MS Abstracts 04b-2g7

Introduction
We studied the responsiveness and predictive value of two widely used clinical outcome measures that document Multiple Sclerosis (MS) disease progression.

The Expanded Disability Status Scale (EDSS) and the Multiple Sclerosis Functional Composite (MSFC)-in patients with Primary/Progressive (PP) MS. Disease course in PPMS shows less fluctuation than in Relapsing/Remitting (RR) MS.

Methods
In a group of 161 patients with PPMS, EDSS and MSFC were performed at three timepoints.

To assess responsiveness, mean change scores and variances were plotted against baseline scores and effect sizes were calculated.

Predictive value was determined by calculating sensitivity, specificity, and likelihood ratios (LRs) of 1-year changes to predict changes over 2 years.

Furthermore, multivariate logistic regression models were used to assess the predictive value of short-term worsening on EDSS and MSFC.

Results
Responsiveness of both EDSS and MSFC was shown to be limited and mean changes were highly dependent on the baseline scores. Effect sizes for EDSS and MSFC were small and inconclusive (0.239 and 0.161).

The predictive value of a short-term worsening (baseline to year 1) to predict worsening in the long term (baseline to year 2) was expressed for EDSS by a sensitivity of 0.55 and a LR+ of 8.64. For MSFC, sensitivity was 0.68 and LR+ was 3.14.

However, short-term worsening was a poor predictor of subsequent worsening (year 1 to year 2) for EDSS (LR+ 1.06) and this relationship was actually inverse for MSFC (LR+ 0.61).

Conclusion
In this study over a period of 2 years in Primary/Progressive Multiple Sclerosis, the Multiple Sclerosis Functional Composite (MSFC) was less responsive than the Expanded Disability Status Scale (EDSS).

The predictive value of neither EDSS nor MSFC was very powerful.

With the purpose of demonstrating the use of Positron Emission Tomography (PET) and radiolabelled Glia Markers to indicate Regional Cerebral damage.

We measured with PET in four young Multiplex Sclerosis (MS) patients in two consecutive measurements the global and regional Brain uptake as well as regional distribution and Binding Potential (BP) of [(11)C]Vinpocetine and [(11)C]PK11195.

Both Ligands showed increased uptake and BP in the regions of local Brain Damage. However, regional BP values for [(11)C]Vinpocetine were markedly higher than those for [(11)C]PK11195.

This feature of the former RadioLigand may be related to its high Brain uptake and marked affinity to the Peripheral Benzodiazepine Receptor Binding Sites (PBRS), characteristic for Glia Cells.

As local Brain traumas entail reactive Glia accumulation in and around the site of the damage:

The present findings may indicate that [(11)C]Vinpocetine marks the place or boundaries of local Brain damage by binding to the PBBS present in Glia Cells, which, in turn, accumulate in the region of the damage.

The impact of relapses on long-term disability in Multiple Sclerosis remains unclear; however some evidence suggests that relapses play an important role in determining subsequent prognosis.

We report on outcome, prognostic factors for recovery and the contribution of relapses to the accumulation of fixed disability in a large series of patients with documented relapses.

Two hundred and seventynine relapses in 182 patients were assessed before, during and after relapse by Expanded Disability Status scale and data analysed to assess degree of recovery.

Factors affecting outcome were considered including sex, age and site of relapse. Mean EDSS prior to relapse was 3.73, during relapse 5.18 and post relapse 4.23.

Mean interval to post relapse assessment was 127 days post relapse. Mean residual change in EDSS score (pre to post relapse) was 0.50 points.

Overall 49.4 % of patients had a residual increase in disability post relapse of at least 0.5 EDSS points and 32.7 % had an increase of at least 1 point.

No significant difference was observed in mean residual EDSS for sex, site of relapse or age at relapse or in the proportion of patients with a residual increase in disability of >/= 1 EDSS point post relapse.

14.4 % of patients had no increase in EDSS score during relapse compared to pre relapse.

These results suggest that acute relapses are commonly associated with an objective worsening of disability in the majority of patients with MS and that recovery is incomplete in approximately half and not influenced by gender, age or site of lesion.

Therapies which reduce relapse frequency and/or severity might therefore be expected to slow or prevent worsening of disability if initiated prior to the onset of more permanent damage.

We performed a prospective multi-center study using functional Magnetic Resonance Imaging (fMRI) to better characterize the relationships between clinical expression and Brain function.

In patients with Multiple Sclerosis (MS) at eight European sites (56 MS patients and 60 age-matched, healthy controls).

