MS Abstracts 04a-2g6

Multiple Sclerosis (MS) is thought to predominantly affect White Matter (WM).

Recently, however, loss of Cortical Gray Matter has also been described.

Little is known about the cause of Cortical Atrophy in MS, whether it occurs early in the disease course, and whether it affects all Cortical regions equally.

Or, if there is a preferential pattern of focal Cortical Atrophy.

An automated method was used to compute the thickness at every vertex of the Cortical surface of the Brains of 425 early Relapsing/Remitting MS patients.

We correlated Cortical thickness with the WM lesion load and the Expanded Disability Status Scale score. Mean Cortical thickness correlated with WM lesion load and disability.

The correlations of Cortical thickness with total lesion load and disability were most significant in Cingulate Gyrus, Insula, and Associative Cortical regions.

Conversely, primary Sensory, Visual, and Motor Areas showed a less significant relationship. The highest amount of Atrophy per lesion volume or disability scale unit was in the Anterior Cingulate Cortex.

This study confirms the relation between Cortical Atrophy, WM lesion load, and disability in MS, and suggests that Cortical Atrophy occurs even in MS patients with only mild disability.

Most interestingly, we show a specific regional pattern of focal Atrophy in MS that is distinctively different from the one in normal aging.

The predilection of the Atrophic process for areas that are heavily inter-connected with other Brain regions.

Suggests that interruption of WM tracts by MS plaques contributes, at least in part, to the development of Cortical Atrophy.

Objective
To assess Whole Brain and Central Brain Atrophy as well as their differential relation to Memory, Cognitive performance, Fatigue, Depression and quality of life in patients with Relapsing/Remitting Multiple Sclerosis (RRMS).

Methods
A 3D flow compensated gradient recalled T₁-weighted MRI was acquired in 45 RRMS patients.

An automated analysis tool was used to calculate Brain Parenchymal Fraction (BPF) and Ventricular Brain Fraction (VF).

All patients were assessed with NeuroPsychological tests focusing on Memory and self-rating scales for Depression, Fatigue and quality of life.

Age corrected partial correlations between Brain Atrophy, motor performance, Psychological scales and test scores were calculated.

Results
BPF correlated moderately (0.3 < or = r < 0.5) with duration of symptoms and disease, the Expanded Disability Status Scale (EDSS), the upper extremity motor performance, and with mental aspects of quality of life.

VF correlated moderately with EDSS, upper and lower extremity motor performance and Memory functions.

Neither BPF nor VF correlated with Fatigue and Depression.

Results of several Cognitive tests correlated moderately with Depression and Fatigue, the Paced Auditory Serial Addition Test (PASAT) showing the largest correlation.

Conclusions
Memory performance shows a correlation with relative Ventricular size in RRMS patients.

Indicating the strategic location of the Ventricle system, along the structures of the Limbic System and its vulnerability in MS.

The PASAT and several other Cognitive tests show moderate correlations with Depression and Fatigue, arguing for an inter relation between the Cognitive functioning and the emotional state of patients.

However, this relation is independent of measurable Brain Atrophy.

The precise mechanisms leading to CNS Inflammation and Myelin destruction in both Multiple Sclerosis (MS) and Experimental Autoimmune Encephalomyelitis (EAE) remain the subject of intense debate.

In both MS and EAE, AutoAntibodies (AutoAbs) are thought to be involved in tissue destruction.

Through recruiting Fc Receptor (FcR)-bearing cells or direct cytotoxic effects through the activation of the Complement Pathway.

Whereas Intrathecal ImmunoGlobulin (Ig) production and Ig deposition in inflammatory lesions is a hallmark of MS, mice deficient in B-Cells and Igs develop severe EAE.

Paradoxically, mice of the same genetic background but deficient in FcRgamma are EAE-resistant.

We found that the functional expression of FcRgamma on systemic Accessory Cells.

