MS Abstracts 02a-2g7

Previous studies using Magnetization Transfer Ratio (MTR) Histogram analysis have demonstrated the existence of global Gray Matter (GM) abnormalities in patients with early Relapsing/Remitting Multiple Sclerosis (RRMS).

However, MTR histogram analysis does not provide any information on the localization of the morphological changes within the GM. The aim of this study was to investigate the localization of GM injury in early RRMS, performing voxel-based analysis of GM MTR maps.

Statistical mapping analysis of GM MTR maps was performed in a group of 38 patients with early RRMS and 45 healthy controls.

Between-group comparisons (P < 0.05, corrected for multiple comparisons) demonstrated significant GM MTR decrease in patients located in the Bilateral Lenticular Nuclei, the Bilateral Insula, the Left Posterior Cingulate Cortex, and the Right OrbitoFrontal Cortex.

To limit the potential confounding effect of Regional GM Atrophy, the percentages of GM were assessed in the regions showing significant MTR decrease, and no GM Atrophy was evidenced in these regions.

This study demonstrates that several GM regions are commonly affected in patients with early RRMS.

Predominant involvement of these structures may be partly related to their vulnerability to Anterograde or Retrograde Degeneration from transected Axons in the White Matter and/or to the predominant localization of GM DeMyelinating lesions in such regions.

Spasticity is a common and often disabling symptom associated with Multiple Sclerosis (MS).

Transcutaneous Electrical Nerve Stimulation (TENS) has been found effective in reducing Spasticity in conditions such as Stroke, but there is little evidence to support its use in MS.

The aim of this study was to evaluate the effectiveness of TENS on Spasticity in MS and, furthermore, to compare two different application times.

Thirty-two subjects were randomized into two groups, and a single, blind, crossover design was used to compare two weeks of 60 minutes and 8 hours daily of TENS applications (100 Hz and 0.125 ms pulse width).

Outcomes were examined using the Global Spasticity Score (GSS), the Penn Spasm Score (PSS), and a Visual Analogue Scale (VAS) for Pain.

The results of the study demonstrated that there were no statistically significant differences in the GSS following either 60 minutes or 8 hours daily of TENS (P=0.433 and 0.217, respectively).

The 8-hour application time led to a significant reduction in muscle Spasm (P=0.038) and Pain (P = 0.008).

Thus, this study suggests that, while TENS does not appear to be effective in reducing Spasticity, longer applications may be useful in treating MS patients with Pain and muscle Spasm.

Although spontaneous ReMyelination does occur in Multiple Sclerosis lesions, its extent within the global population with this disease is presently unknown.

We have systematically analyzed the incidence and distribution of completely ReMyelinated lesions (so-called shadow plaques) or partially ReMyelinated lesions (shadow plaque areas) in 51 autopsies of patients with different clinical courses and disease durations.

The extent of ReMyelination was variable between cases. In 20% of the patients, the extent of ReMyelination was extensive with 60-96% of the global lesion area ReMyelinated.

Extensive ReMyelination was found not only in patients with Relapsing Multiple Sclerosis, but also in a subset of patients with Progressive disease.

Older age at death and longer disease duration were associated with significantly more ReMyelinated lesions or lesion areas.

No correlation was found between the extent of ReMyelination and either gender or age at disease onset.

These results suggest that the variable and patient-dependent extent of ReMyelination must be considered in the design of future clinical trials aimed at promoting CNS repair.

In Multiple Sclerosis (MS), Oligodendrocyte and Myelin destruction lead to DeMyelination with subsequent Axonal Loss.

Experimental DeMyelination in rodents has highlighted the activation of the SubVentricular Zone (SVZ) and the involvement of Progenitor Cells expressing the polysialylated form of Neural Cell Adhesion Molecule (PSA-NCAM) in the repair process.

In this article, we studied the distribution of early PSA-NCAM⁺ Progenitors in the SVZ and MS lesions in human postmortem Brains.

Compared with controls, MS SVZ showed a 2- to 3-fold increase in cell density and proliferation, which correlated with enhanced numbers of PSA-NCAM⁺ and Glial Fibrillary Acidic Protein-positive (GFAP⁺) cells.

PSA-NCAM⁺ Progenitors mainly were Sox9⁺, and a few expressed Sox10 and Olig2, markers of Oligodendroglial specification.

PSA-NCAM⁺ Progenitors expressing Sox10 and Olig2 also were detected in DeMyelinated MS lesions.

