MS Abstracts 03a-2g7

Tryptophan and its metabolites are of great interest in understanding the pathogenesis of Multiple Sclerosis (MS).

The total levels of Tryptophan and its metabolites, Kynurenine and Kynurenic Acid were determined in plasma by Capillary Liquid Chromatography Electrospray Ionisation Tandem Mass Spectrometry.

This is the first report of the plasma levels of these analytes in healthy controls and Relapsing/Remitting MS patients receiving long-term and acute Interferon-beta (IFN-ß) treatment.

Twenty-four hours post-administration increased Kynurenine levels (first IFN MS versus healthy, P = 0.042) and Kynurenine/Tryptophan ratio (K/T; first IFN MS versus healthy, P =0.027; first IFN MS versus long-term IFN MS, P = 0.036) were found.

The long-term IFN MS group had higher K/T ratios at 4 and 12 h post-administration (P = 0.015 and 0.009, respectively).

The increase of K/T ratio in the first IFN MS group indicate an induction of the enzyme Indolamine-2,3-Dioxygenase (IDO), as reported earlier in Experimental Allergic Encephalomyelitis.

As IDO is participating in both inflammatory and NeuroDegenerative processes, further knowledge of its involvement in the pathogenesis of MS is of great importance.

The aims of this study were to improve, using a 3.0 Tesla (T) scanner and Diffusion Tensor (DT) Magnetic Resonance Imaging (MRI) with sensitivity encoding, our understanding of:

1) the possible pathological substrates of Normal-Appearing White Matter (NAWM) and Gray Matter (GM) damage in Multiple Sclerosis (MS) and

2) the factors associated to WM and GM Atrophy in this condition.

Conventional and DT MRI of the Brain were acquired from 32 Relapsing/Remitting (RR) MS patients and 16 controls.

Lesion load, WM (WMV), overall GM (GMV), and NeoCortical GM (NCV) Volumes were measured. NAWM Mean Diffusivity (MD) and Fractional Anisotropy (FA), and GM MD were calculated.

GMV and NCV were lower (p < /= 0.001) in MS patients than controls, whereas WMV did not differ significantly. MS patients had higher NAWM and GM average MD and lower NAWM average FA (p < /= 0.001) than controls.

Moderate correlations were found between intrinsic lesion and tissue damage with both GM Volumetric and Diffusivity changes ()0.41 < /= r < /= 0.42, p < /= 0.04).

DT MRI and Volumetry measurements at 3.0 T confirm the presence of NAWM and GM abnormalities in RRMS patients.

Although histopathology was not available, Axonal and Neuronal Damage and consequent reactive Glial proliferation are the most likely substrates of the changes observed.

Working Memory Impairment is frequently observed in patients with early Multiple Sclerosis (MS).

MRI and functional MRI studies have shown that Working Memory Impairment is mostly due to diffuse White Matter (WM) damage affecting the connectivity between distant Cortical areas.

However, Working Memory Deficits in early MS patients can be either completely or partly masked by compensatory functional plasticity.

It seems likely that concomitantly with the WM bundle injury resulting from pathological processes, the functional plasticity present in early MS patients may be accompanied by reactive structural WM plasticity.

This structural plasticity may effectively compensate for connectivity disturbances and/or contribute to functional Brain reorganization.

The Diffusion characteristics of WM bundles involved in Working Memory were assessed here by performing quantitative Diffusion Tensor Imaging (DTI) Tractography on 24 patients with early Relapsing/Remitting MS and 15 healthy control subjects.

The DTI Tractography findings showed that WM connections constituting the Executive System of Working Memory were structurally impaired (the Fractional Anisotropy was lower than normal and the Mean Diffusivity, higher than normal).

A significantly larger number of connections between the Left and Right Thalami was concurrently observed in the MS patients than in the control subjects, which suggests that the WM is endowed with reactive structural plasticity.

Vagus Nerve Stimulation (VNS), an adjunctive approach for the treatment of Epilepsy, was performed in three Multiple Sclerosis (MS) patients displaying Postural Cerebellar Tremor (PCT) and Dysphagia.

Following VNS, improvement of PCT and Dysphagia was manifested over a period of two and three months, respectively.

