Brigham and Women's Hospital
Department of Neurology

Author Of 2 Presentations

Imaging Oral Presentation

HT05.03 - Presentation 03 - 7T MRI cerebral leptomeningeal enhancement predicts gray and white matter lesion accumulation one year later in relapsing-remitting multiple sclerosis

Speakers
Presentation Number
HT05.03
Presentation Topic
Imaging
Lecture Time
10:39 - 10:51

Abstract

Background

We recently showed that 7T MRI leptomeningeal enhancement (LME) is common in relapsing-remitting multiple sclerosis (RRMS) and is related to gray matter (cortical/thalamic) and white matter (WMLs) lesions.

Objectives

To investigate the dynamics of LME longitudinal change and relationship to subsequent lesion accumulation using 7T MRI.

Methods

25 RRMS subjects [age 44.5±11.2 years (mean±SD), 68% women, Expanded Disability Status Scale (EDSS) 2.0±1.5, 92% on disease-modifying therapy-DMT] and 12 healthy controls (HC) underwent brain 3D MP2RAGE and FLAIR 7T MRI with 0.7 mm3 voxels at baseline and ~1 year. Gadolinium-enhanced 3D-FLAIR was evaluated for LME. WMLs, cortical lesions (CLs) and thalamic lesions (TLs) were expert-quantified. Wilcoxon rank-sum, two-sample t-tests and Spearman’s correlations were investigated.

Results

LME was found in 17/25 (68%) RRMS subjects at baseline and 18/25 (72%) at follow-up vs. a single stable focus in 1/12 HC (8.3%). In the RRMS group, 42 LME foci [mean 2.5±1.1 (range 1-5) per LME+ subject] were identified at baseline versus 48 foci [2.7±1.2 (1-5)] at follow-up. LME foci number at follow-up was unchanged in 18 (72%) RRMS subjects, increased in 6 (24%), decreased in 1 (4%). All 6 subjects with increased LME foci were on treatment [glatiramer acetate, interferon-β (2), rituximab, ocrelizumab, fingolimod]. The subject with LME resolution was treated with ocrelizumab. LME+ subjects had an on-study increase in volume of WMLs (baseline 11.0±14.4 vs. follow-up 12.6±16.3 ml, p<0.001), CLs (0.85±1.2 vs. 1.0±1.4 ml, p=0.002) and TLs (0.103±0.093 vs. 0.117±0.099 ml, p=0.005), whereas LME- subjects had an increase only in WML volume (2.7±2.3 vs. 3.3±2.6 ml, p=0.023). Baseline LME foci number correlated with 1-year change in CL (r=0.36, p=0.078) and WML (r=0.50, p=0.010) volumes. Minimal EDSS change over 1 year was noted. We used these data as the basis for a sample size calculation for a hypothetical trial of a putative therapy that would reduce the rate of MRI lesion accrual by 80% over 1 year. For a single-arm study with 1-year run-in on standard therapy and 1 year on new treatment to achieve 80% power, sample sizes of n=46, n=56 and n=79 were calculated for CL volume, TL volume and LME foci number, respectively.

Conclusions

The evolution of cerebral LME may be a dynamic process in the short term in RRMS, providing a monitoring tool, with about one quarter of patients showing new foci at one year. LME may pose a risk for the subsequent development of new lesions in widespread brain regions, implicating meningeal involvement as a marker or mediator of increased disease severity.

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Invited Presentations Invited Abstracts

PS03.01 - MRI Phenotypes and miRNA Signatures in MS

Speakers
Presentation Number
PS03.01
Presentation Topic
Invited Presentations
Lecture Time
10:30 - 10:45

Abstract

Abstract

Background: Multiple sclerosis is characterized by both neuroinflammation and accelerated brain atrophy. These two processes can be quantified by MRI, are at least partially independent, and have different underlying pathological mechanisms. MicroRNA (miRNA) have previously shown strong ties to various neurological disease processes, and have potential as biomarkers in MS.

Objectives: To classify and immunologically characterize persons with MS based on serum miRNA profiles in conjunction with MRI phenotypes, as defined by relative burden of cerebral T2-hyperintense lesion volume (T2LV) and brain parenchymal fraction (BPF).