In active and chronic active lesions, the number of PSA-NCAM⁺ Progenitors was 8-fold higher compared with chronic silent lesions, shadow plaques, and Normal-Appearing White Matter.

In active and chronic active lesions, PSA-NCAM⁺ Progenitors were more frequent in PeriVentricular lesions (30-50%) than in lesions remote from the Ventricular wall.

These data indicate that, as in rodents, activation of GlioGenesis in the SVZ occurs in MS and suggest the mobilization of SVZ-derived early Glial Progenitors to PeriVentricular lesions, where they could give rise to Oligodendrocyte Precursors.

These early Glial progenitors could be a potential target for therapeutic strategies designed to promote Myelin repair in MS.

Diffusion MRI and Magnetic Resonance Spectroscopic measurements of selectively Neuronally localized N-AcetylAspartate (NAA) both have been used widely to assess White Matter integrity and Axonal Loss.

We have tested directly the relationship between changes in Diffusion MRI parameters and NAA concentrations in the Corpus Callosum (CC) in an in vivo study of patients with MS.

Fifteen MS patients (median EDSS 2.5, range 1-4) were studied with T₁ anatomical, T₂-weighted, and Diffusion-sensitised MRI and PRESS single-voxel MRS.

A recently described method, Tract-Based Spatial Statistics (TBSS) [Smith, S.M., Jenkinson, M., Johansen-Berg, H., Rueckert, D., Nichols, T.E., Mackay, C.E. et al., 2006.

Tract-based spatial statistics: voxel wise analysis of multi-subject Diffusion data. NeuroImage 31, 1487-1505] also was used to perform exploratory Voxel wise Whole-Brain analysis of White Matter Diffusion Fractional Anisotropy (FA).

We found a strong correlation between Callosal size and both mean FA (r=0.68, p < 0.005) (related specifically to changes in the radial tensor component) and mean Inter-Hemispheric Motor Tract connectivity probability (r=0.74, p < 0.001).

TBSS confirmed that the Diffusion Anisotropies of White Matter voxels specifically within the Callosum were correlated with the Callosal size.

Individual patient global T₂ lesion volumes were correlated with both the probability of Callosal connectivity (r=-0.69, p < 0.005) and Fractional Anisotropy across the Callosum (r=-0.76, p < 0.001).

However, absolute concentrations of NAA from the voxel showed no correlation with Callosal cross-sectional area, mean connectivity or Fractional Anisotropy within the Callosal Pathway.

We conclude that diffusion MRI shows changes consistent with sensitivity to Axonal Loss, but that relative NAA changes are not necessarily related directly to this.

Axonal metabolic function, independent of structural integrity, may be a major determinant of NAA measures in MS.

Axonal loss is thought to be the predominant cause of disability in Progressive Multiple Sclerosis (MS).

The Retinal Nerve Fiber Layer (RNFL) is composed largely of UnMyelinated Axons of Retinal Ganglion Cells, and is accessible to study with Optical Coherence Tomography (OCT), giving a measure of Axonal loss.

OCT measures of the RNFL thickness (RNFLT) and Macular volume were studied in 23 patients with Primary/Progressive Multiple Sclerosis (Primary/Progressive MS) (13 male; 10 female; mean age 52 years; median EDSS 6.0; mean disease duration 11 years).

And 27 patients with Secondary/Progressive Multiple Sclerosis (Secondary/Progressive MS) (8 male; 19 female; mean age 50 years; median EDSS 6; mean disease duration 22 years).

Of the patients with Secondary/Progressive MS, 14 had clinical history of Optic Neuritis (ON) in a single eye; the remaining patients had not had ON.

Twenty healthy controls (11 male; 9 female; mean age 46 years) had RNFLT and Macular volume studied.

Of the patients' eyes not previously affected by ON, both the mean RNFL thickness and Macular volume were reduced when compared with control values.

The mean RNFL thickness and Macular volume were significantly reduced in Secondary/Progressive MS, but not in Primary/Progressive MS when compared with control RNFL thickness and Macular volume.

RNFL loss was most evident in the Temporal quadrant, where significant reduction was seen in Primary/Progressive MS versus controls and in Secondary versus Primary/Progressive MS.

There were significant correlations of decreased RNFLT and Macular volume with measures of Visual Acuity, low contrast Visual Acuity and Visual Field mean deviation in the MS patients.