Patients showed greater task-related activation bilaterally in Brain regions including the Pre- and Post-Central, Inferior and Superior Frontal, Cingulate and Superior Temporal Gyri and Insula (P < 0.05, all statistics corrected for multiple comparisons).

Both patients and healthy controls showed greater Brain activation with increasing age in the Ipsilateral Pre-Central and Inferior Frontal Gyri (P < 0.05).

Patients, but not controls, showed greater Brain activation in the Anterior Cingulate Gyrus and the Bilateral Ventral Striatum (P < 0.05) with less hand dexterity. An interaction between functional activation changes in MS and age was found.

This large fMRI study over a broadly selected MS patient population confirms that movement for patients demands significantly greater Cognitive 'resource allocation' and suggests age-related differences in Brain responses to the disease.

These observations add to evidence that brain functional responses (including potentially Adaptive Brain Plasticity) contribute to modulation of clinical expression of MS pathology and demonstrate the feasibility of a multi-site functional MRI study of MS.

The concept of preclinical Multiple Sclerosis is now well recognised, and a diagnosis of silent Brain T2 lesions is frequent because of the ease of performing MRI. Nevertheless, patients with incidental Brain MRI fulfilling Barkhof- Tintoré criteria are more rare.

We report a descriptive retrospective study of clinical and 5 year MRI follow-up in patients with subclinical DeMyelinating lesions fulfilling MRI Barkhof-Tintoré criteria with a normal Neurological Examination.

30 patients were identified and the first Brain MRI was performed for various medical events: Headaches (n = 14), Migraine with (n = 2) or without (n = 4) aura, CranioCerebral Trauma (n = 3), Depression (n = 3), Dysmenorrhoea (n = 2), Epilepsy (n = 1) and Cognitive Changes (n = 1).

Mean time for the second Brain MRI was 6 months (range 3-30). 23 patients had TemporoSpatial dissemination (eight with gadolinium enhancement). 11 patients had clinical conversion: Optic Neuritis (n = 5), BrainStem (n = 3), Sensitive Symptoms (n = 2) and Cognitive Deterioration (n = 1).

Eight (72%) already had criteria of Dissemination to Space and Time before the clinical event. Mean time between the first Brain MRI and Clinically Isolated Syndrome (CIS) was 2.3 years.

To our knowledge, this is the first cohort of CIS with preclinical follow-up. Early treatment should be discussed in view of the predictive value on conversion of the MRI burden of the disease.

Understanding the contribution of the Brain White Matter pathways to Declarative Verbal Memory Processes has been hindered by the lack of an adequate model in humans.

An attractive and underexplored approach to study White Matter region functionality in the living human Brain is through the use of non-aprioristic models which specifically search disrupted White Matter pathways.

For this purpose, we employed Voxel-based Lesion-Function Mapping to correlate White Matter lesions on the Magnetic Resonance Images of 46 Multiple Sclerosis patients with their performance on Declarative Verbal Memory Storage and Retrieval.

White Matter correlating with storage was in the Temporal Lobe-particularly lateral to the Hippocampus and in the Anterior Temporal Stem-, in the Thalamic region and in the Anterior Limb of the Internal Capsule, all on the Left Hemisphere, and also in the Right Anterior Temporal Stem.

The same volumes were relevant for Retrieval, but to them were added Temporo-Parieto-Frontal Paramedian bundles, particularly the Cingulum and the Fronto-Occipital Fasciculus.

These 3D maps indicate the White Matter regions most critically involved in Declarative Verbal Memory in humans.

Objective
To identify evidence of a discrete, specific Immune Response in Multiple Sclerosis (MS) by analyzing the distribution of ImmunoGlobulins and Complement.

In tissue derived from cases of MS, and from control Inflammatory White Matter Diseases known to express Viral and AutoAntigens in the Brain and Spinal Cord.

Methods
Autopsy tissue from 25 MS patients and 24 patients with Other Neurological Diseases was examined ImmunoHistoChemically for ImmunoGlobulins and activated Complement (C3d and C9neo).

Results
In tissue remote from focal lesions in MS and Other Neurological Diseases, IgG was detected in many normal structures but not in Myelin or Ramified Microglia.

Disrupted Myelin in areas of active Myelin breakdown and in Phagocytes stained positively for C3d and C9neo, and equivocally for IgG in MS and all other Neurological Diseases examined, including Ischemic infarcts.

