UCL Queen Square Institute of Neurology

Author Of 4 Presentations

Invited Presentations Invited Abstracts

HT02.02 - Aging and MS: an MRI perspective

Speakers
Authors
Presentation Number
HT02.02
Presentation Topic
Invited Presentations
Lecture Time
09:27 - 09:39
Imaging Late Breaking Abstracts

LB01.04 - Brain microstructural and metabolic alterations detected in vivo at the onset of the first demyelinating event.

Speakers
Presentation Number
LB01.04
Presentation Topic
Imaging
Lecture Time
09:36 - 09:48

Abstract

Background

In early multiple sclerosis, a clearer understanding of normal-brain tissue microstructural and metabolic abnormalities will provide valuable insights into its pathophysiology. Here, we studied the brain of patients with their first demyelinating episode using neurite orientation dispersion and density imaging (NODDI), for information about neuro-axonal density and spatial distribution, and 23Na MRI, for total sodium concentration reflecting neuro-axonal metabolic dysfunction and loss.

Objectives

To detect, using a multi-parametric quantitative MRI approach, clinically relevant alterations in the brain of early patients not captured by conventional MRI.

Methods

We enrolled 42 patients with clinically isolated syndrome or multiple sclerosis within 3 months from the onset and 16 healthy controls. We assessed physical and cognitive scales. On a 3T scanner, we acquired brain and spinal cord structural scans, and brain NODDI. Thirty-two patients and 13 healthy controls also underwent brain 23Na MRI. In the brain normal-appearing white matter, white matter lesions, and grey matter, we measured, from NODDI, the neurite density index (NDI), a marker of neuro-axonal density, and the orientation dispersion index (ODI), reflecting the fanning and crossing of neurites, and, from 23Na MRI, the TSC. We used linear regression models, adjusted for brain parenchymal fraction and lesion load, and Spearman correlation tests. For robust regression estimates, we used a p≤0.01.

Results

Patients showed higher ODI in normal-appearing white matter, including the corpus callosum, where they also showed lower NDI and higher TSC, compared with controls. In grey matter, compared with controls, patients had lower ODI in frontal, parietal and temporal cortex; lower NDI in parietal, temporal and occipital cortex; and higher TSC in limbic and frontal cortex. Brain volumes did not differ between patients and controls. In patients, higher ODI in corpus callosum was associated with worse performance on timed walk test (p=0.009, B=0.01, 99% Confidence Interval=0.0001-0.02), independent of brain and lesion volumes. Higher TSC in left frontal middle gyrus was associated with higher disability on Expanded Disability Status Scale (rs=0.5, p=0.005).

Conclusions

We found increased axonal dispersion in normal-appearing white matter, particularly corpus callosum, where we found also reduced axonal density and total sodium accumulation suggesting that this structure can be early affected by neurodegeneration. The association between increased axonal dispersion in the corpus callosum and worse walking performance implies that morphological and metabolic alterations in this structure may contribute to disability in multiple sclerosis. Brain volumes were neither altered nor related to disability in patients, so these two advanced MRI techniques can be more sensitive at detecting clinically relevant pathology in very early multiple sclerosis.

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Invited Presentations Invited Abstracts

PS07.01 - Spinal Cord Imaging

Speakers
Authors
Presentation Number
PS07.01
Presentation Topic
Invited Presentations
Lecture Time
12:45 - 13:00

Abstract

Abstract

Spinal cord imaging

Recent radiological advances in spinal cord imaging include: (1) Recommendations on standardised protocols for diagnosis, prognosis and monitoring of MS patients (2020 MAGNIMS-CMSC-NAIMS international consensus guidelines); (2) Recommendations on using spinal cord atrophy in clinical trials and clinical practice (2020 MAGNIMS consensus recommendations); (3) Development of registration-based methods, such as the generalized boundary shift integral (GBSI), to assess spinal cord atrophy, which show advantages when compared with segmentation-based methods; (4) Advanced, quantitative MRI and multi-modal imaging to assess spinal cord microstructural damage in MS; (5) Imaging assessment of the whole neuraxis (both spinal cord and brain) in order to understand the pathological changes that explain disability in MS.