But, not CNS-resident cells, appears to be vital for the development of CNS inflammation, independent of Antigen-Presenting Cell function or Ab involvement.

On the other hand, we found that the injection of AntiMyelin Oligodendrocyte GlycoProtein-Abs drastically worsens disease severity, inflammation, and DeMyelination.

Using FcRgamma(-/-) and C1q(-/-) mice, we could definitively establish that the DeMyelinating capacity of such AutoAb in vivo relies entirely on Complement activation and is FcR-independent.

Aquaporin-4 (AQP4) has recently been implicated in the pathogenesis of NeuroMyelitis Optica (NMO).

Where it has been identified, as the first defined AutoAntigen pertinent to an Inflammatory DeMyelinating Disorder of the human CNS.

Furthermore, a recent case report has shown a lack of AQP4 expression in the Spinal Cord lesions of NMO.

However, the pattern of AQP4 expression in Multiple Sclerosis (MS) tissues has not been well-defined.

In the present investigation, we have confirmed a lack of expression of AQP4 in Optic and Spinal Cord lesions in NMO.

Which contrasted sharply with the increased levels of AQP4 expression seen in MS lesions.

Furthermore a detailed ImmunoHistoChemical and semi-quantitative analysis is used to describe the expression pattern of AQP4 on well-characterized tissue microarray samples of MS and control White Matter.

Anatomically AQP4 was more highly expressed in all categories of MS tissue compared to normal control tissues with the most abundant expression in active lesions.

Within active lesions AQP4 expression was significantly correlated with expression of the pro-inflammatory Cytokine Osteopontin.

At the cellular level, dual-labeling immunofluoresence demonstrated that increased expression of AQP4 was most pronounced at the Astrocytic endfeet.

But was also associated with the cell bodies of Astrocytes in the tissue Parenchyma.

The finding of increased AQP4 expression in MS lesions in contrast to the lack of expression in NMO lesions may suggest different mechanisms of initiation and progression between the two disease states.

Accumulating evidence indicates an ImmunoSuppressive role for CD4⁺CD25⁺ Regulatory T-Cells (Tregs) in Autoimmune Diseases.

Although an impaired Treg function in patients with Relapsing/Remitting Multiple Sclerosis (RR-MS) has been reported recently, no information is available so far about Treg function in the progressive stage of the disease.

In the present study, the phenotypic and functional characteristics of CD4⁺CD25⁺ T-Cells isolated from the peripheral blood of patients with RR-MS and Secondary/Progressive Multiple Sclerosis (SP-MS) were investigated.

No significant quantitative or phenotypic abnormalities in CD4⁺CD25⁺ T-Cells from RR- and SP-MS patients were detected.

However, whereas a reduced suppressor function of CD4⁺CD25⁺ T-Cells toward proliferation and Interferon-gamma production of CD4⁺CD25(-) responder T-Cells was found in RR-MS patients.

SP-MS patients showed a normal Treg function.

The suppressive capacity of MS-derived CD4⁺CD25⁺ T-Cells was correlated with disease duration.

But not with age, indicating that Treg function is more affected in the early phase of the disease process.

Consistently with the suppressive capacity, CD4⁺CD25⁺ T-Cells from SP-MS patients showed normal levels of FOXP3 mRNA in contrast to RR-MS patients that had a reduced FOXP3 expression.

These data are the first to demonstrate differences in function and FOXP3 expression of CD4⁺CD25⁺ T-Cells from patients with RR- and SP-MS.

(c) 2006 Wiley-Liss, Inc.

SimvaStatin, a lipophilic Statin that crosses the Blood-Brain Barrier, is being evaluated as a potential therapy for Multiple Sclerosis (MS) due to its anti-inflammatory properties.

We assessed the effects of SimvaStatin on cultures of rat newborn and human fetal Oligodendrocyte Progenitor Cells (OPCs).

