Advancements in multiple sclerosis

Abstract

The global prevalence of multiple sclerosis (MS) is increasing, and early diagnosis and treatment is essential in mitigating disability. While recent therapeutic advancements have significantly reduced relapse rates, the progressive and degenerative aspects of MS continue to pose major challenges. This year updates to the McDonald diagnostic criteria aim to enhance sensitivity and facilitate earlier use of disease-modifying therapies in asymptomatic patients. Additionally, novel biomarkers will gain ground in clinical practice and offer new approaches to optimising care. Following the widespread use of cell depleting immunosuppressive agents, innovative therapeutic directions such as chimeric antigen receptor T-cell therapy and Epstein-Barr virus (EBV) vaccination represent promising new directions in the management of MS. This clinical perspective provides a comprehensive overview of the disease while highlighting important advancements shaping the future of the field.

Keywords: MRI; multiple sclerosis; neuroimmunology; neurology.

Figure 1

Reproduced from Prineas et al. 2021. “Exceptionally early lesions in exceptionally early multiple sclerosis. The lesion at the far right showed, at high magnification, pyknotic oligodendrocytes and pale but intact myelin. The large lesion on the left showed commencing loss of myelin in the presence of numerous early phagocytes and monocytes. Unidentified large IgG + mononuclear cells were present throughout the section (A) Luxol fast blue‐PAS, (B) CD45, (A and B) × 2.5”.

Figure 2

Sagittal and Axial T2 FLAIR lesions in characteristic periventricular distribution with perpendicular/perivenular orientation (A, B), juxtacortical white matter lesions (C – red arrows), infratentorial brain stem and cerebellum (D), right optic nerve (E – yellow arrow), spinal cord (F – green arrows).

Figure 3

Non‐contrast Axial T1 with focal hypointense “black holes” (A – blue arrows). Post‐contrast Axial T1 with incomplete ring of enhancement (B – yellow arrow). Axial SWI (T2*) and magnified image shows lesion with a “central vein sign” (green arrow) and “paramagnetic rim lesion” (red arrows) (C).