Multiple Sclerosis Journal

BackgroundMultiple sclerosis (MS) is a complex autoimmune disease with the HLA region showing the strongest known genetic influence. Although HLA-DRB1*15:01 is a well-known risk allele in European populations, data from Southeastern Europe--and Albania specifically--are still limited. ObjectiveTo assess allele- and haplotype-level associations at HLA class I (A*, B*, C*) and class II (DRB1*, DQB1*) loci with MS risk in Albanians, and to explore their correlations with clinical phenotypes. MethodsWe conducted a case-control study involving 128 consecutive Albanian MS patients diagnosed according to the 2017 revised McDonald criteria and 148 unrelated healthy Albanian controls. Second-field HLA genotyping (PCR-SSP) was performed at A*, B*, C*, DRB1*, and DQB1* loci. Allele frequencies were calculated through direct gene counting, and Hardy-Weinberg equilibrium (HWE) was tested for each locus. Frequencies of five-locus haplotypes (A[~]B[~]C[~]DRB1[~]DQB1) were estimated using maximum likelihood with an expectation-maximization (EM) algorithm. Differences between groups were evaluated with Fishers exact test and odds ratios (OR), along with 95% confidence intervals (CI). Multiple testing corrections were applied using the Bonferroni and Benjamini-Hochberg false discovery rate (FDR) methods. Clinical correlations were compared between DRB1*15:01 carriers and non-carriers across phenotype categories (RR, SP, PP), EDSS scores, relapse rates, and MRI activity. ResultsAll loci in controls conformed to HWE; in patients, class I loci conformed while DRB1* and DQB1* showed deviations. Carrier status for HLA-DRB1*15:01 was significantly higher in patients (40.6%) compared to controls (16.2%) (OR = 3.53; p < 0.0001), remaining significant after Bonferroni and FDR corrections. HLA-DQB1*06:02 also stayed significant after correction, consistent with linkage disequilibrium with DRB115:01. Other significant statistical differences did not persist after multiple testing adjustments. Patients exhibited greater five-locus haplotype diversity than controls (17 vs. 10 haplotypes [&ge;]1%). A patient-enriched haplotype, A*68:01[~]B*18:01[~]C*07:01[~]DRB1*15:01[~]DQB1*06:02, was common among cases and absent in controls, whereas A*02:01[~]B*51:01[~]C*15:02[~]DRB1*16:01[~]DQB1*05:02 was less frequent in cases and remained protective after Bonferroni correction. No significant differences were seen in clinical course (RR/SP/PP), EDSS measures, relapse rate, or MRI activity between DRB115:01 carriers and non-carriers. At the population level, MS prevalence across 22 European countries was positively correlated with DRB115:01 frequency (Spearman {rho} = 0.645; p = 0.0012). ConclusionsIn Albanians, HLA-DRB1*15:01 significantly increases the risk of MS, with DQB1*06:02 reflecting the same signal due to strong linkage. Risk- and protection-associated five-locus haplotypes further clarify the HLA genetic architecture in MS patients; however, DRB1*15:01 carriage does not noticeably influence the clinical phenotype or the severity of disease outcome. The relatively lower frequency of the DRB1*15:01 allele in the Albanian population may help explain the countrys lower MS prevalence compared to Northern Europe. Larger cohorts and inclusion of non-HLA loci are necessary to identify additional factors contributing to MS susceptibility and progression in this population.

ObjectivesSlow-burning inflammation at the edge of chronic multiple sclerosis lesions and loss of myelin in the depths of the lesions have emerged as a key components of disease progression. However, their relative contribution to progressive axonal damage has not been investigated. Therefore, the aim of the study was to examine relative weight of those factors in axonal attrition inside the chronic MS lesions by measuring tissue rarefication of the lesion core. MethodsPre- and post-gadolinium 3D-T1, 3D FLAIR, diffusion tensor images, Optical Coherence tomography and multifocal visual evoked potentials were acquired from 52 patients. Analysis was performed between baseline and 48 months. Lesion expansion was measured using in-house software. The degree of lesional tissue damage was determined by measuring increase of Mean Diffusivity (MD) in lesion core normalised over MD dynamic range. ResultsThere were 104 expanding and 257 stable lesions. Rate of normalised MD (nMD) increase was several folds higher in expanding vs stable lesions (0.21% vs 1.12% per year, p=0.01). The magnitude of nMD change was significantly associated with the rate of lesion expansion (r=0.4, p<0.001). Analysis of visual system revealed the rate of axonal loss similar to the degree of tissue rarefication in stable lesions. InterpretationThe current study demonstrated a significant increase in water content in chronic MS lesions, which was, however, markedly higher in slowly expanding compared to stable lesions. This suggests that slow-burning inflammation at the lesion rim, when present, is likely to play a more significant role in axonal attrition than chronic demyelination.

