Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Review
. 2024 Feb 7:17:17562864241229325.
doi: 10.1177/17562864241229325. eCollection 2024.

Prognostic relevance of MRI in early relapsing multiple sclerosis: ready to guide treatment decision making?

Olaf Hoffmann  1 , Ralf Gold  2 , Sven G Meuth  3 , Ralf A Linker  4 , Thomas Skripuletz  5 , Heinz Wiendl  6 , Mike P Wattjes  7
Affiliations
Review

Prognostic relevance of MRI in early relapsing multiple sclerosis: ready to guide treatment decision making?

Olaf Hoffmann et al. Ther Adv Neurol Disord. .

Abstract

Magnetic resonance imaging (MRI) of the brain and spinal cord plays a crucial role in the diagnosis and monitoring of multiple sclerosis (MS). There is conclusive evidence that brain and spinal cord MRI findings in early disease stages also provide relevant insight into individual prognosis. This includes prediction of disease activity and disease progression, the accumulation of long-term disability and the conversion to secondary progressive MS. The extent to which these MRI findings should influence treatment decisions remains a subject of ongoing discussion. The aim of this review is to present and discuss the current knowledge and scientific evidence regarding the utility of MRI at early MS disease stages for prognostic classification of individual patients. In addition, we discuss the current evidence regarding the use of MRI in order to predict treatment response. Finally, we propose a potential approach as to how MRI data may be categorized and integrated into early clinical decision making.

Keywords: MRI; brain; multiple sclerosis; prognosis; spinal cord.

Plain language summary

Can MRI help select appropriate therapy for recently diagnosed multiple sclerosis? MS is a chronic autoimmune disease of the brain and spinal cord that causes physical and cognitive disability. Initially, most people with MS (pwMS) experience attacks of new symptoms and periods of partial recovery; this is called relapsing-remitting MS (RRMS). RRMS transitions to secondary progressive MS (SPMS), where there is a gradual worsening of disability. MS medications dampen parts of the immune system. They reduce the risk of relapses and delay transition to SPMS if started early. Once a person has SPMS, treatment can slow but not stop further deterioration. MS medications vary in their effects on the immune system, level of efficacy, and treatment risks. The course of MS is highly individual. When starting therapy, it can therefore be difficult to decide whether a drug with lower or higher efficacy is required. Some of the acute and chronic inflammatory changes in MS are shown as focal lesions (‘spots’) on MRI of the brain and spinal cord. They are very useful for diagnosing MS and determining disease activity. Even if there are no relapses, new lesions indicate that a MS medication is not fully effective. In addition, MRI provides a snapshot of tissue damage that has accumulated up to the examination. At the time of diagnosis, MRI reflects the natural history of MS in the individual, even before the first attack, and contains prognostic information. We review studies that investigate an association between certain MRI findings obtained early after the initial attack and the later course of MS. We propose that these metrics can be applied to a concept of grading and staging of MS as well as estimating functional reserve. We review thresholds that identify pwMS at risk of disability progression and transition to SPMS, who should be recommended highly effective therapy first line. Leveraging the prognostic capabilities of MRI may support initial treatment decisions.

