject. Annualised PBVC was calculated using all methods, and correlations between the measurement techniques were evaluated using linear regression. Results Mean (SD) annualised PBVC estimated by SIENA, SIENAX and MSmetrix-long was −0.64% (0.73) −0.49% (3.05) and −0.59% (0.65), respectively. Annualised PBVC was >0.4% loss in 55.88% of subjects using SIENA, 56.86% using SIENAX and 57.84% using MSmetrix-long. There was a strong correlation (Pearson’s r) between SIENA and MSmetrix-long derived measures of annualised PBVC; 0.805 (p<0.001). Correlations between SIENAX and the other methods were weaker; 0.313 compared with SIENA, and 0.264 compared with MSmetrix-long (p<0.01). Conclusions WBA measurements derived using the fully automated MSmetrix-long correlated strongly with the results using SIENA, however, measurements using SIENAX correlated weakly. Longitudinal registration-based techniques hold promise for use in MS clinical practice but are currently not validated at the individual patient level. Fully automated, easy-to-use platforms are likely to accelerate translation from the research setting into routine MS care, and subsequently warrant further investigation. Segmentation-based methods currently have measurement error rates that render them suboptimal for use in longitudinal assessment, especially at the individual level. Technical improvements and the development of reference populations may result in these techniques having a place in future MS patient care.

Wallerian Degeneration in the Corticospinal Tract Following Tumefactive Demyelination: Conventional and Advanced Magnetic Resonance Imaging.

A 24-year-old man with no prior medical history or neurological symptoms presented with the subacute onset of dysarthria and mild right-sided weakness involving the face, arm, and leg. On examination, the only abnormalities were a right upper motor neurone facial droop and mild right pyramidal weakness. 3-Tesla magnetic resonance imaging (MRI) of the brain revealed a large, isolated, nonenhancing, peripherally diffusion-restricted T2 hyperintense lesion in the left frontal lobe with minimal edema and mass effect; and a T2 hypointense rim, typical of a tumefactive demyelinating lesion (TDL) (Figure 1A,B). MRI of the whole spine was normal. Oligoclonal bands in the cerebrospinal fluid were positive and visual evoked potentials were mildly prolonged bilaterally, consistent with demyelination. Serum aquaporin− 4 antibody was negative. He was treated with intravenous methylprednisolone 1 g daily for 5 days, followed by interferon beta− 1a. His neurological deficits improved to normal over several months. Repeat imaging 2 years later showed involution of the TDL, with MRI changes in the left corticospinal tract (CST) consistent with Wallerian degeneration (WD) (Figure 1C). Application of diffusion tensor imaging (DTI) using probabilistic tractography (Figure 1D,E) showed higher axial diffusivity (AD; 1.26 vs 1.07 μm/ms) and radial diffusivity (RD; 0.75 vs 0.59 μm/ms) in the affected CST compared with the normal-appearing contralateral side. Moderate increases of AD (1.23 vs 1.16 μm/ms) and RD (0.58 vs 0.52 μm/ms) were observed in the tract proximal to the lesion, whereas higher AD (1.40 vs 1.34 μm/ms) but similar RD (0.45 vs 0.46 μm/ms) was measured in the CST distal to the lesion. Four years later, the patient has no neurological symptoms and remains clinically and radiologically stable.