BackgroundProper identification of disability accumulation in the routine clinical care of progressive multiple sclerosis (PMS) patients is usually a challenging task. Patient-reported outcome measurements (PROMs) can provide a practical, cost-efficient, and remotely accessible tool to assess disease progression. MethodsEmBioProMS is a prospective, multicentric cohort, conducted in 7 specialized MS centers in Germany. PROMs were evaluated at inclusion and compared between patients with retrospective evidence of disease progression in the last two years and those with stable disease. Patients with either primary or secondary progressive MS according to the McDonald criteria 2017 were included in the analysis, while patients with incomplete PROMs scores, MS relapses, other neurological or systemic inflammatory diseases were excluded. The disease progression was assessed using a combined outcome parameter, including EDSS score, timed 25-foot walk test, and nine-hole-peg test. Results185 patients were included in the final analysis (SPMS, n=77; PPMS, n=108). The median age and disease duration were 55 years and 13 years, respectively. Disease progression was diagnosed in 114 of 185 patients (61.6%). BDI-II, MSIS-29, and FSMC scores were worse in patients with evidence of disease progression in the last two years. Patients with any of the included PROMs above the 90th percentile had an odds ratio of 3.8 (95% confidence interval: 1.4-10.6, P=0.01) for having progression in the last two years in a binomial regression model adjusted for age, sex, disease duration, treatment status, center effect, and Expanded Disability Status Scale (EDSS). Similar results were observed in patients with PROM scores in the 80th and 70th percentile (OR: 2.9 and 3.7, P=0.015 and 0.003, respectively). ConclusionPROMs can be a simple and effective way to detect disability worsening in a chronic neurological disease like PMS and, therefore, substantially contribute to better classification and prognostication of the disease course through objective and structural patient-doctor communication. Trial RegistrationGerman Clinical Trials Register (Deutsches Register Klinischer Studien - DRKS), DRKS00020132

Background and objectivesCortical lesions (CL) are common in multiple sclerosis (MS) and associate with disability and progressive disease. We asked whether CL continue to form in people with stable white matter lesions (WML) and whether the association of CL with worsening disability relates to pre-existing or new CL. MethodsA cohort of adults with MS were evaluated annually with 7 tesla (T) brain magnetic resonance imaging (MRI) and 3T brain and spine MRI for 2 years, and clinical assessments for 3 years. CL were identified on 7T images at each timepoint. WML and brain tissue segmentation were performed using 3T images at baseline and year 2. Results59 adults with MS had [&ge;]1 7T follow-up visit (mean follow-up time 2{+/-}0.5 years). 9 had "active" relapsing-remitting MS (RRMS), defined as new WML in the year prior to enrollment. Of the remaining 50, 33 had "stable" RRMS, 14 secondary progressive MS (SPMS), and 3 primary progressive MS. 16 total new CL formed in the active RRMS group (median 1, range 0-10), 7 in the stable RRMS group (median 0, range 0-5), and 4 in the progressive MS group (median 0, range 0-1) (p=0.006, stable RR vs PMS p=0.88). New CL were not associated with greater change in any individual disability measure or in a composite measure of disability worsening (worsening Expanded Disability Status Scale or 9-hole peg test or 25-foot timed walk). Baseline CL volume was higher in people with worsening disability (median 1010l, range 13-9888 vs median 267l, range 0-3539, p=0.001, adjusted for age and sex) and in individuals with RRMS who subsequently transitioned to SPMS (median 2183l, range 270-9888 vs median 321l, range 0-6392 in those who remained RRMS, p=0.01, adjusted for age and sex). Baseline WML volume was not associated with worsening disability or transition from RRMS to SPMS. DiscussionCL formation is rare in people with stable WML, even in those with worsening disability. CL but not WML burden predicts future worsening of disability, suggesting that the relationship between CL and disability progression is related to long-term effects of lesions that form in the earlier stages of disease, rather than to ongoing lesion formation.

BackgroundGrey matter (GM) atrophy has been suggested as the most accurate marker of neurodegeneration in multiple sclerosis (MS) progression. However, long-term comparisons between MS and healthy controls (HC) are rare, and the most significantly atrophying brain regions and their clinical importance still need robust and longitudinal validation. MethodsThis multi-cohort longitudinal observational study used two relapsing remitting MS (RRMS) cohorts (N=386, T1w-scans=940) sampled for up to 12 years to map grey matter atrophy localisation and disease progression (Expanded Disability Status Scale (EDSS), Paced Auditory Serial Addition Test (PASAT), Fatigue Severity Scale (FSS)). The identified region-specific significant atrophy was compared with 2,163 HCs (T1w-scans=4,326). ResultsThe strongest, replicable, significant brain atrophy patterns in RRMS were found in the frontal lobes, specifically, in the superior frontal cortex (SFC, {beta}age[&le;]-0.27), pars orbitalis ({beta}age[&le;]-0.25), and thalami ({beta}age[&le;]-0.20). Across samples, the examined significant atrophy patterns in MS were more pronounced than in a sample of more than 20-years older HCs in the right SFC (Z>2.41, p<0.009), caudal-middle frontal cortex (Z>2.08, p<0.019), caudate (Z>2.09, p<0.019), and the left frontal pole (Z>2.42, p<0.008). The replicability of associations between volumetric and clinical outcome changes was limited and better described by whole-brain than regional volume changes. ConclusionsOur findings indicate accelerated GM atrophy in people with RRMS, specific to the SFL and thalamus and related to disability-progression. These results can inform further studies examining the role of thalamic and SFC atrophy as MS-biomarkers. Key MessagesO_ST_ABSWhat is already known on this topicC_ST_ABSGrey matter atrophy is considered a hallmark of neurodegeneration in multiple sclerosis, with regional atrophy, especially in the thalamus, linked to disability progression. However, few studies have longitudinally examined region-specific atrophy and its clinical relevance or compared MS-related atrophy with normal ageing using large control samples. What this study addsThis study identifies replicable, region-specific grey matter atrophy in the superior frontal cortex and thalamus across two independent RRMS cohorts. It shows that atrophy in these regions occurs earlier and more rapidly in MS than in healthy controls who are approximately 20 years older. Frontal lobe atrophy was most consistently associated with disability progression. Yet, associations between atrophy and changes in clinical scores were weak and sample dependent. How this study might affect research, practice or policyOur findings suggest to further explore frontal grey matter atrophy as a potential imaging biomarker for MS progression. This could inform future clinical trials, improve prognostic models, and guide the development of personalized treatment strategies based on region-specific brain changes.