In view of the involvement of the main BrainStem Visceral component of the Vagus, the Nucleus Tractus Solitarius (NTS), in modulating Central Pattern Generators (CPGs) linked to both Olive Complex Pathway and swallowing, improvement is likely to be VNS related.

The results obtained suggest an additional therapeutic application for VNS and may represent a novel form of treatment in patients with severe MS.

Multiple Sclerosis 2007; 13: 000-000. http://msj.sagepub.com.

The primary goal of this study was to investigate associations between regional Gray Matter (GM) Atrophy and NeuroPsychological function in Multiple Sclerosis (MS), while accounting for the influence of Central Brain Atrophy (i.e. Third Ventricular Enlargement).

Using a cross-sectional design, we studied 59 MS patients with Brain MRI and NeuroPsychological testing.

Regional Gray Matter Fractions (rGMFs) were calculated from MRI images for 11 homologous Brain areas using the SemiAutomatic Brain Region Extraction (SABRE) technique.

NeuroPsychological testing followed consensus panel guidelines and included tests emphasizing Episodic Memory, Working Memory and Processing Speed.

The analytic approach was stepwise linear regression, with forward selection and p< 0.05 threshold for significance.

Consistent with previous research, there were significant correlations between Third Ventricle Width and NeuroPsychological tests.

Stepwise linear regression analyses controlling for Third Ventricle Width retained rGMFs obtained from specific regions within the PreFrontal Cortex.

Left Frontal Atrophy was associated with tests emphasizing Auditory/Verbal Memory.

Right Frontal Atrophy was associated with impairment in Visual Episodic and Working Memory.

For the first time, we show an independent relationship between Cortical Atrophy and Cognitive Impairment after accounting for the effects of Central Atrophy.

The purpose of this study was to:
1. Identify the optimal TE for FLAIR-imaging at 3.0 T assessing three different echo times qualitatively and quantitatively and
2. Evaluate the diagnostic efficacy of high-field 3.0-T FLAIR imaging in comparison to conventional 1.5-T MRI in patients with Multiple Sclerosis (MS)

Twenty-two patients with clinically definite MS underwent axial FLAIR imaging at 1.5 and 3.0 T. In 15 of these patients further FLAIR images with a TE of 100, 120 and 140 ms were acquired at 3.0 T.

Imaging protocols were modified for 3.0 T using the increased Signal-Noise-Ratio (SNR) to acquire more and thinner slices while maintaining a comparable scan time.

FLAIR images of either different TEs or different field strengths were ranked for each patient qualitatively by two observers.

Signal intensity measurements were obtained in the Gray and White Matter, CSF and representative White Matter Lesions (WML).

At 3.0 T, a TE of 100 and 120 ms proved superior in all qualitative categories when compared to 140 ms.

In the quantitative assessment CNR of WML was highest for 120 ms (CNR: 19.8), intermediate for 100 ms (17.2) and lowest for 140 ms (15.3) (P < 0.003).

For lesion conspicuity and overall image quality, 3.0 T was judged superior to 1.5 T, whereas no difference was found for Gray-White differentiation and image noise.

With regard to artifacts, 3.0 T was inferior to 1.5 T. The CNR for WML was slightly lower at 3.0 T, but the difference was not significant (22.6 vs. 28.0, P=ns).

However, significantly more WML were detected at 3.0 T than at 1.5 T (483 vs. 341, P < 0.0001). The optimal echo time for FLAIR imaging at 3.0 T is 120 ms due to the significantly higher CNR of WML.

By trading the higher SNR at 3.0 T for better spatial resolution, nearly the same CNR level could be maintained, increasing lesion detectability at 3.0 T compared to 1.5 T.

Thus, high-field MRI may further strengthen the role of MRI as the most sensitive paraclinical test for the early diagnosis of MS.

Background
Multiple Sclerosis has a clinically significant heritable component. We conducted a genomewide association study to identify alleles associated with the risk of Multiple Sclerosis.

Methods
We used DNA microarray technology to identify common DNA sequence variants in 931 family trios (consisting of an affected child and both parents) and tested them for association.

For replication, we genotyped another 609 family trios, 2322 case subjects, and 789 control subjects and used genotyping data from two external control data sets.

A joint analysis of data from 12,360 subjects was performed to estimate the overall significance and effect size of associations between alleles and the risk of Multiple Sclerosis.

