← MS Living Well: Key Info from Multiple Sclerosis Experts
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- [00:00]
Professor Xavier Montauban
Foreign.
- [00:06]
Dr. Barry Singer
Welcome back all, to the Ms. Living well podcast. I'm Dr. Barry Singer, director of the Ms. Center for Innovations in Care at Missouri Baptist Medical center in St. Louis. This episode is Diagnosing Multiple Sclerosis. This episode is sponsored by TG Therapeutics at Norax Pharm. TG Therapeutics is a biopharmaceutical company focused on treatments for B cell diseases such as Brienne Viv for multiple sclerosis. Evidence clearly shows that early intervention is key to living well with multiple sclerosis, particularly in this era of highly effective therapies. However, early symptoms of Ms. Are diverse, wide ranging, and sometimes even hard to detect. And as a result, many patients in the first stages of disease are undiagnosed or misdiagnosed. This can delay effective treatment, often for years. With so much at stake, it's vital that clinicians in every field are well informed about Ms. Symptoms and that our tools for early diagnosis are accurate, swift, and widely available. Later in the show, I'll be talking to a global leader in the world of ms, Professor Xavier Montauban from Barcelona, about new changes in diagnosing Ms. But first, I'm delighted to introduce Dr. Leora Freeman to the show. Dr. Leora Freeman is an assistant professor in the Dell Medical School Department of Neurology and a neurologist at the UT Health Austin Multiple Sclerosis and Neuroimmunology Center. Dr. Freeman earned both her medical degree and doctorate from the Universite Pierre and Marie Curie in Paris, France, where she completed a neurology residency and Ms. Fellowship. She finished her postdoctoral research training in neuroimaging at the Brain and Spine Institute in Paris. Her current research focuses on the application of advanced imaging techniques to determine the mechanisms driving disability progression and multiple sclerosis. Dr. Freeman, welcome to the Ms. Livingwell podcast.
- [02:07]
Dr. Leora Freeman
Oh, hi, Barry. Such a pleasure to be with you today.
- [02:10]
Dr. Barry Singer
Likewise. Leora, what are the first symptoms that might indicate someone has multiple sclerosis?
- [02:15]
Dr. Leora Freeman
Yeah, so it's important for people to understand that Ms. Is a condition that can affect any part of the central nervous system. So by this, we mean the optic nerve, the brain, the spinal cord. And because of this, people have very diverse presentations. Typical first symptoms of ms, however, can be visual. When the optic nerve is affected, that's what we call optic neuritis, where patients can have vision loss that can be more or less profound. With pain, people can present with sensory changes that affects the face or part of the body. They can have dizziness or imbalance. They may have some motor symptoms, usually asymmetric One leg more affected than the other. For example, sometimes people can have other types of visual symptoms like double vision. Those are all fairly typical presentation of Ms. But again, the key is to remember that it's a condition that can present in many different ways.
- [03:12]
Dr. Barry Singer
Yeah. So you kind of have to be on the lookout and so does the primary care physician or the gynecologist, whoever is seeing patients on a regular basis.
- [03:21]
Dr. Leora Freeman
Yeah, absolutely. And this is part of the difficulty with diagnosing this condition. It can look many different ways.
- [03:27]
Dr. Barry Singer
Yeah. And sometimes overlooked for quite some time before the diagnosis is made. A lot of patients, about 85% of patients, start out with relapses. So what actually is a relapse?
- [03:38]
Dr. Leora Freeman
So we have a technical definition for a relapse, which is that relapse consists of new neurological symptoms or the return of old symptoms for a period of 24 hours or more in the absence of an infection or a significant change in body temperature. So it's important to separate a relapse from a pseudo relapse. And that's what this definition alludes to. You know, when people have an infection, they have fever. This can lead to some neurological symptoms that are not due to new damage to the brain or central nervous system in general.
- [04:13]
Dr. Barry Singer
And some patients don't have relapses at the beginning. And how do you describe that?
