CHAIR SUMMIT 7TH ANNUAL #CHAIR2014. Master Class for Neuroscience Professional Development. September 11 13, Westin Tampa Harbour Island

Transcription

1 #CHAIR2014 7TH ANNUAL CHAIR SUMMIT Master Class for Neuroscience Professional Development September 11 13, 2014 Westin Tampa Harbour Island Sponsored by

2 #CHAIR2014 Use of MRI in Clinical Decision- Making in MS Michael K. Racke, MD Wexner Medical Center at The Ohio State University Columbus, OH

3 Michael K. Racke, MD Disclosures Grants/Research Support: National Institutes of Health; National Multiple Sclerosis Society Consultant: Accorda Therapeutics; Biogen Idec; Questcor Pharmaceuticals, Inc.; Teva Neuroscience; Novartis Corporation Other Financial or Material Support: Honoraria for serving on editorial boards: JAMA Neurology; Journal of Neuroimmunology

4 #CHAIR2014 Learning 1 Objective Implement MRI in MS diagnosis strategy

5 #CHAIR2014 Learning 2 Objective Implement MRI to determine treatment selection

6 The Prognostic Value of Brain MRI in Clinically Isolated Syndromes of the CNS (a 10-Year Follow-Up) The rate of progression to clinically definite multiple sclerosis overall and for each clinical syndrome according to the baseline MRI Normal MRI Abnormal MRI All cases 3/27 (11%) 45/54 (83%) Optic neuritis 1/14 (7%) 25/28 (89%) Brainstem syndrome 0/5 (0%) 10/11 (91%) Spinal cord syndrome 2/8 (25%) 10/15 (67%) O Riordan et al. Brain. 1998;121(Pt 3), PMID

7 Clinical Outcome After 14 Years in Patients With Isolated Clinical Syndromes Clinical Outcome No. and Median Volume of Asymptomatic Lesions at Baseline* 0 (0 cm 3 ) (n = 21) 1-3 (0.6 cm 3 ) (n = 18) 4-10 (0.9 cm 3 ) (n = 15) Brex PA, et al. N Engl J Med. 2002;346(3): PMID: *The median volume was included when available. >10 (5.6 cm 3 ) (n = 17) Isolated syndrome no. (%) 16 (76) 1 (6) 0 1 (6) Clinically probable MS no. (%) 1 (5) 1 (6) 2 (13) 1 (6) CDMS no. (%) 4 (19) 16 (89) 13 (87) 15 (88) EDSS score no. > Median EDSS score Range of EDSS scores

8 MRI as a Predictor of Disability in patients with Multiple Sclerosis Long-term follow-up studies! Brex et al year follow-up! Increase lesion load predicts future disability! Fisher et al year follow-up! Atrophy predicts future disability Fisher E, et al. Neurology. 2002;59: ; PMID: Brex PA, et al. N Engl J Med. 2002;346(3): PMID:

9 Three Patients were Diagnosed with Multiple Sclerosis 5 Years Ago The diagrams below demonstrate the MRI activity of each patient over the past two years.

10 Signifies an exacerbation

11 A 35 Year Old Previously Healthy Female Referred to you for a 3 day history of lower back pain, weakness and burning sensation in her lower extremities and loss of bowel and bladder control! MRI of the spinal cord shows an enhancing lesion at T10! You start her on pulse doses of methylprednisolone and her symptoms begin to resolve over the next week

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13 If instead your work up yields a normal CSF analysis and no evidence of delay in visual evoked potentials. Her MRI is shown below

14 If instead your work-up had revealed a normal CSF analysis, no evidence of delay on visual evoked potential and the following MRI: Fleming JO. Diagnosis and Management of Multiple Sclerosis Johnson KA, et al.

15 A 31 Year Old Previously Healthy Female Saw her internist after having severe pain and weakness in her legs! She received pulse steroids and her symptoms resolved! Her internist referred her to a neurologist who ordered an MRI of her brain and spinal cord

16 MRI

17 A 24 Year Old Previously Healthy White Female Presents to her internist s office with 3 days of left eye pain! She noted blurry vision beginning that morning She is referred to an ophthalmologist who reports a normal exam except for decreased visual acuity of the left eye! She is given 3 days of pulse steroids with a taper and her vision improves and her pain diminishes

18 She is then referred to a neurologist who continues her work up.

19 Her neurologist meets with the patient and conducts an in depth history and physical exam A more detailed history illuminates an episode of 10 days of numbness in the right foot 3 years earlier! At that time, she was about to schedule a doctor s appointment when the numbness resolved and she did not think much of it Her neurologist ordered a battery of labs including Antinuclear Antibody (ANA), Rapid Plasma Reagin (RPR), B12, folate, Rheumatoid Factor (RF) that all returned negative

20 Revised McDonald s Criteria for Diagnosis of Multiple Sclerosis Paper-TipSheet_-2010-Revisions-to-the-McDonald-Criteria-for-the-Diagnosis-of-MS.pdf

21 Use of MRI in Diagnosing Multiple Sclerosis Demonstrate dissemination in space: Barkhof criteria: 1 Enhancing or 9 T2 (3 out of 4) 1 Juxtacortical-Cortical 3 Periventricular 1 Infratentorial No. of abnormal MRI criteria* Prevalence in 74 patients (%) Barkhof F, et al. J Neurol. 1997;244(2): PMID: Observed risk (% with CDMS) 0 24 (32) (12) (22) (16) (18) 87

22 Natural History of Multiple Sclerosis Measures of brain volume Relapses and impairment MRI burden of disease MRI activity Secondary-progressive Preclinical Relapsing-remitting Time

23 Clinical Connections Utilize MRI in Suspected MS (Report of the TTA Subcommittee of the American Academy of Neurology [AAN]) Recommendations: 1. 3 white matter lesions on T2 MRI has >80% sensitivity in predicting clinically defined multiple sclerosis (CDMS) in 7-10 years 2. 2 Gd-enhancing lesions predictive of CDMS 3. A new T2 or Gd-enhancing lesion identified 3 or more months after a clinically isolated syndrome (CIS) is very predictive of CDMS in the near future Frohman, et al. Neurology. 2003;61(5): PMID:

24 Questions & Answers #CHAIR2014