Results
A transmission disequilibrium test of 334,923 Single-Nucleotide Polymorphisms (SNPs) in 931 family trios revealed 49 SNPs having an association with Multiple Sclerosis (P < 1x10(-4)); of these SNPs, 38 were selected for the second-stage analysis.

A comparison between the 931 case subjects from the family trios and 2431 control subjects identified an additional nonoverlapping 32 SNPs (P < 0.001).

An additional 40 SNPs with less stringent P values ( < 0.01) were also selected, for a total of 110 SNPs for the second-stage analysis.

Of these SNPs, two within the InterLeukin-2 Receptor alpha gene (IL-2RA) were strongly associated with Multiple Sclerosis (P=2.96x10(-8)).

As were a nonsynonymous SNP in the InterLeukin-7 Receptor alpha gene (IL-7RA) (P=2.94x10(-7)) and multiple SNPs in the HLA-DRA locus (P=8.94x10(-81)).

Conclusions
Alleles of IL-2RA and IL-7RA and those in the HLA locus are identified as heritable risk factors for Multiple Sclerosis.

Copyright 2007 Massachusetts Medical Society.

We report that N-Acetyl-L-Cysteine (NAC) treatment blocked induction of TNF-, IL-1ß, IFN-γ and iNOS in the CNS and attenuated clinical disease in the Myelin Basic Protein induced model of Experimental Allergic Encephalomyelitis (EAE) in Lewis rats.

Infiltration of MonoNuclear Cells into the CNS and induction of Inflammatory Cytokines and INOS in Multiple Sclerosis (MS) and EAE have been implicated in subsequent disease progression and pathogenesis.

To understand the mechanism of efficacy of NAC against EAE, we examined its effect on the production of Cytokines and the infiltration of inflammatory cells into the CNS.

NAC treatment attenuated the transmigration of MonoNuclear Cells thereby lessening the NeuroInflammatory Disease.

Splenocytes from NAC-treated EAE animals showed reduced IFN-γ production, a Th1 Cytokine and increased IL-10 production, an AntiInflammatory Cytokine.

Further, Splenocytes from NAC-treated EAE animals also showed decreased Nitrite production when stimulated in vitro by LPS.

These observations indicate that NAC treatment may be of therapeutic value in MS against the inflammatory disease process associated with the infiltration of activated MonoNuclear Cells into the CNS.

Purpose
To retrospectively document HyperIntense lesions on nonenhanced T₁-weighted Magnetic Resonance (MR) images in patients with Multiple Sclerosis (MS) and study their relationship to physical disability, disease course, and other MR markers of tissue damage (Brain Atrophy).

Materials and Methods
Institutional review board approval was obtained; informed consent was waived for this HIPAA-compliant study, with 145 patients with MS (mean age, 43 years).

Patients had Relapsing/Remitting (RR) (n = 92) or Secondary/Progressive (S/P) (n = 49) MS; clinical course was unknown in four. Mean Expanded Disability Status Scale (EDSS) score was 3.5.

T₁ lesions were compared with normal White Matter on nonenhanced images and judged HyperIntense.

Spearman rank correlation, Wilcoxon rank sum, and Fisher exact probability tests and analysis of variance and analysis of covariance (ANCOVA) were employed.

Results
At least one T₁ HyperIntense lesion was found in 113 patients (total, 340 lesions).

Two-thirds of lesions had HyperIntense rim; others were uniformly HyperIntense.

Lesions were more common in patients with SP MS (P = .003, Wilcoxon test) and correlated with EDSS score (Spearman rho = 0.19, P = .04) and Brain Atrophy measures (total Cortical Atrophy, Spearman rho = 0.42, P < .001;

Third Ventricular Width, Spearman rho = 0.40, P < .001) but not disease duration (Spearman rho = 0.038, P = .69).

Lesions were more likely multiple in the SP versus RR group (P < .001, Fisher test). After adjustment for disease course, T₁ Hyperintense lesions remained associated with Brain Atrophy (P < /= .001, ANCOVA).

No independent effect of imager type (ANCOVA F value = 1.4, P = .24) or Spin-Echo method (P = .67, Wilcoxon test) on number of lesions was detected.