Methods: Cerebral T2LV and BPF were retrospectively quantified from 1.5T MRI, and used to define the following MRI phenotypes. Type I: low T2LV, low atrophy; type II: high T2LV, low atrophy; type III: low T2LV, high atrophy; type IV: high T2LV, high atrophy, in a large cross-sectional cohort (n = 1,088) and a subset with 5-year longitudinal follow-up (n = 153). Serum miRNAs were assessed on a third MS cohort with 2-year MRI phenotype stability (n = 98). A proportional odds logistic regression model was used to determine significant associations been MRI features and miRNA expression.

Results: One-third of the patients showed dissociation between lesion burden and atrophy severity as defined by MRI phenotypes II or III. At 5-year follow-up, all phenotypes showed increased atrophy (p < 0.001), disproportionally in type II (BPF −2.28%). Only type IV experienced significantly worse neurological disability scores. Types I and II had a 5-year MRI phenotype conversion rate of 33% and 46%, whereas III and IV had >90% stability. Type II switched primarily to IV (91%); type I switched primarily to II (47%) or III (37%). Baseline higher age (p = 0.006) and lower BPF (p < 0.001) predicted 5-year phenotype conversion. MicroRNA analysis revealed sixteen miRNA differentially expressed (p < 0.05, uncorrected) between the four phenotypes. Each phenotype demonstrated a distinct miRNA signature. Biological interpretation of these miRNA suggest a role for blood-brain barrier pathology. miR-22-3p, miR-361-5p, and miR-345-5p were the most valid differentiators.

Conclusions: MRI-defined MS phenotypes show high conversion rates characterized by relentless brain atrophy with or without ongoing inflammation, and results support the partial independence of these two features. Differentially expressed serum microRNA for the MRI phenotypes implicates the blood-brain barrier as an important mechanism determining pathological course. MicroRNA are promising as biomarkers in MS but require significant further verification and methodological standardization.

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Author Of 4 Presentations

Pathogenesis – Role of Glia Late Breaking Abstracts

LB1224 - Thalamic and whole brain atrophy are linked with white matter microglial activation: A [F-18]PBR06-PET study in multiple sclerosis  (ID 2099)

Speakers
Presentation Number
LB1224
Presentation Topic
Pathogenesis – Role of Glia

Abstract

Background

Thalamic and whole brain atrophy have been extensively studied as biomarkers of neurodegeneration in multiple sclerosis but their mechanism is not clear. [F-18]PBR06-Positron Emission Tomography (PET) is a novel molecular imaging technique to assess microglial activation.

Objectives

To determine the relationship of thalamic and whole brain atrophy with white matter (WM) microglial activation in multiple sclerosis.

Methods

22 individuals (13 MS, including 8 relapsing-remitting and 5 secondary progressive, and 9 healthy control (HC)) subjects underwent 3T MRI and [F-18]PBR06-PET. Individualized z-score maps of WM microglial activation were generated by voxel-by-voxel comparison between each subject's PET SUVR images and a control dataset. Glial activity load on PET in WM (“GALP-WM”) was calculated as the sum of voxel-by-voxel z-scores ≥4 in the WM subjects and its logarithmic transformation (“ln-GALP”) was also obtained. "Z-max" score was calculated as the highest z-score in the WM matter averaged over surrounding 5 voxels. SIENAX and FSL-FIRST pipelines determined normalized brain parenchymal volume (BPV) and thalamic volumes (Th-V) respectively. A p-value <0.05 was considered statistically significant.

Results

Th-V and BPV were lower in MS vs. HC (19.7±2.2 vs. 22.4±1.6 ml, 1376.6±81.3 vs. 1475.1±70.9 ml, both p<0.01). GALP-WM, Z-max and ln-GALP were higher in MS vs. HC (18757.9±13646 vs. 7580.5±12216, 13.2±2.9 vs. 8.3±4.1, and 9.5±0.92 vs. 7.4±1.9, all p<0.05). Th-V and BPV were inversely correlated with WM microglial activation, represented by GALP-WM, Z-max and ln-GALP (r=-0.62, -0.66 and -0.62, all p<0.01 for Th-V and r=-0.68, -0.643 and -0.678, all p<0.01 for BPV) that remained significant after adjustment for age (all p<0.05).