Disease-specific deposits of IgG or Complement were detected in Virus-infected cells in Progressive Multifocal Leukoencephalopathy, Subacute Sclerosing PanEncephalitis, and CytomegaloVirus Encephalitis; in Glial-limiting membranes in NeuroMyelitis Optica; and in senile plaques in Alzheimer's Dementia.

Specific to MS were unusual Microglial nodules containing short, linear deposits of activated Complement (C3d) on partly DeMyelinated Axons located in Normal-Appearing PeriPlaque White Matter.

Interpretation
IgG and Complement immunostaining of disrupted Myelin in MS lesions, frequently cited as an indication of pathogenic Anti-Myelin AntiBodies:

Is a nonspecific feature that cannot be interpreted as evidence of a distinct pathogenesis or serve to define particular variants of the disease.

The unusual Microglial nodules described in this study may constitute a specific biomarker with pathogenetic significance in MS.

Ann Neurol 2009;65:32-46.

Therapeutic Vaccination using T-Cell Receptor (TCR) Peptides from V genes commonly expressed by potentially pathogenic T-Cells remains an approach of interest for treatment of Multiple Sclerosis (MS) and other Autoimmune Diseases.

We developed a trivalent TCR Vaccine containing Complementarity Determining Region (CDR) 2 Peptides from BV5S2, BV6S5 and BV13S1:

Emulsified in incomplete Freund's adjuvant that reliably induced high frequencies of TCR-specific T-Cells.

To evaluate induction of regulatory T-Cell subtypes, Immunological and Clinical parameters were followed in 23 treatment-naïve subjects with Relapsing/Remitting or Progressive MS.

Who received 12 monthly injections of the Trivalent Peptide Vaccine over 1 year in an open-label study design.

Prior to Vaccination, subjects had reduced expression of Forkhead Box (Fox) P3 message and protein, and reduced recognition of the expressed TCR repertoire by TCR-reactive Cells compared with healthy control donors.

After three or four injections, most Vaccinated MS subjects developed high frequencies of circulating InterLeukin-10 (IL-10)-secreting T-Cells specific for the injected TCR Peptides.

And significantly enhanced expression of FoxP3 by regulatory T-Cells present in both 'native' CD4⁺ CD25⁺ and 'inducible' CD4⁺ CD25^- Peripheral Blood Mononuclear Cells (PBMC).

At the end of the trial, PBMC from vaccinated MS subjects retained or further increased FoxP3 expression levels.

Exhibited significantly enhanced recognition of the TCR V gene repertoire apparently generated by perturbation of the TCR network, and significantly suppressed NeuroAntigen but not Recall Antigen responses.

These findings demonstrate that therapeutic Vaccination using only three commonly expressed BV gene determinants can induce an expanded ImmunoRegulatory Network in vivo that may optimally control complex AutoReactive responses that characterize the inflammatory phase of MS.

The value of Experimental Autoimmune Encephalomyelitis (EAE), an animal model of Multiple Sclerosis, in deriving novel diagnostic and therapeutic input has been subject to recent debate.

This study is the first to report a disseminated distribution of plaques including Cranial Nerves, prior to or at early stages of disease in murine adoptive transfer EAE, irrespective of the development of clinical symptoms.

We induced EAE by adoptive ProteoLipid Protein-specific T-Cell transfer in 26 female SJL/J mice, and applied high-field-strength Magnetic Resonance Imaging (MRI) scans longitudinally, assessing Blood-Brain Barrier (BBB) disruption by Gadopentate dimeglumine enhancement.

We visualized inflammatory Nerve Injury by Gadofluorine M accumulation, and Phagocytic Cells in inflamed tissue by Very Small Anionic Iron Oxide Particles (VSOP-C184).

MRI was correlated with ImmunoHistological sections. In this study, we discovered very early BBB breakdown of White and Gray Brain Matter in 25 mice; one mouse developed exclusively Spinal Cord inflammation.

Widely disseminated Contrast-Enhancing Lesions preceded the onset of disease in 10 animals.

Such lesions were present despite the absence of any clinical disease formation in four mice, and coincided with the first detectable symptoms in others.

Cranial Nerves, predominantly the Optic and Trigeminal Nerves, showed signal intensity changes in Nuclei and Fascicles of 14 mice. At all sites of MRI lesions we detected cellular infiltrates on corresponding Histological sections.

The discrepancy between the disease burden visualized by MRI and the extent of disability indeed mimics the human Clinico-Radiological Paradox.

MRI should therefore be implemented into evaluational in vivo routines of future therapeutic EAE studies.