An effect of other MR protocol adjustments (analysis of variance F value = 5.6, P = .001) was unconfirmed after clinical characteristic adjustment (ANCOVA F value = 1.1, P = .35).

Conclusion
HyperIntense MS plaques on T₁-weighted MR images are common and associated with Brain Atrophy, disability, and advancing disease; a HyperIntense lesion may be a clinically relevant biomarker.

(c) RSNA, 2007.

Background
Several controlled studies provide evidence that treatment with Interferon-beta in patients with a first event suggestive of Multiple Sclerosis (MS) delays conversion to Clinically Definite MS (CDMS).

Our aim was to determine whether early initiation of treatment with Interferon-ß prevents development of confirmed disability in MS.

Methods
In the initial placebo-controlled phase of the double-blinded BENEFIT study, patients with a first event suggestive of MS.

And a minimum of two clinically silent lesions in MRI were randomized to receive either Interferon-ß-1b 250 microg (n=292) or placebo (n=176) subcutaneously every other day for 2 years, or until diagnosis of CDMS.

Patients were then eligible to enter the follow-up phase with open-label Interferon-ß-1b.

In the current prospectively planned analysis 3 years after randomization, the effects of early Interferon-ß-1b treatment were compared with those of delayed treatment initiated after diagnosis of CDMS or after 2 years on the study.

The primary outcomes of this ITT analysis were time to diagnosis of CDMS, time to confirmed Expanded Disability Status Scale (EDSS) progression, and score on a patient-reported functional assessment scale (FAMS-TOI).

This trial is registered with:
ClinicalTrials.gov, number NCT00185211.

Findings
Of the 468 patients originally randomized, 418 (89%) entered the follow-up phase; 392 (84%) completed 3 years' post-randomization follow-up.

After 3 years, 99 (37%) patients in the early group developed CDMS compared with 85 (51%) patients in the delayed treatment group.

Early treatment reduced the risk of CDMS by 41% (hazard ratio 0.59, 95% CI 0.44-0.80; p=0.0011; absolute risk reduction 14%) compared with delayed treatment.

Over 3 years, 42 (16%) patients in the early group and 40 (24%) in the delayed group had confirmed EDSS progression; early treatment reduced the risk for progression of disability by 40% compared with delayed treatment (0.60, 0.39-0.92; p=0.022.

Absolute risk reduction 8%). The FAMS-TOI score was high and stable in both groups over the 3-year period (p=0.31).

Interpretation
Our data suggest that early initiation of treatment with Interferon-ß-1b prevents the development of confirmed disability, supporting its use after the first manifestation of Relapsing/Remitting MS.

Objectives
To define the extent of overall Brain Damage in patients with Clinically Isolated Syndromes (CIS) suggestive of Multiple Sclerosis (MS) and to identify non-conventional Magnetic Resonance (MR) metrics predictive of evolution to definite MS.

Methods
Brain conventional and Magnetization Transfer (MT) MRI scans were obtained from 208 CIS patients and 55 matched healthy controls, recruited in four centers.

Patients were assessed clinically at the time of MRI acquisition and after a median period of 3.1 years from disease onset. The following measures were derived:

T₂, T₁ and gadolinium (Gd)- enhancing Lesion Volumes (LV), Normalized Brain Volume (NBV), MTR Histogram-derived quantities of the Normal-Appearing White Matter (NAWM) and Gray Matter (GM).

Results
During the follow-up, 43 % of the patients converted to definite MS. At baseline, a significant inter-center heterogeneity was detected for T₂ LV (p = 0.003), T₁ LV (p = 0.006), NBV (p < 0.001) and MTR Histogram-derived metrics (p < 0.001).

Pooled average MTR values differed between CIS patients and controls for NAWM (p = 0.003) and GM (p = 0.01).

Gd activity and positivity of International Panel (IP) criteria for disease Dissemination In Space (DIS), but not NAWM and GM MTR and NBV, were associated with evolution to definite MS.

The final multivariable model retained only MRI IP criteria for DIS (p = 0.05; HR = 1.66, 95 % CI = 1.00-2.77) as an independent predictor of evolution to definite MS.

Conclusions
Although irreversible tissue injury is present from the earliest clinical stages of MS, macroscopic focal lesions but not "diffuse" Brain damage measured by MTR are associated to an increased risk of subsequent development of definite MS in CIS patients.