And, human adult mature Oligodendrocytes (OLGs) with respect to cellular events pertaining to Myelin maintenance and repair.

Short-term SimvaStatin treatment of OPCs (1 day) induced robust process extension, enhanced differentiation to a mature phenotype, and decreased spontaneous migration.

These effects were reversed by Isoprenoid products and mimicked with an inhibitor of Rho kinase (ROCK), the downstream effector of the Isoprenylated protein RhoA GTPase.

Prolonged treatment (2 days) caused process retraction that was rescued by Cholesterol, and increased cell death (4 days) partially rescued by either Cholesterol or Isoprenoid co-treatment.

In comparison, SimvaStatin treatment of human mature OLGs required a longer initial time course (2 days) to induce significant process outgrowth, mimicked by inhibiting ROCK.

Prolonged treatment of mature OLGs was associated with process retraction (6 days) and increased cell death (8 days).

Human-derived OPCs and mature OLGs demonstrated an increased sensitivity to SimvaStatin relative to the rodent cells, responding to nanomolar versus micromolar concentrations.

Our findings indicate the importance of considering the short- and long-term effects of systemic ImmunoModulatory therapies on Neural Cells affected by the MS disease process.

(c) 2006 Wiley-Liss, Inc.

Background
The Controlled High Risk Subjects Avonex Multiple Sclerosis Prevention Study (CHAMPS) showed:

That IM Interferon-beta-1a (IFN-ß-1a) significantly slows the rate of development of Clinically Definite Multiple Sclerosis (CDMS).

Over 2 years in high-risk patients who experience a first clinical DeMyelinating event.

This report highlights the primary results of a 5-year, open-label extension of CHAMPS (the Controlled High Risk Avonex Multiple Sclerosis Prevention Study in Ongoing Neurologic Surveillance [CHAMPIONS Study]).

Objective
To determine if the benefits of IFN-ß-1a observed in CHAMPS are sustained for up to 5 years.

Methods
CHAMPS patients at participating CHAMPIONS sites were enrolled in the study.

All patients were offered, but not required to take, IFN-ß-1a 30 microg IM once weekly for up to 5 years (from CHAMPS randomization).

Patients who received placebo in CHAMPS were considered the Delayed Treatment DT group.

And patients who received IFN-ß-1a in CHAMPS were considered the Immediate Treatment IT group.

The primary outcome measure was the rate of development of CDMS.

Additional outcomes included disease state classification at 5 years, annualized relapse rates, disability level at 5 years (Expanded Disability Status Scale), and MRI measures at 5 years.

Results
Fifty-three percent (203/383) of patients enrolled in CHAMPIONS (n = 100, IT group; n = 103, DT group) and 64% (32/50) of CHAMPS study sites participated in CHAMPIONS.

The median time to initiation of IFN-ß-1a therapy in the DT group was 29 months.

The cumulative probability of development of CDMS was significantly lower in the IT group compared with the DT group (5-year incidence 36 +/- 9 vs 49 +/- 10%; p = 0.03).

Multivariate analysis suggested that the only factors independently associated with an increased rate of development of CDMS were randomization to the DT group and younger age at onset of Neurologic symptoms.

Few patients in either group developed major disability within 5 years.

Conclusions
These results support the use of IM Interferon-ß-1a after a first clinical DeMyelinating event.

And indicate that there may be modest beneficial effects of immediate treatment compared with delayed initiation of treatment.

Although Multiple Sclerosis (MS) has been considered a White Matter disease, MS lesions are known to occur in Gray Matter.

Recent ImmunoHistoChemical studies have demonstrated extensive Gray Matter DeMyelination in chronic MS.

The most common lesion type consists of purely Cortical lesions extending inward from the surface of the Brain.

This lesion subgroup is grossly underestimated by standard HistoChemical Myelin staining methods.

Some MS patients have SubPial DeMyelinatio in all Cortical areas of the Brain; this pattern has been termed ''general Cortical SubPial DeMyelination''.