BackgroundIn multiple sclerosis (MS), 7 Tesla (7T) MRI improves the visualization of cortical (CLs) and white matter (WM) lesions with a paramagnetic rim (PRLs), associated with smoldering inflammation. Spinal cord (SC) atrophy is a critical determinant of clinical disability in MS, but its importance relative to PRLs and CLs in predicting neurological disability remains unclear. PurposeTo identify the most relevant predictors for baseline neurological disability and 4-year disease progression independent of relapse activity (PIRA) in a heterogeneous MS cohort. Materials and MethodsOne-hundred-twelve MS patients (83 relapsing-remitting, 29 secondary progressive) were prospectively recruited between 2010 and 2024. 7T T2*-susceptibility-weighted imaging was acquired to segment CLs, PRLs, and non-rim WM lesions, and 3T T1-weighted brain MRI to estimate cortical thickness, brain WM volume, and the SC C2-C3 cross-sectional area (CSA) using FreeSurfer and Spinal Cord Toolbox. Expanded Disability Status Scale (EDSS) was assessed at baseline and longitudinally, in 97/112 MS patients, after a mean follow-up of 4.0 years. Associations between imaging metrics and clinical outcomes were evaluated using regression models. ResultsBaseline EDSS was associated with non-rim WM lesion volume (p=<0.001), CL volume (p=0.001), brain WM volume (p=0.017), and C2-C3 CSA (p=0.003). At follow-up, 23/97 patients showed PIRA. PIRA was associated with PRL volume (p=0.030), CL volume (p=0.011), and brain WM volume (p<0.001). A stepwise logistic regression identified CL volume as the strongest independent predictor of PIRA (Nagelkerke R2=0.200, OR=1.0006, p=0.005). Patients with a CL load > 403 mm3 progressed in half of cases (70% sensitivity, 50% specificity) within 4 years. ConclusionIn MS, different imaging biomarkers are associated with either the current disability or PIRA. Spinal cord atrophy mainly explains the current EDSS, while brain WM atrophy and PRLs provide additional insights into future disability trajectory. Among all markers, CLs emerged as the main driver for PIRA.

Background/PurposeLeptomeningeal enhancement (LME) on post-contrast FLAIR is described as a potential biomarker of meningeal inflammation in multiple sclerosis (MS). Here we report a comprehensive assessment of the impact of MRI field strength and acquisition timing on meningeal contrast enhancement (MCE). MethodsThis was a cross-sectional, observational study of 95 participants with MS and 17 healthy controls (HC) subjects. Each participant underwent an MRI of the brain on both a 7 Tesla (7T) and 3 Tesla (3T) MRI scanner. 7T protocols included a FLAIR image before, soon after (Gd+ Early 7T FLAIR), and 23 minutes after gadolinium (Gd+ Delayed 7T FLAIR). 3T protocol included FLAIR before and 21 minutes after gadolinium (Gd+ Delayed 3T FLAIR). ResultsLME was seen in 23.3% of participants with MS on Gd+ Delayed 3T FLAIR, 47.4% on Gd+ Early 7T FLAIR (p = 0.002) and 57.9% on Gd+ Delayed 7T FLAIR (p < 0.001 and p = 0.008, respectively). The count and volume of LME, leptomeningeal and paravascular enhancement (LMPE), and paravascular and dural enhancement (PDE) were all highest for Gd+ Delayed 7T FLAIR and lowest for Gd+ Delayed 3T FLAIR. Non- significant trends were seen for higher proportion, counts, and volumes for LME and PDE in MS compared to HCs. The rate of LMPE was different between MS and HCs on Gd+ Delayed 7T FLAIR (98.9% vs 82.4%, p = 0.003). MS participants with LME on Gd+ Delayed 7T FLAIR were older (47.6 (10.6) years) than those without (42.0 (9.7), p = 0.008). Conclusion7T MRI and a delay after contrast injection increased sensitivity for all forms of MCE. However, the lack of difference between groups for LME and its association with age calls into question its relevance as a biomarker of meningeal inflammation in MS.