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Imaging Oral Presentation

PS07.03 - Predicting disability progression and cognitive worsening in multiple sclerosis with gray matter network measures 

Speakers
Presentation Number
PS07.03
Presentation Topic
Imaging
Lecture Time
13:15 - 13:27

Abstract

Background

In multiple sclerosis (MS), MRI measures at a whole and regional brain level have proven able to predict future disability, albeit to a limited degree. Their modest prognostic ability may reflect how cognitive and neurological functions are served by distributed networks rather than by single brain regions.

Objectives

We aimed to identify data-driven MRI network-based measures of covarying gray matter (GM) volumes that can predict disability progression.

Methods

We used baseline MRI and longitudinal clinical data from 988 patients with secondary progressive MS (SPMS) from a randomized, double-blind, placebo-controlled, multicenter trial (ASCEND). We applied spatial-ICA to baseline structural GM probability maps to identify co-varying GM regions. We computed correlations between the loading of our ICA components and expanded disability status scale (EDSS), 9 hole peg test (9HPT), and symbol digit modalities test (SDMT) scores. We estimated the progression of the EDSS confirmed at 3 months, 6 months, and 1 year, and respectively the 20% and 10% worsening of 9HPT and SDMT. We used Cox proportional hazard models to determine the prognostic value of our ICA-components and conventional MRI measures (whole and deep GM volumes, and white matter lesion load).

Results

We identified 15 networks of co-varying GM patterns that were clinically relevant. At baseline, SDMT and 9HPT scores correlated more strongly with ICA-components than the conventional MRI measures. The highest correlations were with a mainly basal ganglia component (encompassing the thalamus, caudate, putamen, frontal and temporal lobe). EDSS correlated more closely with an ICA-component involving cerebellum, brainstem, temporal and parietal lobes (r= -0.11, p<0.001). Prognostically, the baseline volume of caudate predicted EDSS progression confirmed at 3 months (HR= 0.81, 95%CI [0.68: 0.98], p<0.05), while some GM network-based measures outperformed conventional MRI measures in predicting SDMT and 9HPT worsening. SDMT progression was predicted by 6 ICA-components (component 8 (HR= 1.26, 95% CI [1.08-1.48], p< 0.005, and component 13 (HR= 1.25, 95% CI [1.07:1.46], p<0.005)). Two ICA-components were predictors of 9HPT worsening (HR=1.30, 95% CI [1.06:1.60], p<0.01; and HR= 1.21, 95%CI [1.01:1.45], p<0.05).

Conclusions

Data-driven MRI network-based measures of covarying GM volumes predict disability progression better than volumetric measures of GM and white matter lesion loads. ICA of MRI shows promise as a method that could enrich clinical MS studies with patients more likely to show a treatment response.

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Presenter Of 2 Presentations

Invited Presentations Invited Abstracts

HT02.02 - Aging and MS: an MRI perspective

Speakers
Authors
Presentation Number
HT02.02
Presentation Topic
Invited Presentations
Lecture Time
09:27 - 09:39
Invited Presentations Invited Abstracts

PS07.01 - Spinal Cord Imaging

Speakers
Authors
Presentation Number
PS07.01
Presentation Topic
Invited Presentations
Lecture Time
12:45 - 13:00

Abstract

Abstract

Spinal cord imaging

Recent radiological advances in spinal cord imaging include: (1) Recommendations on standardised protocols for diagnosis, prognosis and monitoring of MS patients (2020 MAGNIMS-CMSC-NAIMS international consensus guidelines); (2) Recommendations on using spinal cord atrophy in clinical trials and clinical practice (2020 MAGNIMS consensus recommendations); (3) Development of registration-based methods, such as the generalized boundary shift integral (GBSI), to assess spinal cord atrophy, which show advantages when compared with segmentation-based methods; (4) Advanced, quantitative MRI and multi-modal imaging to assess spinal cord microstructural damage in MS; (5) Imaging assessment of the whole neuraxis (both spinal cord and brain) in order to understand the pathological changes that explain disability in MS.