- [04:18]
Dr. Leora Freeman
Yeah, as you mentioned, you know, about 85% of patients start with what we call a relapsing remitting course, where people experience attacks of new symptoms or old symptoms that return that then tend to go in remission. But there's about 10 to 15% of people with Ms. Who never have relapses. They may experience a slow, gradual onset of neurological symptoms over time. Those symptoms can be, in a lot of cases, symptoms that affect their ability to walk, motor weakness, stiffness in the legs, sometimes urinary symptoms. It can be also progressive worsening of cognitive symptoms. So it's important to really assess people thoroughly.
- [05:04]
Dr. Barry Singer
Yeah. And trying to categorize someone as relapsing or progressive is not always that clean in the real world. So some people have never had a big relapse, but they have long term fatigue and bladder issues at the same time. They're also not really progressive. So not everybody fits neatly into these categories.
- [05:23]
Dr. Leora Freeman
Exactly. And I think that's the whole difficulty is all of these invisible symptoms of Ms. Are entirely part of this condition. You know, the fatigue, sometimes the brain fog. And sometimes people may have these symptoms for quite some time without having a relapse or worsening. And I find that these patients are often those that have the longest delay in diagnosis.
- [05:44]
Dr. Barry Singer
So how does your neurologic examination help you diagnose ms?
- [05:48]
Dr. Leora Freeman
As you know, a neurological exam can give us clues as to what part of the central nervous system is affected when people present with neurological symptoms. So, for instance, if you know, you have a patient that comes to your clinic and they have vision loss in one eye, our examination can help us figure out that the optic nerve is likely affected. And that can lead us to ordering tests that will help identify Ms. Or if we take somebody who, you know, for example, has a motor weakness in the legs, through our exam, we can see sign that can help localize to the spinal cord and at what level. And that can guide us again to look at the spinal cord on MRI and possibly diagnose Ms. Whereas somebody may have similar symptoms, but on exam, they will have different findings that can localize to a different part of the nervous system that is not.
- [06:41]
Dr. Barry Singer
Affected by Ms. And with leg weakness, we also look for an increase in reflexes and muscle stiffness known as spasticity.
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Dr. Leora Freeman
Yeah, absolutely. So these are all the things that we look at to really make sure, first of all, isn't central nervous system affected? Where do we think it is affected? And that's really going to guide us and what tests we're going to order and which direction we're going. So it's always our starting point.
- [07:03]
Dr. Barry Singer
Good. So the next step, what tests would you order if you were suspecting someone might have Ms. Based on their history and their examination?
- [07:11]
Dr. Leora Freeman
I think the MRI is really the single most helpful test if we suspect somebody may have Ms. And that's usually where we start. So usually we recommend imaging of the entire central nervous system. So looking at the brain, looking at the cervical spine and thoracic spine so that we can assess the entirety of the spinal cord. Sometimes, especially if people have visual symptoms, I will order an MRI of the orbits to see if I can see some of the inflammation and damage that occurs. The MRI is usually where we start for people that we suspect may have.
- [07:43]
Dr. Barry Singer
Ms. Yeah, I mean, sometimes it's missed, too, because I've seen people have numbness in their legs going up to their pelvis, and the primary care does an MRI of their lumbar spine, their low back, but the spinal cord ends in the thoracic region, so there's really no spinal cord, just nerve roots in the lower part of their spine. So they actually miss the spinal cord.
- [08:02]
Dr. Leora Freeman
Yeah. That really highlights how important it is to know what test to Order. Multiple sclerosis, again, is a disease of the central nervous system. So we need to make sure that we image areas that help us.
- [08:13]
Dr. Barry Singer
Can you explain what the central nervous system is?
- [08:16]
Dr. Leora Freeman
The central nervous system is composed of the brain and the optic nerves and then also the spinal cord.
- [08:24]
Dr. Barry Singer
Excellent. So when you order an MRI scan of the brain and spinal cord, what are you looking for?