Background and ObjectivesWolfram syndrome (WFS) is a genetic disorder mainly caused by pathogenic variants in the WFS1 gene. It is characterized clinically by optic atrophy (OA), diabetes mellitus (DM), sensorineural hearing loss (SNHL), diabetes insipidus (DI), and variable neurological/psychiatric symptoms. WFS typically manifests before age 20 and progresses into adulthood. Classical neuroradiological features include cerebellar and/or brainstem atrophy as well as white matter abnormalities ranging from small, ovoid lesions to diffuse, symmetrical changes along the visual pathway. Following the identification of multifocal, progressive white matter abnormalities that prompted the consideration of multiple sclerosis (MS) in two molecularly confirmed WFS subjects, we sought to verify whether MS-like lesions constitute a novel WFS-associated MRI pattern. MethodsWe conducted an international multicenter retrospective study of the clinical, genetic, and radiological data from 17 unrelated WFS subjects. ResultsSeven subjects (7/17; 41%) showed at least one focal white matter lesion evocative of MS. Among these seven, three fulfilled the McDonald radiological criteria of dissemination in space and time, suggesting an inflammatory demyelinating process. All subjects reviewed in the study had at least one of the classical WFS MRI features. ConclusionsOur report expands the WFS spectrum of white matter involvement to include progressive, seemingly inflammatory demyelinating lesions. While we cannot exclude the possibility of a WFS-MS dual diagnosis in some cases, the role of WFS1 in myelination suggests a selective white matter vulnerability in WFS. Our findings suggest that follow up MRI should be recommended to adult subjects with WFS. Further identification and longitudinal study of adult WFS subjects is required to confirm whether a WFS molecular diagnosis confers susceptibility to the development of MS.

IntroductionCortical grey (CoGM) and white matter (WM) microglial activation (MA) is involved in the pathogenesis of multiple sclerosis (MS). [F-18]PBR06 positron emission tomography (PET) targeting 18kilodalton-translocator protein (TSPO) can detect abnormal MA in MS. Aims and ObjectivesThe goal of this study is to determine the effect of disease modifying treatment (DMT) efficacy on modulating the extent and clinical and radiological correlates of MA in MS patients. MethodsThirty [F-18]PBR06 PET scans were performed in 22 MS patients (13 RR, 9 SP, mean age 46{+/-}14 years, 15 females, median EDSS 3.5, mean T25FW 7.2{+/-}4.6s) and 8 healthy controls (HC). Individualized z-score maps of brain parenchymal MA were generated by voxel-by-voxel comparison between each subjects PET SUVR images and a HC dataset. Logarithmically transformed Glial activity load on PET scores (calculated as the sum of voxel-by-voxel z-scores [&ge;]4 in CoGM and WM regions), lnGALP, were compared between MS subjects on DMT with high efficacy (HT; including rituximab, ocrelizumab, natalizumab and fingolimod, n=13) versus those on no or lower efficacy treatment (LT; including glatiramer acetate and interferons), and correlated with clinical measures and cortical thickness (measured using Freesurfer). p<0.05 was considered statistically significant. ResultsCoGM and WM lnGALP scores were higher in MS vs. HCs (10.0{+/-}1.5 vs. 7.5{+/-}1.5 and 9.8{+/-}1.5 vs. 6.6{+/-}2.4, both p<0.01) and were inversely correlated with cortical thickness across groups (r=-0.44 and - 0.48, both p<0.05, n=30). In HT-MS group, CoGM and WM lnGALP was significantly lower as compared to LT-MS group (9.1{+/-}1.0 vs. 11.3{+/-}1.1 and 9.1{+/-}1.3 vs. 10.8{+/-}1.4, p=0.000075 and 0.006) but remained abnormally higher than in HC group (p=0.006 and 0.02, respectively). Within HT-MS patients, CoGM lnGALP scores were higher in SP vs. RR subgroups (p=0.008), correlated positively with EDSS, T25FW, fatigue scores and serum GFAP levels (r=0.65,0.79, 0.75 and 0.67, all p<0.05), and inversely with cortical thickness (r=-0.66, p=0.01). ConclusionsHigh-efficacy DMTs decrease, but do not normalize, CoGM and WM MA in MS patients. Such "residual" MA in CoGM is associated with clinical disability, symptom severity and cortical degeneration. Individualized mapping of TSPO-PET using [F-18]PBR06 can potentially serve as an imaging biomarker for evaluating emerging therapies targeting MA in MS patients who are worsening despite high-efficacy DMTs.