Extensive Cortical DeMyelination is associated with the Progressive phases of disease, as less Cortical DeMyelination has been detected in Relapsing/Remitting MS.

The pathology of Gray Matter lesions differs from that of White Matter lesions.

Gray Matter lesions are less inflammatory, with less Macrophage and Lymphocyte infiltration.

In purely Cortical lesions there is no significant increase in Lymphocytes.

Compared with Non-DeMyelinated adjacent Cortical areas in MS patients or Cerebral Cortex in control patients.

Significant Axonal transection and Neuronal loss have been demonstrated in other MS lesions.

Current Magnetic Resonance Imaging (MRI) methods are not sensitive for purely Cortical MS lesions.

The clinical significance of Cortical MS lesions may not be characterized until more sensitive MRI methods are developed.

Impaired Immune surveillance and constitutive ImmunoSuppressive properties make the Central Nervous System (CNS) a particular challenge to Immune defense.

And require that CNS-resident cells be capable of rapidly recognizing and responding to infection.

We have previously shown that Astrocytes respond to treatment with a TLR3 ligand, poly I:C, with the upregulation of Innate Immune functions.

In the current study, we examine the activation of Innate Immune functions of Astrocytes by Theiler's Murine Encephalomyelitis Virus (TMEV).

A PicornaVirus, which establishes a persistent infection in the CNS of susceptible strains of mice and leads to the development of an Autoimmune DeMyelinating Disease that resembles human Multiple Sclerosis.

Astrocytes infected with TMEV are activated to produce Type 1 Interferons, the Cytokine IL-6, and Chemokines CCL2 and CXCL10.

We further examined the mechanisms that are responsible for the activation of Astrocytes in response to direct Viral infection and treatment with poly I:C.

We found that the cytoplasmic dsRNA-activated kinase PKR is important for Innate Immune responses to TMEV infection, but has no role in their induction by poly I:C delivered ExtraCellularly.

In contrast, we found that TLR3 has only a minor role in responses to TMEV infection, but is important for responses to poly I:C.

These results highlight the differences between responses induced by direct, nonlytic Virus infection and ExtraCellular poly I:C.

The activation of Astrocytes through these different pathways has implications for the initiation and progression of Viral Encephalitis and DeMyelinating Diseases such as Multiple Sclerosis.

(c) 2006 Wiley-Liss, Inc.

InterLeukin-15 (IL-15) is a novel ProInflammatory Cytokine having similar biological activities to IL-2 which is implicated in the pathogenesis of Multiple Sclerosis.

It is produced by activated blood Monocytes, Macrophages and Glial Cells. There is little information about the involvement of IL-15 in the development of Multiple Sclerosis (MS).

The objective of our study was to measure IL-15 Serum and CerebroSpinal Fluid (CSF) levels in MS patients and to correlate Serum and CSF IL-15 concentrations with clinical parameters of the disease.

CSF IL-15/Serum IL-15 ratio (c/s IL-15 ratio) was introduced to assess the origin of elevated IL-15 levels.

Materials And Methods
We measured Serum and CSF IL-15 levels in 52 patients with MS and 36 age and gender matched patients with Inflammatory (IND) and Non-Inflammatory Neurological Diseases (NIND) studied as control groups.

IL-15 levels were correlated with clinical parameters as duration, disability, MRI activity and clinical subtypes of the disease.

Results
MS patients were found to have significantly higher Serum IL-15 levels compared with IND (p=0.00016) and NIND patients (p=0.00045).

Elevated levels of IL-15 were also found in CSF samples from MS patients compared with patients with IND (p=0.00034) and NIND (p=0.0003).

Among MS subgroups there were no statistically different IL-15 Serum and CSF concentrations.

No significant correlation of Serum and CSF IL-15 concentrations with MRI activity, disability assessed by EDSS score and duration of the disease were also found.