Conclusions

Thalamic and whole brain atrophy are linked with white matter microglial activation in MS, representing a link between neuroinflammation and neurodegeneration across central nervous system compartments. Further investigation of the “GALP” method as a novel, individualized approach for evaluating glial activity in MS is warranted. Prospective longitudinal studies to determine the impact of therapeutically targeting microglial activation on neurodegeneration in MS patients are urgently needed.

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COVID-19 Late Breaking Abstracts

LB1262 - Low Prevalence of SARS-CoV-2 Antibodies in People with Multiple Sclerosis Residing in Massachusetts (ID 2159)

Abstract

Background

Seroepidemiology is an important tool to characterize the epidemiology and immunobiology of SARS-CoV-2. Most people with multiple sclerosis (MS) are treated with immunomodulators or immunosuppressants, so it is crucial to understand the immune response to the novel SARS-CoV-2 in people with MS.

Objectives

To investigate the prevalence and persistence of the SARS-CoV-2 antibody response in MS and how this relates to MS phenotype and treatment.

Methods

227 consecutive people with MS residing in MA and receiving care at Massachusetts General Hospital or Brigham and Women’s Hospital and 143 of their cohabitants were enrolled May 29-July 23, 2020. In addition, 8 people with MS receiving care elsewhere who tested positive for SARS-CoV-2 nasal swab PCR and 7 cohabitants of that group were enrolled to enrich the sample for select analyses. Each participant remotely submitted a dried blood card for in-house MGH SARS-CoV-2 IgG ELISA assay testing. The assay displays 99.7% sensitivity and 100% specificity >14 days from symptom onset. Participants completed a REDCap questionnaire covering demographics, MS history and treatments, comorbidities, and COVID-19 symptoms and exposure. Antibody prevalence in MS participants will be compared to that in their cohabitants using Pearson’s Chi-squared tests.

Results

The majority of MS participants were characterized as relapsing/remitting (76.8%) and were taking disease modifying therapies (72.6%) at the time of collection. SARS-CoV-2 antibodies were detected in 3.5% of people with MS residing in MA and 6.3% of their cohabitants (X2=1.54, p=0.22). For comparison, ~1.5% of the MA population had tested positive by PCR in this date range. Exposure and treatment data will be presented in 13 cases of antibody discordance between the person with MS and his/her cohabitant; the person with MS was antibody-negative in 10 cases and antibody-positive in 3 cases with discordance. In total there were 6 MS participants and no cohabitants who previously tested positive by nasal swab PCR but lacked antibodies at follow-up. Of the COVID-positive participants (by PCR or antibody), 54.5% (6 of 11) of MS and 88.9% (8 of 9) of cohabitants were asymptomatic (p=0.16).

Conclusions

Antibody prevalence was low overall in people with MS residing in MA. Discordance between MS participants and their cohabitants and lack of detectable antibodies in some people with MS with prior nasal swab PCR positivity suggest SARS-CoV-2 antibodies may be less persistent in people with MS.

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Prognostic Factors Poster Presentation

P0488 - Relapse recovery in MS: Effect of treatment and contribution to long-term disability (ID 1039)

Speakers
Presentation Number
P0488
Presentation Topic
Prognostic Factors

Abstract

Background

Although a small number of studies has shown that recovery from relapses in multiple sclerosis appears to contribute to long-term outcomes, relapse recovery has largely been ignored as a treatment endpoint and predictor of disability. We hypothesized that relapse recovery in the early stages of disease will impact longer term disability.

Objectives

The first aim of this study was to identify demographic and clinical predictors associated with incomplete recovery from relapses in the first 3 years from the first MS symptom. The second aim was to examine the relationship between incomplete recovery in first 3 years and 10-year disability outcomes.