BackgroundThe choroid plexus (CP), central to cerebrospinal fluid (CSF) regulation and immune cell trafficking, has been implicated in multiple sclerosis (MS). ObjectivesWe investigated TSPO-PET standardized uptake value ratio (SUVR) in the CP, with relation to T{square} relaxation times and CP volume using 7T MRI. MethodsQuantitative T1 (qT1) maps were obtained from 38 MS participants and 21 healthy controls (HCs) using 7T MRI. Within 4 weeks, PET imaging was conducted with [{superscript 1}{superscript 1}C]PBR28 to measure SUVR in the CP. Group differences and associations in CP SUVR, qT1, and CP volume were assessed. ResultsCP SUVR, CP qT1, and head{square}size-corrected CP volumes were higher in MS than HCs (p<0.05). CP volume associated strongly with CP qT1 (r=0.52, p<0.05). In MS, CP SUVR inversely correlated with qT1 ({rho}= -0.45, p<0.05). No significant associations were observed with disability scores, white{square}matter lesion burden and cortical lesion counts. ConclusionsOur findings support elevated microglial/macrophage activation in CP alongside structural alterations. CP volume emerges as a complementary MRI marker of inflammation rather than a direct surrogate for TSPO-PET tracer uptake. The inverse CP SUVR-qT{square} relationship in MS suggests that chronic extracellular expansion can accelerate tracer washout.

BackgroundMultiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD) share overlapping clinical and imaging features, complicating differential diagnosis. The choroid plexus is increasingly recognized as a regulator of neuroinflammation and may play a critical role in the pathogenesis and differentiation of these conditions. Choroid plexus cysts (CPCs) are difficult to detect with conventional MRI resolution and standard anatomical approaches. High-resolution 7T MRI enables their visualization as readily identifiable and quantifiable morphological changes, offering a new direction for choroid plexus research. ObjectiveTo characterize choroid plexus cysts (CPCs) in aquaporin-4 antibody-positive NMOSD and relapsing-remitting MS (RRMS) using ultra-high-field 7T MRI. MethodsFourteen patients aged 16-30 years were prospectively recruited, including seven NMOSD (mean age 22.9 years) and seven MS (mean age 22.1 years). CPCs were assessed on UHR-T2WI-TSE images for number, maximum/minimum diameter, and cross-sectional area. Conventional brain lesions were evaluated on T2-FLAIR. Independent readings by two radiologists were adjudicated by a senior neuroradiologist. ResultsCPCs were present in all NMOSD patients (7/7) but only 57% of MS patients (4/7). Compared with MS, NMOSD showed a higher CPC burden with greater counts (median 4 vs 1; p=0.037) and non-significant trends toward larger diameters and areas (maximum diameter 4.17 mm vs 2.27 mm; minimum diameter 3.58 mm vs 1.82 mm; cross-sectional area 4.41 mm2 vs 2.02 mm2; p=0.072-0.095). Both groups demonstrated right-sided predominance. In contrast, brain lesions were more prevalent in MS (7/7) than in NMOSD (3/7; p=0.015). Conclusions7T MRI reveals distinct CPCs characteristics in NMOSD and MS. Despite fewer brain lesions in NMOSD compared with MS, CPCs burden remained consistently higher. These findings suggest that CPCs may represent a more sensitive and quantifiable structural change, serving as a potential imaging-biomarker for distinguishing NMOSD from MS. Validation in larger cohorts is warranted to advance understanding of neuroimmunological diseases and to clarify the role of CPCs in neuroinflammation. Key pointO_LIIdentifying additional differences in brain injury between NMOSD and MS is crucial for diagnosis and therapy. C_LIO_LICPCs are more prevalent and distinct in NMOSD than in MS, unveiling an "iceberg" of structural pathology hidden at conventional imaging resolution. C_LIO_LICPCs are readily identifiable and quantifiable, indicating their potential as a novel imaging biomarker for differential diagnosis in clinical practice. C_LI

BackgroundMultiple sclerosis (MS) is a chronic autoimmune disorder affecting the central nervous system (CNS). Reactivation of Human herpesvirus 6 (HHV-6) and Epstein-Barr virus (EBV) is observed in MS. ObjectivesThis study investigates immunoglobulins (Ig)G, IgM, and IgA directed against EBV nuclear antigen EBNA-366-406, HHV-6 and EBV deoxyuridine-triphosphatase (dUTPase), and different immune profiles in 58 patients with relapsing remitting MS (RRMS) compared to 60 healthy controls. MethodsWe employed enzyme-linked immunosorbent assays (ELISA) to measure the immunoglobulins to viral antigens. Multiplex immunoassays were used to measure cytokines, chemokines and growth factor levels that were used to compute immune profiles, including M1 macrophage, T helper (Th)-1, Th-17, and overall immune activation. We assessed disabilities using the Expanded Disability Status Scale (EDSS) and disease progression using the Multiple Sclerosis Severity Score (MSSS). ResultsIgG/IgA/IgM directed to the three viral antigens were significantly higher in RRMS than in controls. RRMS was significantly discriminated from controls by using IgG and IgM against HHV-6 dUTPase, yielding an accuracy of 91.5% (sensitivity=87.3% and specificity=95.2%). Neural network analysis showed that using IgG to EBV-dUTPase, IgM to EBV-dUTPase, and immune profiles yielded an area under the ROC curve of 1 and a predictive accuracy of 97.1%. There were strong associations between IgG/IgM responses to HHV-6 and EBV-dUTPases and the EDSS/MSSS scores and aberrations in M1, Th-17, profiles, and overall immune activation. ConclusionsHHV-6 and EBV reactivation play a key role in RRMS and these effects are mediated by activation of cytokine profiles.