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Invited Speaker Of 2 Presentations

Invited Presentations Invited Abstracts

HT02.02 - Aging and MS: an MRI perspective

Speakers
Authors
Presentation Number
HT02.02
Presentation Topic
Invited Presentations
Lecture Time
09:27 - 09:39
Invited Presentations Invited Abstracts

PS07.01 - Spinal Cord Imaging

Speakers
Authors
Presentation Number
PS07.01
Presentation Topic
Invited Presentations
Lecture Time
12:45 - 13:00

Abstract

Abstract

Spinal cord imaging

Recent radiological advances in spinal cord imaging include: (1) Recommendations on standardised protocols for diagnosis, prognosis and monitoring of MS patients (2020 MAGNIMS-CMSC-NAIMS international consensus guidelines); (2) Recommendations on using spinal cord atrophy in clinical trials and clinical practice (2020 MAGNIMS consensus recommendations); (3) Development of registration-based methods, such as the generalized boundary shift integral (GBSI), to assess spinal cord atrophy, which show advantages when compared with segmentation-based methods; (4) Advanced, quantitative MRI and multi-modal imaging to assess spinal cord microstructural damage in MS; (5) Imaging assessment of the whole neuraxis (both spinal cord and brain) in order to understand the pathological changes that explain disability in MS.

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Author Of 6 Presentations

Diagnostic Criteria and Differential Diagnosis Poster Presentation

P0247 - Comparison of the 2017 and 2010 revisions of the McDonald criteria in patients with cis suggestive of MS: a multicentre MAGNIMS study (ID 1121)

Abstract

Background

In 2017, a revision of the 2010 McDonald criteria for multiple sclerosis (MS) diagnosis in clinically isolated syndrome (CIS) patients has been proposed. However, its validation in a large multicenter cohort of CIS patients is still needed.

Objectives

To compare the performance of 2017 and 2010 revisions of the McDonald criteria with respect to MS development in a large multicentric cohort of CIS suggestive of MS.

Methods

Brain and spinal cord magnetic resonance imaging (MRI) and cerebrospinal fluid (CSF) examination obtained ≤5 months from CIS onset and a follow-up brain MRI acquired ≤15 months from CIS onset were assessed in 626 CIS patients from 9 European MS centres. The occurrence of a second clinical attack (clinically definite [CD] MS) was recorded. Performances of the 2017 and 2010 revisions of McDonald criteria for dissemination in space (DIS), time (DIT) and DIS plus DIT, also including OCB assessment, were evaluated with a time-dependent receiver operating characteristic curve analysis. Median time to MS diagnosis for the different sets of criteria was estimated through Kaplan-Meier curves.

Results

At the last evaluation (median=61.9 months [IQR=39.1-102.5]), 319 (51%) of 626 patients had CDMS. At 36 months, for DIS, the 2017 MRI criteria had higher sensitivity (0.84 [95% CI=0.79-0.88] vs 0.77 [0.72-0.82]), lower specificity (0.33 [0.28-0.39] vs 0.40 [0.35-0.46]), and similar area under the curve values (AUC, 0.59 [0.55-0.62] for both). The 2017 DIS plus DIT MRI criteria had higher sensitivity (0.68 [0.63-0.74] vs 0.62 [0.56-0.68]), lower specificity (0.55 [0.49-0.61] vs 0.62 [0.56-0.68]), and similar AUC values (0.62 [0.58-0.66] for both). CSF-specific OCB assessment as part of the 2017 criteria revision, increased the sensitivity (0.81 [0.75-0.85]), decreased specificity (0.40 [0.34-0.46]) and preserved AUC values (0.60 [0.56-0.64]). Median time to MS diagnosis was earlier with the 2017 revision compared to the 2010 or CDMS criteria, especially with OCB assessment (2017 revision with OCBs=3.6 months [3.1-4.0], 2017 revision without OCB=11.6 months [7.8-13.5], 2010 revision=13.9 months [12.4-15.3], CDMS=56.3 months [43.8-76.0]).

Conclusions

The 2017 revision of the McDonald criteria showed overall similar accuracy to the 2010 McDonald criteria in predicting CDMS development. The suggested modifications are expected to simplify the clinical use of MRI criteria without reducing accuracy and allow an earlier diagnosis of MS.

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Imaging Poster Presentation

P0557 - Characterizing 1-year development of cervical cord atrophy across different MS phenotypes: a voxel-wise, multicenter analysis (ID 1115)

Abstract

Background

In multiple sclerosis (MS) the cervical spinal cord is often affected by demyelination and neuro-axonal injury, leading to irreversible tissue loss.

Objectives

To use voxel-wise analysis to evaluate the distribution and changes over time of cervical cord atrophy in MS patients from a multicentre dataset acquired at 7 European sites.