There are significant global reductions in RNFLT and Macular volume in the eyes of Secondary/Progressive MS patients not previously affected by ON, but not in Primary/Progressive MS patients, compared with controls.

This may indicate a difference in the extent of the pathological processes that cause Axonal Loss in the Retina, and by inference the Optic Nerve, in Secondary/Progressive MS and Primary/Progressive MS.

Objective
To evaluate the efficacy, safety, and tolerability of combination therapy with intramuscular Interferon-beta-1a and oral Doxycycline.

A potent inhibitor of Matrix MetalloProteinases, in patients with Relapsing-/Remitting Multiple Sclerosis (RRMS) having breakthrough disease activity.

Design & Setting
Open-label, 7-month trial. Louisiana State University Health Sciences Center, Shreveport.

Patients Fifteen patients with RRMS taking Interferon-ß-1a with breakthrough disease activity took Doxycycline for 4 months.

Patients underwent monthly Neurologic Examination, Magnetic Resonance Imaging of the Brain using triple-dose Gadolinium, and safety blood work.

Interventions
Ongoing treatment with intramuscular Interferon-ß-1a plus oral Doxycycline, 100 mg daily, for 4 months.

Main Outcome Measures
The primary end point was Gadolinium-enhancing lesion number change, and the secondary end points were relapse rates.

Safety and tolerability of the combination of Interferon-ß-1a and Doxycycline in patients with MS, Expanded Disability Status Scale score, Serum Matrix MetalloProteinase-9 levels, and TransEndothelial migration of Monocytes exposed to Serum from patients with RRMS.

Results
Combination of Doxycycline and Interferon-ß-1a treatment resulted in reductions in contrast-enhancing lesion numbers and posttreatment Expanded Disability Status Scale values (P < .001 for both).

Only 1 patient relapsed. Multivariate analyses indicated correlations between decreased Serum Matrix MetalloProteinase-9 levels and enhancing lesion activity reduction.

TransEndothelial migration of Monocytes incubated with Serum from patients with RRMS undergoing combination therapy was suppressed.

Adverse effects were mild; no adverse synergistic effects of combination therapy or unexpected adverse events were reported.

Conclusions
Combination of intramuscular Interferon-ß-1a and oral Doxycycline treatment was effective, safe, and well tolerated.

Controlled clinical trials in larger cohorts of patients with MS are needed to evaluate the efficacy and tolerability of this combination.

Trial Registration clinical trials.gov Identifier: NCT00246324Published online December 10, 2007 (doi:10.1001/archneurol.2007.41).

Therapy with Interferon-beta (IFN-ß) has well-established clinical effects in Multiple Sclerosis (MS), albeit the ImmunoModulatory mechanisms are not fully understood.

We assessed the prevalence and functional capacity of CD4⁺ and CD8⁺ T-Cells in healthy donors, and in untreated and IFN-ß-treated MS patients, in response to Myelin Oligodendrocyte Glycoprotein (MOG).

The proportion of CD45RO⁺ Memory T-Cells was higher in MS patients than in healthy donors, but returned to normal values upon therapy with IFN-ß.

While CD45RO⁺ CD4⁺ T-Cells from all three groups responded to MOG in vitro.

Untreated patients showed augmented proliferative responses compared to healthy individuals and IFN-ß treatment reduced this elevated reactivity back to the values observed in healthy donors.

Similarly, the response of CD45RO⁺ CD8⁺ T-Cells to MOG was strongest in untreated patients and decreased to normal values upon ImmunoTherapy.

Overall, the frequency of peripheral CD45RO⁺ Memory T-Cells ex vivo correlated with the strength of the Cellular in vitro response to MOG in untreated patients but not in healthy donors or IFN-ß-treated patients.

Compared with healthy individuals, responding CD4⁺ and CD8⁺ cells were skewed towards a Type 1 Cytokine phenotype in untreated patients, but towards a Type 2 phenotype under IFN-ß therapy.

Our data suggest that the beneficial effect of IFN-ß in MS might be the result of the suppression or depletion of AutoReactive, pro-inflammatory Memory T-Cells in the periphery.

Assessment of T-Cell subsets and their reactivity to MOG may represent an important diagnostic tool for monitoring successful ImmunoTherapy in MS.

Background And Purpose
Our aim was to evaluate the hypothesis that water Diffusion alterations are present in Normal-Appearing White Matter of patients with Relapsing/Remitting Multiple Sclerosis (RRMS) and to assess their change with time.