ObjectiveRecent studies suggest that disruptions of the blood-cerebrospinal fluid barrier within the choroid plexus (ChP) may contribute to MS pathogenesis. We investigated the relationship between a quantitative marker of ChP enhancement and markers of focal and diffuse brain tissue injury in multiple sclerosis (MS). Methods34 MS participants underwent 7T MRI including MP2RAGE-based qT1 mapping pre- and post-contrast, and FLAIR acquisitions. "Delta T1" ({Delta}T1) maps were calculated by subtraction of post-contrast from co-registered pre-contrast qT1 maps. ChP, white matter lesions (WML), normal-appearing white matter (NAWM) and grey matter (GM) were segmented. Linear regression analyses were conducted between mean {Delta}T1 values of ChP and (1) WML volume, (2) pre-Gd mean qT1 of WML, (3) pre-Gd mean qT1 of NAWM, and (4) pre-Gd mean qT1 of GM. Results{Delta}T1 of ChP was significantly associated with pre-Gd qT1 of NAWM ({beta} =0.20, R2 = 0.54, p<0.001) and GM ({beta} = 0.32, R2 = 0.62, p<0.001). No significant associations were found between ChP {Delta}T1 and WML volume (p = 0.3) or WML qT1 (p = 0.05). InterpretationThe strong associations we observed between the degree of ChP contrast enhancement and markers of diffuse brain tissue injury, combined with a lack of a relationship with lesion volume or qT1 within lesions, support the hypothesis that entry of toxic factors into the CSF via the ChP may constitute an additional mechanism of brain tissue injury distinct from the classic lesion-based pathology of MS.

BackgroundPredicting response to treatment and risk of long-term disability in multiple sclerosis (MS) is challenging. In other disease areas, combining genetic risk variants enabled detection of relevant clinical endophenotypes associated with important outcomes, but this has never been applied to MS. MethodsWe applied unsupervised hierarchical clustering to genomic risk scores of two cohorts (the prospective cohort study of 1455 Welsh MS patients was used as the discovery cohort and replication was performed in a multi-centre post-mortem Netherlands Brain Bank cohort of 272 MS patients) to predict relevant disease outcomes using survival analysis for time to disability milestones (expanded disability status scale, EDSS), and ANOVA to compare linear clinical outcomes. ResultsThree genomic clusters were identified, in each cluster patients had similar genetic profiles. Baseline demographic characteristics were similar between clusters. Welsh patients in cluster 1 attained key disability milestones later, reaching EDSS6, 6 years later (p=0.003) and EDSS8, 13 years later (p=0.02) than those in clusters 2 and 3. Time to EDSS6 was also significantly longer for patients in cluster 1 versus cluster 2 in the NBB-MS cohort (6 years, p=0.04). Genomic clustering is an independent predictor for disease progression compared with well-validated risk factors (Hazard ratio for time to EDSS6 1.3-2.0, all p<0.05). Welsh patients in cluster 2 and 3 also had a significantly greater annual increase in T2 lesion load on serial MR imaging (p=0.04). In cluster 2, patients who had received MS disease modifying treatments (DMT) had a longer time to EDSS6 (p=0.003) compared to those that had received no DMTs, whereas no differences were observed in either cluster 1 or cluster 3. In the NBB-MS cohort, we also observed differences in symptomatology, including earlier development of swallowing problems (p=0.02) or muscle spasticity (p= 0.0008) in cluster 2 patients. ConclusionThis study demonstrates that unsupervised genetic clustering has utility to detect clinically relevant endophenotypes of MS, with genetic cluster 2 patients having a more severe phenotype and higher risk of disability. Moreover, genetic stratification is able to predict response to DMTs and could potentially be used for precision medicine in MS management.

Patient-reported outcomes importantly reflect the lived experiences of persons with multiple sclerosis (MS); however, given the broad array of MS symptoms, comprehensive evaluation can be burdensome, especially with lengthy questionnaires. The MS Impact Scale queries twenty different physical difficulties (MSIS-20). In 1150 patients with MS, evaluation of internal consistency indicated redundancy in the MSIS-20 (Cronbachs alpha: 0.96), but optimal internal consistency (0.90) of a six-item short form (MSIS-SF; first six MSIS items). The MSIS-20 and MSIS-SF showed comparably strong associations with objective physical disability. The MSIS-SF provides a psychometrically robust, less burdensome, and time-efficient option for assessing patient-reported physical disturbance.