Methods

Baseline and 1-year 3D T1-weighted cervical cord scans and clinical evaluation were obtained from 54 healthy controls (HC) and 110 MS patients (13 clinically isolated syndromes [CIS], 75 relapsing-remitting [RR] and 22 progressive [P]MS). A pipeline optimized for longitudinal analysis was used to co-register baseline and 1-year follow-up cervical cord scans to a cord template, obtained by averaging straightened HC images from all centers. Voxel-wise differences of cervical cord atrophy, their longitudinal changes and correlations with clinical variables were assessed using SPM12 and full factorial models (sex-, age-, center- and total cord volume-corrected).

Results

Compared to HC, MS patients exhibited significant (p<0.05, family-wise error [FWE] corrected) baseline cervical cord atrophy, mainly located in anterior, posterior and lateral cord regions at C1/C2, as well as in posterior regions between C4 and C6. While CIS patients showed a slight cord tissue expansion vs HC at posterior C4, RRMS presented significant clusters of cord atrophy vs CIS, mostly in lateral and posterior C2-C4 regions, and PMS showed widespread cord atrophy vs RRMS patients at C4-C5 and C7 levels. During the follow-up, a significant progression (p<0.05, FWE) of cord atrophy was detected in MS patients, predominantly in the posterior and lateral cord at C2, and between C4 and C6. Such pattern of cord atrophy progression was mainly driven by RRMS patients, while CIS patients did not show cord tissue loss at follow-up vs baseline, and PMS patients showed circumscribed tissue loss in posterior regions at C2 and C6. A strong relationship (p<0.05, FWE) was found between baseline clinical disability and baseline cord atrophy in the posterior and lateral cord at C2-C4. Also, baseline atrophy in the lateral cord at C3-C4 correlated with clinical disability at 1-year follow-up.

Conclusions

Voxel-wise analysis of cervical atrophy allowed to detect a differential involvement of cord levels and to characterize 1-year evolution of tissue loss across phenotypes. Cord atrophy was clinically relevant and contributed to explain follow-up clinical disability.

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Imaging Poster Presentation

P0567 - Diffusion-based Structural connectivity abnormalities in MS phenotypes. (ID 1271)

Abstract

Background

People with MS present disruption of structural brain networks, but the differential characteristics of such changes among MS phenotypes and their clinical impact are not well elucidated.

Objectives

To characterize diffusion-based brain connectivity abnormalities in different MS phenotypes and their relation with disability in a large cohort of patients.

Methods

In this multicenter, retrospective, cross-sectional study, we collected clinical and brain MRI data from 344 patients with MS [median Expanded Disability Status Scale, EDSS 2.0 (range 0-7.0)] and 91 healthy volunteers (HV) from four MAGNIMS centers. Cognition was assessed with the Paced Auditory Serial Addition Test (PASAT) and Symbol Digits Modalities Test (SDMT) in 298 patients. We collected 3D-T1, FLAIR, diffusion-weighted images (DWI) and T2 or field maps acquisitions. FSL and ANTs packages were used to carry out DWI preprocessing and MRtrix software to generate connectivity matrices based on fractional anisotropy values. We computed six network measures (strength, global and local efficiency, clustering coefficient, assortativity and transitivity), and applied the ComBat tool to reduce inter-site variability. We calculated age-adjusted differences in graphs between groups using Mann-Whitney with FDR correction or Kruskal-Wallis with Dunn’s Test when necessary. Associations with clinical features were explored with Spearman’s rank correlation.

Results

Thirty-eight (11%) patients presented a clinically isolated syndrome (CIS), 262 (76%) had relapsing-remitting (RR) and 44 (13%) secondary progressive (SP) MS. CIS patients showed reduced global and local efficiency, clustering coefficient and transitivity compared to HV (corrected p<0.001), whilst RRMS did not differ from CIS patients. Compared with CIS and RRMS, patients with SPMS showed larger changes for the same previous graphs measures (corrected p<0.05), and lower strength than RRMS (corrected p=0.019).

In patients, reduced measures of strength, global and local efficiency, clustering and transitivity correlated with higher EDSS (rho:-0.12–-0.16, corrected p<0.034), lower PASAT (rho:0.26–0.30, corrected p<0.001) and worse SDMT scores (rho:0.28–0.32, corrected p<0.001).

