Spinal Cord as an Adjunct to Brain Magnetic Resonance Imaging in Defining “No Evidence of Disease Activity” in Multiple Sclerosis

Abstract

CME/CNE Information Activity Available Online: To access the article, post-test, and evaluation online, go to http://www.cmscscholar.org. Target Audience: The target audience for this activity is physicians, physician assistants, nursing professionals, and other health-care providers involved in the management of patients with multiple sclerosis (MS). Learning Objectives: Accreditation Statement: This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the Consortium of Multiple Sclerosis Centers (CMSC), Nurse Practitioner Alternatives (NPA), and Delaware Media Group. The CMSC is accredited by the ACCME to provide continuing medical education for physicians. The CMSC designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Nurse Practitioner Alternatives (NPA) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. NPA designates this enduring material for 1.0 Continuing Nursing Education credit (none in the area of pharmacology). Laurie Scudder, DNP, NP, has served as Nurse Planner for this activity. She has disclosed no relevant financial relationships. Disclosures: Editor in Chief of the International Journal of MS Care (IJMSC), has served as Physician Planner for this activity. He has received royalties from Springer Publishing; has received consulting fees from Acorda Therapeutics, Merz Pharma, and Ipsen; and has performed contracted research for Biogen, Acorda Therapeutics, and Adamas Pharmaceuticals.Francois Bethoux, MD, has served as Nurse Planner for this activity. She has disclosed no relevant financial relationships.Laurie Scudder, DNP, NP, has disclosed no relevant financial relationships.Subhash Tummala, MD, has disclosed no relevant financial relationships.Tarun Singhal, MD, has disclosed no relevant financial relationships.Vinit V. Oommen, MD, has disclosed no relevant financial relationships.Gloria Kim, BA, has disclosed no relevant financial relationships.Fariha Khalid, MD, has received research support from Genzyme, Merck Serono, Novartis, and Verily Life Sciences.Brian C. Healy, PhD, has received consulting fees from AbbVie, Alkermes, Biogen, Novartis, and Questcor; and has received research support from Biogen, Genzyme, Merck Serono, Novartis, and Teva. Dr. Bakshi's spouse owns stock in Biogen.Rohit Bakshi, MD, One anonymous peer reviewer for the IJMSC has received consulting fees or honoraria from Actelion, Bayer HealthCare, Biogen Idec, Chugai, EMD Canada, Genzyme, Merck Serono, Novartis, Hoffman-La Roche, Sanofi-Aventis, and Teva Canada Innovation; has served on a speakers' bureau for Genzyme; has served on an advisory board, a board of directors, or another similar group for Actelion, Bayer HealthCare, Biogen Idec, Hoffman-La Roche, Merck Serono, MedDay, Novartis, and Sanofi-Aventis; and has received research support from Genzyme. The other two reviewers have disclosed no relevant financial relationships. The staff at the IJMSC, CMSC, NPA, and Delaware Media Group who are in a position to influence content have disclosed no relevant financial relationships. Method of Participation: Release Date: May 1, 2017 Valid for Credit Through: May 1, 2018 In order to receive CME/CNE credit, participants must: Statements of Credit are awarded upon successful completion of the post-test with a passing score of >70% and the evaluation. There is no fee to participate in this activity. Disclosure of Unlabeled Use: This CME/CNE activity may contain discussion of published and/or investigational uses of agents that are not approved by the FDA. CMSC, NPA, and Delaware Media Group do not recommend the use of any agent outside of the labeled indications. The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of CMSC, NPA, or Delaware Media Group. Disclaimer: Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any medications, diagnostic procedures, or treatments discussed in this publication should not be used by clinicians or other health-care professionals without first evaluating their patients' conditions, considering possible contraindications or risks, reviewing any applicable manufacturer's product information, and comparing any therapeutic approach with the recommendations of other authorities.

Brain and spinal cord MRI lesions in primary progressive vs. relapsing-remitting multiple sclerosis

“…Our spinal cord imaging may have been limited by lower sensitivity with the reliance on available routine clinical images. With higher resolution research-dedicated protocols and other more sensitive sequences, such as short time inversion recovery (STIR), we may have been able to capture more lesions [ 37 , 38 ]. In addition, the MRI scans were performed at 1.5T; however, with the growing use of 3T scanners for routine MS care and 7T scanners for research investigations, and their potentially higher lesion sensitivity in the brain and spinal cord [ 15 , 39 ], it would be of interest to extend our results to higher field strengths.…”

Limited utility of adding 3T cervical spinal cord MRI to monitor disease activity in multiple sclerosis

“…16 SC-MRI monitoring in pwMS on first-line DMT also led to a modest but statistically significant 7.8% decrease in the proportion of pwMS with NEDA in another recent study. 18 However, Tummala et al 17 showed a low diagnostic yield of 3T SC-MRI in the 1-year evaluation of NEDA with 39/61 (63.9%) pwMS achieving NEDA by brain MRI; only one showed disease activity on SC-MRI that was also clinically symptomatic, resulting in no or disability worsening over median follow-up intervals ranging from 14 to 42 months. 14,15,32 These results further underscore the notion that the utility of SC-MRI for disease monitoring may be limited, even when using NEDA, the "highest bar" of treatment outcome measures.…”

“…16 SC-MRI monitoring in pwMS on first-line DMT also led to a modest but statistically significant 7.8% decrease in the proportion of pwMS with NEDA in another recent study. 18 However, Tummala et al 17 showed a low diagnostic yield of 3T SC-MRI in the 1-year evaluation of NEDA with 39/61 (63.9%) pwMS achieving NEDA by brain MRI; only one showed disease activity on SC-MRI that was also clinically symptomatic, resulting in no failure of NEDA based on SC-MRI alone. Although we were not able to evaluate NEDA in our study due to the lack of availability of EDSS scores that were done concurrently with MRIs, we were still able to evaluate those who were clinically stable with respect to relapses and MRI disease activity, and the relative contribution of adding SC-MRI to brain MRI in evaluating NEDA.…”

“…14,15 Reported decrease in "No Evidence of Disease Activity" (NEDA) status with inclusion of SC-MRI as part of MRI disease activity in pwMS also varied from a mere 2.6% to up to 12.4%. [16][17][18] While SC-MRI is still not routinely recommended in most practice guidelines, including the recent 2021 Magnetic Resonance Imaging in MS (MAGNIMS)-Consortium of MS Centers (CMSC)-North American Imaging in MS Cooperative (NAIMS) consensus recommendations, 7,[19][20][21] many MS neurologists do routinely order SC-MRI together with brain MRI for disease-monitoring purposes in MS.…”

Brain microstructural injury occurs in patients with RRMS despite ‘no evidence of disease activity’

“…However, routine clinical MRIs may not have offered the same surveillance as do more frequent MRIs performed in clinical trials. Additionally, not all patients underwent routine spinal cord surveillance, although this is low yield in monitoring for NEDA 24. While our study utilised medical record documentation of fatigue complaints, a comparison of DTI changes with formal assessments of fatigue and cognition would be beneficial in future studies.…”