BackgroundTreatment strategy for relapsing multiple sclerosis (RMS) is increasingly shifting towards first-line use of high-efficacy DMT (H-DMT). However, DMT efficacy declines with increasing age and the benefit of first line H-DMT at higher age remains unclear. Here, we aimed to investigate whether the superiority of H-DMT over moderate-efficacy DMT (M-DMT) depends on age. MethodsUsing the Austrian MS database, we included previously DMT-naive RMS patients aged [&ge;]18 years, who i) initiated a DMT continuing it for [&ge;]12 months, ii) had MRI at baseline, and iii) had clinical follow-up for [&ge;]24 months. Cox regression analyses including age and DMT strategy (H-DMT vs. M-DMT) plus an interaction effect were employed to predict time to relapse. ResultsA total of 215 RMS patients (median age of 41 years [25th-75th percentiles: 32-53], 66% females) were observed over a median of 42 (28-58) months. During this period, eighty-one (38%) patients had a relapse. While increasing age was associated with decreased risk of relapse (hazard ratio (HR) 0.95 per year, 95% confidence interval [CI]: 0.93-0.98, p<0.001), the use of H-DMT lowered the risk of relapse compared to M-DMT (HR 0.06, 95%-CI: 0.01-0.45, p=0.007). In patients with H-DMT, the benefit of treatment was reduced by increasing age (HR: 1.06, 95%-CI: 1.01-1.11, per year, p=0.031). Superiority of H-DMT over M-DMT was estimated to be lost at the age of approximately 50 years. ConclusionThe benefit of H-DMT over M-DMT as first-line treatment decreases with increasing age and seems to vanish in patients above approximately 50 years. What is already known on this topicHigh-efficacy disease-modifying treatments (H-DMTs) are increasingly used as first-line therapy in relapsing multiple sclerosis (RMS) due to their superior effectiveness in reducing inflammatory disease activity. However, both clinical and radiological disease activity naturally decline with age, and prior meta-analyses suggest that the relative benefit of H-DMT over moderate-efficacy DMTs (M-DMTs) diminishes in older patients. These findings have largely been derived from clinical trials with restricted age ranges and enriched disease activity, limiting their generalizability to real-world, treatment-naive populations across the full adult age spectrum. What this study addsIn a real-world, national cohort of DMT-naive RMS patients across a wide range of age, this study shows that while H-DMTs significantly reduce the risk of relapse compared to M-DMTs, their superiority is progressively attenuated with advancing age. Notably, the benefit of initiating H-DMTs as first-line therapy becomes statistically indistinguishable from M-DMTs around the age of 50 years. These findings were independent of baseline disease duration and other covariates, emphasizing age as a key modifier of treatment effect. How this study might affect research, practice or policyThese findings support the integration of age as a critical factor in guiding first-line DMT decisions for RMS. For patients over 50 years, M-DMTs may offer a more appropriate initial treatment option, minimizing exposure to the higher risk profiles of H-DMTs in the absence of clearly superior efficacy. This study underscores the importance of personalized treatment approaches and highlights the need for future clinical trials to include broader age ranges, facilitating evidence-based, age-adjusted treatment strategies in multiple sclerosis.

BackgroundAccelerated long-term forgetting (ALF), defined as an increased rate of memory loss over extended intervals, has so far been detected in a pilot study of patients with mild multiple sclerosis (MS). This study aimed to (I) confirm the presence of ALF in a larger, heterogeneous MS sample, (II) explore associations with patient-reported outcomes, and (III) assess the diagnostic performance of ALF tests for subjective memory impairment. MethodsThis study compared 62 MS patients and 65 age-, sex-, and education-matched healthy controls using standardized memory tests (RAVLT, WMS-IV Logical Memory subtest). Recall was assessed immediately, after 30 minutes, and after 7 days. Seven-day/30-minute recall ratios (QRAVLT, QWMS) served as primary outcomes. Self-report measures included memory complaints, fatigue, depression, and sleep disturbances. Linear regression and Receiver operating characteristic (ROC) analyses assessed predictors and diagnostic accuracy. ResultsALF was observed in multiple sclerosis since QRAVLT was lower in patients than in controls (0.64 [95% CI 0.59-0.69] vs. 0.78 [0.73-0.82], p < 0.001), as was QWMS (0.79 [95% CI 0.74-0.84] vs. 0.95 [0.90-1.00], p < 0.001), despite comparable initial learning. Greater fatigue, higher memory complaints, longer disease duration, older age, and greater disability were associated with lower ALF scores. The combined ALF score moderately discriminated subjective memory impairment (AUC 0.74; sensitivity 0.73; specificity 0.73). ConclusionMS patients showed ALF despite normal initial learning, indicating a specific memory deficit undetected by standard tests. Long-delay recall using RAVLT and WMS-IV Logical Memory subtest may improve cognitive impairment detection in MS.