Conclusions

Structural network integrity at the whole brain level is already widely reduced in people with MS from the earliest phases of the disease and becomes more abnormal in SPMS. Network modifications may contribute to the clinical manifestations of the disease.

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Imaging Poster Presentation

P0644 - Spinal cord atrophy in a primary progressive multiple sclerosis trial: improved sample size using GBSI (ID 686)

Speakers
Presentation Number
P0644
Presentation Topic
Imaging

Abstract

Background

Spinal cord atrophy is a common feature of multiple sclerosis (MS), can be detected in vivo using MRI, and is one of the main substrates of disease progression. In our previous studies, we have adapted the boundary shift integral (BSI) technique developed for the brain, to be applied to the spinal cord, obtaining the first registration-based method for longitudinal assessment of spinal cord atrophy.

Objectives

We aim to 1) compare spinal cord atrophy measurements using segmentation- and registration-based methods, with possible implications for clinical trial design (e.g., measurement variability, image noise floor); 2) compare spinal cord atrophy measurements obtained from routine brain (C1-2) and dedicated spinal cord MRI (C1-2 and C2-5), using segmentation- and registration-based methods; 3) explore possible clinical correlates, also in relation to conventional brain MRI measures; and 4) explore possible treatment effect.

Methods

We included 220 primary-progressive multiple sclerosis patients from a phase 2 clinical trial, with baseline and week-48 3DT1-weighted MRI of the brain and spinal cord (1x1x1mm3), acquired separately. We obtained segmentation-based cross-sectional spinal cord area (CSA) at C1-2 (from both brain and spinal cord MRI) and C2-5 levels (from spinal cord MRI) using DeepSeg, and, then, we computed corresponding GBSI.

Results

Depending on the spinal cord segment, we included 67.4-98.1% patients for CSA measurements, and 66.9-84.2% for GBSI. Spinal cord atrophy measurements obtained with GBSI had lower measurement variability, than corresponding CSA. Looking at image noise floor, the lowest median standard deviation of the MRI signal within the cerebrospinal fluid surrounding the spinal cord was found on brain MRI at C1-2 level. Spinal cord atrophy derived from brain MRI was related to corresponding measures from dedicated spinal cord MRI, more strongly for GBSI than CSA. Spinal cord atrophy measurements using GBSI, but not CSA, were associated with upper and lower limb motor progression. No treatment effect was detected for any spinal cord atrophy measurements.

Conclusions

Notwithstanding reduced measurement variability, clinical correlates, and possibility of using brain acquisitions, spinal cord atrophy using GBSI should remain a secondary outcome measure in MS studies, until further advancements increase the quality of acquisition and reliability of processing.

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Neuromyelitis Optica and Anti-MOG Disease Poster Presentation

P0708 - Differential MRI biomarkers between MOGAD, AQP4-NMOSD and RRMS: a MAGNIMS multicenter study (ID 1335)

Abstract

Background

Clinical and imaging features of myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) may overlap with those of aquaporin 4-neuromyelitis optica spectrum disorder (AQP4-NMOSD) and relapsing remitting multiple sclerosis (RRMS). There is an unmet need for MRI biomarkers which reflect biological mechanisms involved in MOGAD and can help in the differential diagnosis.

Objectives

We aim to identify imaging features able to differentiate between non-acute MOG-antibody disease, AQP4-NMOSD and RRMS.

Methods

In this ongoing retrospective, cross-sectional MAGNIMS study, we analyzed data collected from 8 centers. All subjects (n=352) had brain and cervical cord 3T MRI. Quantification of MRI biomarkers included brain white matter lesions (WMLs), cortical lesions (CL), brain parenchymal fraction (BPF), white matter fraction (WMF), cortical and deep grey matter fractions (GMF) and cross-sectional cervical cord area (CSA) at C1-C2. Linear regression models were used to compare MRI measures between groups, corrected for age, sex, and centre. Statistical significance was considered when p was <0.05.