- [08:29]
Dr. Leora Freeman
The typical findings of Ms. On MRIs are those bright patches or bright spots that we call lesions. And those represent areas where there's been a loss of the myelin, the insulating layer of the nerves within the brain. And these lesions, which we call demyelinating lesions, are the hallmark of the disease. So they tend to have a certain shape that's kind of elongated. They tend to cluster in certain areas of the brain, such as near the central cavities of the brain, called the ventricle, or near the cortex, which is the outer layer of the brain. Some people, but not all people with ms, will have lesions of the spinal cord as well. Something else that we look at on MRI is whether people have lesions that are currently active. So MRIs, when we inject the contrast product that's called gadolinium, can help us distinguish between lesions that are dormant and lesions that are active. And only lesions that are active will enhance or become bright after you inject the contrast product. And those active lesions are early phase lesions. They are lesions where there's a lot of inflammation, the barrier between the blood and the brain is damaged, and that lets the contrast product leak into the brain. But it really reflects a lesion that's its early phase of formation.
- [09:53]
Dr. Barry Singer
Right. Those active lesions only last one to two months and then sometimes leave a scar behind and sometimes resolve completely. So you see these lesions on the brain, and sometimes it's a very classic appearance in multiple sclerosis, but sometimes it's not so clear. So are there other medical conditions that can cause white matter lesions?
- [10:13]
Dr. Leora Freeman
Yeah, absolutely. I was recently reading an article from colleagues in California who were saying that there's at least 27 conditions that can cause white matter lesions of the brain. The most common ones that we see in clinical practice for me are small vessel disease of the brain. It's a condition that usually affects older adults that's caused by a narrowing or an obstruction of the small vessels of the brain. And it's more frequent in people who have some cardiovascular risk factors like high blood pressure, diabetes, excess cholesterol, and smokers. Smokers? Yeah. That's a huge one.
- [10:49]
Dr. Barry Singer
Right.
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Dr. Leora Freeman
And these people can have neurological symptoms Associated with small vessel disease, often cognitive impairment. Another condition that we see frequently in clinical practice that affects younger people, particularly women, is migraines. People don't know that migraines can cause often those kind of little white spots in the brain that are, you know, usually very, you know, completely asymptomatic and benign. But that can confuse people who don't know Ms. Very well. And of course, there are other more rare conditions. Other autoimmune conditions of the brain in particular, or of the spinal cord can sometimes mimic ms, and it's important for us to differentiate those from Ms. Itself.
- [11:32]
Dr. Barry Singer
And so those conditions would be things like lupus. Right. So vasculitis.
- [11:37]
Dr. Leora Freeman
Yeah, lupus, vasculitis. Even antibody mediated conditions like neuromyelitis optica frequently causes lesions in the brain. MOG associated disorders. All of those are kind of in that spectrum of condition that's autoimmune in nature, but that can cause brain lesions. Sjogren is also one of them. We need to rule out other possible causes for the findings that we have.
- [12:00]
Dr. Barry Singer
Yeah, I tend to do a panel of about 14 different blood tests in the lab. They call it the Singer special. So I scream for all these conditions. I have to say though, like, out here in Missouri, I've been checking Lyme disease for more than two decades and I haven't picked up any Lyme disease. So it depends on where you are. Another one, sarcoid. So I have seen cases of sarcoidosis which usually have active contrast lesions. They tend not to lose their contrast over time.
- [12:25]
Dr. Leora Freeman
Yeah. And they tend to have also lesions that are outside of the brain that affect the meninges and the outer layers of the brain. And that's also some distinguishing characteristics on mri that's important for us to look for.
- [12:37]
Dr. Barry Singer
Yeah, I think it's also challenging. Like at 50, everybody gets a few white manner spots. So there's a lot of patients in their 40s and 50s who maybe have a few white manner spots, but their spinal fluid is normal and they don't have any lesions in the spinal cord. And it's really not clear do they have Ms. Or do they not?
- [12:57]
Dr. Leora Freeman
Yeah, and sometimes it's a very legitimate answer to not know. I think what we try to do in cases like this is really promote close follow up of these patients, close communication. And that really needs to be embedded in a trusting relationship between the neurologist and the patient.
- [13:16]
Dr. Barry Singer
Yeah, I think early in my career a lot of patients were put on the old injectable medications like copaxone or Glutamara acetate. It was very safe and not immunosuppressive if you were 90% confident they had MS, but you weren't really sure. But I think these days many of the medications are very immunosuppressive. So just start going down that path when you're not really conf of the diagnosis is a little worrisome. Yeah.