BackgroundPregnancy in women with multiple sclerosis (MS) is associated with a reduction of long-term disability progression. The mechanism that drives this effect is unknown, but converging evidence suggests a role for epigenetic mechanisms altering immune and/or central nervous system function. ObjectivesWe aimed to identify whole blood and immune cell-specific DNA methylation patterns associated with parity in relapse-onset multiple sclerosis. MethodsWe compared whole-blood methylation patterns between 96 matched pairs of nulligravida and parous females with MS (n=192). Parity was defined as at least one term or pre-term birth, and nulligravida was defined as no prior pregnancies. Methylation was measured with Illumina EPIC arrays, and data was pre-processed and statistically analysed using the ChAMP package. Cell-type proportions were estimated using the EpiDISH package, and cell-specific analysis conducted using linear regression. Gene-set enrichment analysis (GSEA) was performed with ToppGene API and GOmeth. Methylation age was calculated with the methyAge package. Methylation age acceleration (MAA) was calculated by regressing methylation age on chronological age. FDR<0.05 was used to assess significance. ResultsThe median time from last pregnancy to blood collection was 16.66 years (range = 1.45 - 44.42 years). We identified 903 differentially methylated positions (DMPs) in whole blood; 365 were hypomethylated and 528 were hypermethylated in parous women. We further identified two differentially methylated regions (DMRs) in CRYGN on Chromosome 7 and an intergenic region on Chromosome 15. There were four and eight cell type specific DMPs in CD4+ and CD8+ cells, respectively. Differentially methylated genes were enriched in neuronal plasticity pathways. Parity was associated with reduced MAA by a mean of 1.44 to 2.27 years using the PhenoAge (p = 0.002) and GrimAge (p = 0.005) algorithms. ConclusionWhole-blood methylation patterns are associated with birth history in females with relapse-onset multiple sclerosis. We found enrichment of differentially methylated genes encoding neuronal processes and reduced MAA in parous women. These methylation changes could mediate the long-term benefit of pregnancy for disease progression in multiple sclerosis.

Background: People with multiple sclerosis (MS) are a vulnerable group for severe COVID-19, particularly those taking immunosuppressive disease-modifying therapies (DMTs). We examined the characteristics of COVID-19 severity in an international sample of people with MS. Methods: Data from 12 data-sources in 28 countries were aggregated. Demographic and clinical covariates were queried, alongside COVID-19 clinical severity outcomes, hospitalisation, admission to ICU, requiring artificial ventilation, and death. Characteristics of outcomes were assessed in patients with suspected/confirmed COVID-19 using multilevel mixed-effects logistic regression. Results: 657 (28.1%) with suspected and 1,683 (61.9%) with confirmed COVID-19 were analysed. Older age, progressive MS-phenotype, and higher disability were associated with worse COVID-19 outcomes. Compared to dimethyl fumarate, ocrelizumab and rituximab were associated with hospitalisation (aOR=1.56,95%CI=1.01-2.41; aOR=2.43,95%CI=1.48-4.02) and ICU admission (aOR=2.30,95%CI=0.98-5.39; aOR=3.93,95%CI=1.56-9.89), though only rituximab was associated with higher risk of artificial ventilation (aOR=4.00,95%CI=1.54-10.39). Compared to pooled other DMTs, ocrelizumab and rituximab were associated with hospitalisation (aOR=1.75,95%CI=1.29-2.38; aOR=2.76,95%CI=1.87-4.07) and ICU admission (aOR=2.55,95%CI=1.49-4.36; aOR=4.32,95%CI=2.27-8.23) but only rituximab with artificial ventilation (aOR=6.15,95%CI=3.09-12.27). Compared to natalizumab, ocrelizumab and rituximab were associated with hospitalisation (aOR=1.86,95%CI=1.13-3.07; aOR=2.88,95%CI=1.68-4.92) and ICU admission (aOR=2.13,95%CI=0.85-5.35; aOR=3.23,95%CI=1.17-8.91), but only rituximab with ventilation (aOR=5.52,95%CI=1.71-17.84). Importantly, associations persisted on restriction to confirmed COVID-19 cases. No associations were observed between DMTs and death. Conclusions: Using the largest cohort of people with MS and COVID-19 available, we demonstrated consistent associations of rituximab with increased risk of hospitalisation, ICU admission, and requiring artificial ventilation, and ocrelizumab with hospitalisation and ICU admission, suggesting their use may be a risk factor for more severe COVID-19.

BackgroundLanguage dysfunction is increasingly recognized as a prevalent and early affected cognitive domain in individuals with MS. ObjectivesTo establish a network-level model of language dysfunction in MS. MethodsCognitive data and 3T functional and structural brain MRI were acquired from 54 MS patients and 54 matched healthy controls (HCs). Functional summary measures (anteriority, segregation, betweenness, within-ness) of the extended language network (ELN) were calculated and structural imaging metrics were derived. Group differences in ELN connectivity were evaluated. Associations between ELN connectivity and language performance were assessed; in the MS group, an unsupervised learning approach was used to assess relationships between multimodal neuroimaging features derived from language-related areas and performance on language tasks. ResultsThe MS group performed worse on semantic fluency and rapid automized naming tests (p<0.005) compared to HC. Regarding ELN measures, the MS group exhibited higher within-ELN connectivity than HCs (p<0.05). Principal component analysis (PCA) yielded a multimodal latent component that uniquely correlated with language performance (p<0.05). ConclusionWe identified network-level functional and structural measures to potentially characterize language dysfunction in MS. Further studies leveraging these features may reveal mechanisms and predictors of language dysfunction specific to MS.