C/S IL-15 ratio was found lower in MS patients compared with IND (p=0.01) and not significantly different compared with NIND patients (p=0.14) suggesting that systemic activation might be the source of high CSF IL-15 levels in MS patients.

Conclusions
Our findings suggest a possible role of IL-15 in the ImmunoPathogenetic mechanisms of MS.

PeroxyNitrite (PN) has been implicated in Multiple Sclerosis (MS) and its animal model Experimental Allergic Encephalomyelitis.

Uric Acid (UA) Serum levels of MS patients, a natural scavenger of PN, were found lowered in some recent studies.

Objective/Purpose
The objective of our study was to correlate UA Serum levels and several clinical parameters of MS.

We also tried to investigate Serum UA changes during treatment with ImmunoModulating or ImmunoSuppressing drugs in the last 6 months.

Patients And Methods
We measured UA Serum levels in 190 patients with MS and 58 age and gender matched patients with Inflammatory (IND) and Non-Inflammatory Diseases (NIND) studied as control groups.

UA levels were correlated with clinical parameters as type of the disease, duration, disability, Magnetic Resonance Imaging (MRI) activity and female gender.

Results
In the overall MS group, patients were found to have significantly lower mean Serum Uric Acid levels compared with the IND (p = 0.0029) and the NIND group (p < 0.0001).

UA Serum concentrations were not inversely correlated with duration of the disease (p = 0.87), with disability as assessed by Expanded Disability Status Scale (EDSS) score (p = 0.67) and MRI activity (p = 0.36).

Treatment with ImmunoModulating or ImmunoSuppressing drugs had no influence in UA levels (p = 0.85).

Patients with Clinically Isolated Syndromes (CIS) were found to have significantly lower UA concentrations compared with IND and NIND patients (p = 0.009 and < 0.001, respectively).

Conclusions
Our findings suggest that lower Serum UA levels in MS patients may represent a primary, constitutive loss of protection against Nitric Oxide.

And, the development of CNS inflammation and tissue damage may not have a direct effect to UA Serum levels.

They also provide support that the earlier increase of UA Serum levels might be beneficial in the future treatment of MS.

Objectives
The aim of this study was to assess the motor function of upper extremity and its relation with fatigue, cognitive function and quality of life in Multiple Sclerosis (MS) patients.

Design & Setting
Cross-sectional and controlled study. Outpatient clinic in a university hospital.

Subjects
Thirty-one patients with MS (25 women, 6 men; mean age 39.74 +/- 10.10 years; mean EDSS, 2.56 +/- 1.91) and 30 healthy subjects (20 women, 10 men; mean age 33.56 +/- 8.85 years) were enrolled into the study.

Main Measures
Nine-Hole Peg Test (9-HPT) and Valpar Component Work Sample Test (VCWS-4), Upper Extremity Index (UEI), Paced Auditory Serial Addition Test (PASAT), Fatigue Severity Scale (FSS), and the Multiple Sclerosis Quality of Life-54 (MSQOL-54).

Results
MS patients showed significant impairment in upper extremity motor functions, Cognitive function and excessive Fatigue compared to controls (p < 0.05).

9-HPT in MS group correlated with EDSS, UEI and MSQOL-54 physical health and Cognitive function, whereas VCWS-4 scores (assembly right, assembly left and disassembly) correlated only with EDSS and UEI.

No correlation was found between the VCWS-4 and Cognitive function and Fatigue in both of the groups. Compared to control group, a strong correlation existed between the 9-HPT and VCWS-4 in MS patients (p < 0.05).

Conclusion
The results indicate that disability level (EDSS), UEI and Cognitive function in MS patients are related with impairment in upper extremity motor function.

This again contributes to an impairment in physical domain of quality of life.

A strong correlation of the 9-HPT with VCWS-4 supports the use of the 9-HPT as a measure of manual dexterity and gross motor functions.