PubMed Disclaimer

Conflict of interest statement

OH reports speaker or consultancy honoraria or support for attending scientific meetings from Alexion, Bayer Healthcare, Biogen, Bristol-Myers Squibb/Celgene, Janssen, Merck, Novartis, Roche, Sandoz, Sanofi and Teva; and research support from Biogen, Novartis and Sanofi. RG received speaker honoraria from Biogen, Teva Pharmaceutical Industries Ltd., Bayer Schering Pharma and Novartis; serves as editor for Therapeutic Advances in Neurological Disorders and on the editorial boards of Experimental Neurology and the Journal of Neuroimmunology; and receives research support from Teva Pharmaceutical Industries Ltd., Biogen Idec, Bayer Schering Pharma, Genzyme, Merck Serono and Novartis. Because RG is the Editor-in-Chief of Therapeutic Advances in Neurological Disorders, the peer review process was managed by alternative members of the Board, and the submitting Editor was not involved in the decision-making process. SGM received honoraria for lecturing and travel expenses for attending meetings from Almirall, Amicus Therapeutics Germany, Bayer Health Care, Biogen Idec, Celgene, Diamed, Sanofi-Aventis, MedDay, Merck Serono, Novartis, Novo Nordisk, ONO Pharma, Roche, Chugai Pharma, QuintilesIMS and Teva. His research is funded by the German Ministry for Education and Research (BMBF), Bundesinstitut für Risikobewertung (BfR), Deutsche Forschungsgemeinschaft (DFG), Else Kroener-Fresenius Foundation, Gemeinsamer Bundesausschuss (G-BA), German Academic Exchange Service, Hertie Foundation, Interdisciplinary Center for Clinical Studies (IZKF) Muenster, German Foundation Neurology, and by Alexion, Almirall, Amicus Therapeutics Germany, Biogen Idec, Diamed, Fresenius Medical Care, Sanofi-Aventis, HERZ Burgdorf, Merck Serono, Novartis, ONO Pharma, Roche and Teva. RL received speaker or consultancy honoraria from Biogen, Bristol Myers Squibb/Celgene, Hexal, Janssen Cilag, Merck, Novartis, Roche and Sanofi-Genzyme as well as research support from Biogen and Novartis. TS reports honoraria for lectures and travel grants from Alexion, Alnylam Pharmaceuticals, argenx, Bayer Vital, Biogen, Celgene, Centogene, CSL Behring, Euroimmun, Janssen, Merck Serono, Novartis, Pfizer, Roche, Sanofi, Siemens, Sobi, Teva, Viatris. His research is supported by the German Ministry for Education and Research (BMBF), Bristol-Myers Squibb Foundation for Immuno-Oncology, Claudia von Schilling Foundation for Breast Cancer Research, Else Kröner-Fresenius Foundation, Hannover Biomedical Research School (HBRS), Alnylam Pharmaceuticals, CSL Behring, Novartis, Sanofi Genzyme, VHV Foundation. HW served on Scientific Advisory Boards of Abbvie, Alexion, Argenx, Bristol Myers Squibb, Janssen, Merck and Novartis. He received speaker’s honoraria and travel support from Alexion, Biogen, Bristol-Myers Squibb, F. Hoffmann-La Roche, Genzyme, Merck, Neurodiem, Novartis, Roche, Teva and WebMD Global and acts as a paid consultant for Abbvie, Actelion, Argenx, Biogen, Bristol-Myers Squibb, EMD Serono, Fondazione Cariplo, Gossamer Bio, Idorsia, Immunic, Immunovant, Janssen, Lundbeck, Merck, NexGen, Novartis, PSI Contract Research Organization, Roche, Sanofi, UCB and Worldwide Clinical Trials. His research is funded by Alexion, Amicus Therapeutics, Argenx, Biogen, CSL Behring, F. Hofmann-La Roche, Genzyme, Merck, Novartis, Roche and UCB. MW received speaker or consultancy honoraria from Alexion, Bayer Healthcare, Biogen, Biologix, Bristol Myers Squibb, Celgene, Genilac, Imcyse, IXICO, Icometrix, Medison, Merck-Serono, Novartis, Roche, Sanofi-Genzyme. Publication royalties from Springer and Elsevier.

Figures

Figure 1.
Figure 1.
MRI images of the brain (a–e) and spinal cord (e, f) obtained in MS patients presenting with the first clinical event demonstrate MRI features that provide prognostic information regarding the clinical outcome. (a) Axial FLAIR image showing a high T2 lesion load in the periventricular, deep and juxtacortical white matter; (b) axial contrast-enhanced T1-weighted image showing two contrast-enhancing lesions in the deep white matter of the left hemisphere; (c) axial contrast-enhanced T1-weighted image showing several T1-hypointense lesions (‘black holes’); (d) axial DIR image showing several leucocortical lesions; (e) axial DIR image showing multiple infratentorial lesions including a brain stem lesion; (f, g) sagittal STIR and contrast-enhanced T1-weighted image showing asymptomatic lesions in the cervical spinal cord. DIR, double inversion recovery; FLAIR, fluid-attenuated inversion recovery; MRI, magnetic resonance imaging; MS, multiple sclerosis; STIR, short tau inversion recovery.
Figure 2.
Figure 2.
Integrated view of prognostic MRI findings. The expected course of the disease, in particular the evolution of disability over time, is modulated by the level of disease activity and brain reserve. Initial disease activity can be graded according to the presence of gadolinium-enhancing (Gd+) lesions or the number or volume of new or enlarging T2-hyperintense (NET2) lesions on short-term follow-up scans. White matter and cortical lesion load is a product metric of preclinical disease duration and severity, providing staging-related information. In addition to lesion volume, atrophy and presence of lesions in critical systems such as spinal cord and brain stem indicate lower functional reserve and a risk of more rapid development of disability. Together, staging, grading and reserve-related information may be useful in predicting the individual disease course and recommended treatment intensity. MRI, magnetic resonance imaging.
See this image and copyright information in PMC

Similar articles

See all similar articles

Cited by

See all "Cited by" articles

References

    1. Reich DS, Lucchinetti CF, Calabresi PA. Multiple sclerosis. N Engl J Med 2018; 378: 169–180. - PMC - PubMed
    1. Thompson AJ, Banwell BL, Barkhof F, et al.. Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria. Lancet Neurol 2018; 17: 162–173. - PubMed
    1. Barnett M, Barnett Y, Reddel S. MRI and laboratory monitoring of disease-modifying therapy efficacy and risks. Curr Opin Neurol 2022; 35: 278–285. - PubMed
    1. Wijburg MT, Warnke C, McGuigan C, et al.. Pharmacovigilance during treatment of multiple sclerosis: early recognition of CNS complications. J Neurol Neurosurg Psychiatry 2021; 92: 177–188. - PubMed
    1. Rovira À, Wattjes MP, Tintoré M, et al.. Evidence-based guidelines: MAGNIMS consensus guidelines on the use of MRI in multiple sclerosis-clinical implementation in the diagnostic process. Nat Rev Neurol 2015; 11: 471–482. - PubMed

LinkOut - more resources