Results

91 patients with MOGAD (50F, mean age: 41yrs [±15]), 85 with AQP4-NMOSD (68F, 49yrs [±14]), 90 with RRMS (56F, 41yrs [±11]) and 87 healthy controls (HCs) (54F, 36yrs [±11.6]) were collected. The most common phenotypes at onset were optic neuritis and transverse myelitis in MOGAD (93%) and AQP4-NMOSD (87%). WMLs were detected in 57% MOGAD, 79% AQP4-NMOSD, all RRMS (100%) patients, and in 15% HCs. The mean lesion load and number of lesions were higher in RRMS than both MOGAD (p=0.007, p<0.001) and AQP4-NMOSD (p=0.001, p<0.001). At least one CL was seen in 8% patients with MOGAD (total n=8), 10% patients with AQP4-NMOSD (n=7), and in 69% patients with RRMS (n=150). All patient groups showed lower BPF than HCs, with lower WMF in MOGAD and RRMS than HCs (all p<0.01). Between groups, deep GMF was lower in RRMS than MOGAD (p<0.001) and AQP4-NMOSD (p=0.001). CSA was reduced in all disease groups when compared to HCs (all p<0.01) and lower in AQP4-NMOSD than RRMS (p=0.01).

Conclusions

This ongoing study indicates that MOGAD and AQP4-NMOSD share similar MRI features, and no specific MRI biomarker can distinguish between them. Patients with AQP4-NMOSD showed greater spinal cord atrophy than RRMS, and RRMS patients had a higher number of cortical lesions, and greater deep GM atrophy than AQP4-NMOSD and MOGAD. The next step is to investigate whether lesion distribution differs between the two antibody-mediated disease.

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Neuromyelitis Optica and Anti-MOG Disease Poster Presentation

P0739 - Optic chiasm involvement in MS, aquaporin-4 antibody-positive NMOSD, and MOG antibody-associated disease (ID 1441)

Speakers
Presentation Number
P0739
Presentation Topic
Neuromyelitis Optica and Anti-MOG Disease

Abstract

Background

Inflammatory demyelination in the anterior optic pathway, including the optic chiasm (OC), occurs frequently in relapsing-remitting multiple sclerosis (RRMS), aquaporin4 (AQP4) antibody (Ab) positive neuromyelitis optica spectrum disorder (NMOSD), and myelin oligodendrocyte glycoprotein-Ab associated-disease (MOGAD).

Objectives

To evaluate the involvement of the OC in RRMS, AQP4-NMOSD and MOGAD using Magnetization Transfer Ratio (MTR) and explore its relationship with prior optic neuritis (ON).

Methods

We recruited 25 patients with RRMS (16 F, mean age: 44.6 yrs ±11.8, median EDSS: 2.0 [range: 1.0-7.5], mean number of previous episodes of ON: 0.44±0.58, 9 unilateral, 1 bilateral), 13 with AQP4-NMOSD (10 F, mean age: 45.3 yrs ±11.2, median EDSS: 3.0 [1.0-6.5], mean number of ON episodes: 1.54±1.13, 4 unilateral, 6 bilateral), 20 with MOGAD (13 F, mean age: 33.9 yrs ±16.4, median EDSS: 2.0 [0.0-6.5], mean number of ON episodes: 2.85±2.80, 6 unilateral, 11 bilateral) and 29 healthy controls (HC) (23 F, mean age: 35.9 yrs ±12.8). We used T2-weighted, MTon and MToff images to obtain MTR maps of the OC. Age-, sex-, and disease duration-adjusted linear regression models were used to compare the measures between disease and healthy groups (p<0.05).

Results

Chiasmal MTR values in patients with previous ON were lower in AQP4-NMOSD (p=0.040) and MOGAD (p=0.001) than HC but not when compared to patients without previous ON. In patients with RRMS and previous ON, MTR values were lower than patients without prior ON (p=0.003). No differences were found either between patients without ON and HC or between the disease groups.

When considering all patients with demyelinating diseases, patients with previous ON had lower chiasmal MTR values when compared to HC (unilateral: p=0.037; bilateral: p=0.002) and to patients without ON (unilateral: p=0.019; bilateral: p<0.001). This difference persisted when comparing both monophasic and relapsing ON patients to HC (p=0.044; p<0.001) and to patients without ON (p=0.019; p<0.001). No differences were found between patients without history of ON and HC. A correlation was found between MTR values and number of ON episodes (rho=-0.55, p<0.001).

Conclusions

Microstructural damage in the OC correlated with the number of ON episodes across inflammatory demyelinating diseases. A higher number of episodes is associated with lower chiasmal MTR, supporting its role as an accessible target for the assessment of the visual pathway in inflammatory diseases.

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