Methods

Recovery from relapses in the first three years from the first symptom was retrospectively assessed in 360 patients with relapsing remitting multiple sclerosis enrolled in the Comprehensive Longitudinal Investigations in Multiple Sclerosis at Brigham and Women’s Hospital (CLIMB study), a large longitudinal cohort. Complete or incomplete recovery from each relapse was determined based on the return of the Expanded Disability Status Scale (EDSS), Functional System Scale (FSS) and neurologic signs to baseline levels at least 6 months after symptom onset. Univariate and multivariable models were used to associate recovery with demographic and clinical factors and to predict 10-year disability and MRI outcomes (brain parenchymal fraction and T2 lesion volume).

Results

Including their initial episode, the 360 included patients had a total of 736 relapses within the first three years from their first symptom. 44.6% of these relapses had an incomplete recovery at 6 months. Relapses in untreated patients had an incomplete recovery in 51.8% of cases, compared to 28.9% in patients who were being treated with a disease modifying drug (p<0.001). In the multivariable analysis, recovery from relapses in the first 3 years was better younger patients, who were on interferon treatment, had no bowel or bladder symptoms and had a longer interval since their first symptom. For every incomplete recovery in the first three years, the EDSS at 10 years increased by 0.6 points, and the timed 25-foot walk at 10 years increased by 0.5 seconds. Both disability outcomes were also higher with older age at first symptom and higher BMI. Brain atrophy, measured by the brain parenchymal fraction on MRI, was associated only with older age at first symptom, whereas T2-hyperintense lesion volume was only associated with smoking.

Conclusions

Early initiation of first-line disease-modifying treatments can improve relapse recovery, which in turn prevents long-term disability.

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Imaging Poster Presentation

P0555 - Characterization of MRI Activity Following Treatment with Ocrelizumab for Multiple Sclerosis (ID 1543)

Speakers
Presentation Number
P0555
Presentation Topic
Imaging

Abstract

Background

Ocrelizumab (OCR) is a CD20 directed cytolytic monoclonal antibody approved for treatment of relapsing and primary progressive forms of multiple sclerosis (MS). In clinical trials, 5% or fewer developed new MRI gadolinium (Gd)-enhancing lesions on OCR.

Objectives

To characterize frequency and types of radiological relapses on MRI during treatment with OCR in a “real world” study.

Methods

A single center, retrospective review of routine MRI in patients with MS treated with OCR in the Comprehensive Longitudinal Investigation of Multiple Sclerosis at the Brigham and Women’s Hospital (CLIMB) cohort. A patient was considered to have MRI activity if any of the following were present in brain or spinal cord MRI obtained after initiation of OCR: (1) Gd enhancement (2) new restricted diffusivity of a lesion, or (3) a new or enlarging T2 lesion in comparison to a baseline MRI acquired at the start or following start of OCR.

Results

There were 383 patients treated with OCR [68% female, mean age 48.4 (SD 12.3) years, mean disease duration 15 (SD 10.9) years, median EDSS 2.5 (range 0-8) of whom 68% had relapsing-remitting (RRMS), 21% secondary progressive (SPMS), and 11% primary progressive (PPMS) disease. The last MRI was obtained 14.2 (SD 7.3) months after starting OCR with total of 458 patient-years of imaging follow-up. Of the 383 patients, 333 (87%) did not have evidence of MRI activity, 26 (6.7%) had new/enlarging T2 lesions but no new baseline scan at the start of OCR. In total, there were 25 MRI relapses identified in 24 (6.2%) patients [23 new Gd enhancing, 1 new restricted diffusion, 1 new T2 lesion]. Patients with MRI activity were 63% female with mean age of 41.4 (SD 11.3) years, median EDSS of 3 of whom 79% had RRMS and 21% had SPMS. Radiological relapses were present in scans acquired median of 8 months (range 0-21 months) after starting OCR. There were two distinct patterns of radiological relapses. The first was new lesion formation, present in 11 MRI scans (8 brain, 3 spinal cord) obtained median of 5 months after OCR start. The second pattern was gadolinium enhancement or new restricted diffusion of an old lesion present in a scan prior to start of OCR. This pattern occurred in 14 MRI scans (6 brain, 8 spinal cord) acquired a median of 9 months after OCR start. One patient with recurrent enhancement pattern had a brain biopsy showing active demyelination.

Conclusions

Radiological relapse is infrequent in OCR but can occur early or late. The more common pattern of radiological relapse was recurrent activity at an old lesion site with predominance in the spinal cord.

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