Materials And Methods
Fifty-four subjects with clinically diagnosed RRMS, with disease duration of less than 12 months and an Expanded Disability Status Scale (EDSS) score of < 3.5, underwent a Diffusion 3T MR imaging study.

The Apparent Diffusion Coefficient (ADC) maps generated were compared with those of 18 control subjects.

Eighteen of the 54 patients underwent MR imaging assessment at 3 and 6 months after baseline evaluation. Remitting patients were clinically and MR imaging stable for the 2 months before the study.

All patients were drug-free for the 3 months before the study, and in the relapsing patients, the MR imaging was always performed before beginning treatment.

Results
Mean ADC values showed significant differences when Relapsing, Remitting, and control patients were compared.

The Relapsing or Remitting phase showed significant difference when compared both with controls (P < .01) and between them (P < .05).

Comparing mean ADC values of patients with clinical disability (EDSS < 2 versus EDSS >/=2) also provided significant differences with the control group (P < .01).

The data of patients showing a Relapsing episode during the longitudinal part of the study showed a significant difference compared with data from their Remitting phase (P < .01).

Conclusion
Brain MicroStructural changes can be detected and correlate with clinical impairment during the stages of MS. These changes modify with time in the Relapsing group.

Multiple Sclerosis is an Immune-mediated disorder of the Central Nervous System. Major pathological characteristics include the loss of Oligodendrocytes, DeMyelination and NeuroAxonal depletion in association with inflammation.

The complex pathophysiology of Tissue Loss is only partially understood.

Here we discuss a variety of Mitochondrion-driven mechanisms involved in Immune regulation, Oligodendrocyte depletion and NeuroDegeneration.

The recognition of a Mitochondrial link between inflammation and NeuroDegeneration underscores the importance of an early aggressive intervention for halting inflammation.

And, preventing NeuroDegeneration, and identifies the Mitochondrion as a potential target in NeuroProtection.

NeuroDegeneration is the main pathological correlate of accumulating disability in Progressive stages of Multiple Sclerosis (MS), but both histologic and imaging studies detect significant tissue loss even in early disease.

These observations raise the question as to whether NeuroDegeneration in MS is a primary mechanism or whether it develops secondary to inflammation and DeMyelination.

Recent data suggest that the Atrophy of Brain and Cord is directly linked to inflammation and may partly be independent of DeMyelination.

Released products of both residential and infiltrating Immune Cells can induce UltraStructural changes and cell death by multiple mechanism.

We propose that the inflammation-induced tissue response is controlled by genetic variations and to some extent involves a Mitochondrion-driven mechanism in MS, similar to that described in the final pathway of other NeuroDegenerative Disorders.

Current therapeutic strategies primarily target the Immune System which results in a successful down-regulation of plaque formation and of relapse rate.

However, measures of clinical disability best correlate with the degree of NeuroDegeneration rather than with the volume of plaques, and these Immune-modulating regimens may only incompletely affect the accumulating Tissue Loss.

Considering the need for additional therapeutic strategies, we emphasize the degenerative components, and review a Mitochondrial mechanism of tissue loss potentially involved in the process of MS.

A number of recent Magnetic Resonance Imaging studies have challenged the classical view of Multiple Sclerosis (MS) as a "two-stage" disease.

Where an early inflammatory DeMyelinating phase with focal macroscopic lesions formed in the White Matter (WM) of the Central Nervous System is followed by a late NeuroDegenerative phase.

Which is believed to be a mere consequence of repeated Inflammatory insults and irreversible DeMyelination.

These studies have consistently shown the presence of diffuse Normal-Appearing WM damage, marked Gray Matter involvement and significant Cortical functional reorganization.

As well as the occurrence of the NeuroDegenerative component of MS from the earliest clinical stages of the disease with only a partial relation to MRI markers of inflammatory DeMyelination.

The present review argues that MS can no longer be viewed as a "two-stage" disease, which suggests that the two pathological components are dissociated in time, but rather as a "simultaneous two-component" disease.

Where the relative contributions of the various pathological processes of the disease to the development of "fixed" disability, their relationship and their evolution over time need to be clarified.

This new view of MS should inform the development of future research protocols to define its actual physiopathology and prompt the institution of early treatment.

Which should ideally target not only inflammatory DeMyelination, but also the NeuroDegenerative aspects of the disease.

As well as promote NeuroProtection and enhance reparative mechanisms and adaptive functional reorganization of the Cortex.