- [13:38]
Dr. Leora Freeman
You know, that's the flip side of all these misdiagnoses is when we have people who are given a diagnosis erroneously and maybe start on disease modifying therapies and experience all the morbidity that's associated with it. That's one more reason why it's so encouraging to see novel biomarkers being studied so that we can feel more safe in the diagnosis that we give our patients in the treatment that we prescribe.
- [14:02]
Professor Xavier Montauban
Right.
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Dr. Barry Singer
So speaking of novel biomarkers, there's a new test in development that we've actually already implemented here at Missouri Baptist Medical Center. It's called the central vein sign. Leora, can you tell our audience what the central vein sign is and how it might help?
- [14:16]
Dr. Leora Freeman
Yeah, we've actually been part of one of the big studies that's looking at the central vein sign as a potential biomarker for the diagnosis of Ms. So I'm very familiar with those images as well. So we've actually known for a really long time that Ms. Lesions tend to form around tiny veins, and through those tiny veins, immune cells can enter and attack the brain. And that's how lesions are formed. So most Ms. Lesions, if you look at brains of people with Ms. Post mortem, you can see that they have a vein in the middle of their lesions. But we never had a way to look at this in living individuals. Scientists have worked hard to develop these new MRI techniques that can allow us to look at the central vein sign on MRI scans. We're hoping that this will help with misdiagnoses and also help with delays in diagnosis.
- [15:18]
Dr. Barry Singer
Yeah, I think the jury's still out. I've seen some people with definitive Ms. Who have had it, and less than 50% had central veins, even though they have positive spinal fluid and leak lesions in their spinal cord. But I've seen some people where the diagnosis was ambiguous. It wasn't clear for years, and now we find that most of the lesions did have central veins and they do have Ms.
- [15:38]
Dr. Leora Freeman
I think it's going to be very interesting. A place where I think also the central vein sign is going to help us is when you have a person with Ms. Who's been on treatment for many years. And, you know, as they're getting older, they may have new bright spots that appear on their MRIs, but it's unsure whether those bright spots may be caused by Ms. Or not. And having this central vein sign may help us differentiate new lesions that are truly Ms. Related from those that may not be.
- [16:08]
Dr. Barry Singer
Yeah, those are excellent insights. So let's turn to lumbar punctures or the dreaded spinal tap.
- [16:14]
Dr. Leora Freeman
Your patient's favorite topic of discussion.
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Dr. Barry Singer
Oh, favorite topic. So can you explain, first of all, what's this procedure and the risk doing a lumbar puncture?
- [16:26]
Dr. Leora Freeman
So it's a pretty routine procedure at this stage. So what people have to understand is that our brain and our spinal cords are bathed in fluid. When we do a spinal tap, we take a needle and we insert it at the lumbar level to retrieve some of the fluid that's around our central nervous system. Commonly, what we're looking for is the presence of proteins called immunoglobulins that form what we call oligoclonal bands. And the presence of these proteins are a sign of inflammation of the central nervous system. That can give us confirmation that the person have Ms. However, not all people with Ms. Have those oligoclonal bands. I don't do spinal taps on everybody. Sometimes the clinical presentation is very clear. The MRI is very clear. But in some cases, it can give us a clearer picture as to. To whether really we're in the context of multiple sclerosis.
- [17:26]
Dr. Barry Singer
Yeah, that's an excellent overview. And in terms of risk, the main.
- [17:30]
Dr. Leora Freeman
Risk or the most common thing that people experience after a spinal tap is post lumbar puncture headache. So those are headaches that are usually positional, meaning that they worsen when the person is standing up or sitting up, and they improve when the person is laying down.
- [17:48]
Dr. Barry Singer
Do you do blood patches? That's what I typically do.
- [17:51]
Dr. Leora Freeman
Sometimes these headaches tend to go away on their own within 24 or 48 hours. But certainly if the headaches persist, it's really important to refer the patient for a blood patch. We take a little bit of blood from a peripheral vein, and then we inject it right when the lumbar puncture was done, and then the symptoms improve significantly.
- [18:11]
Dr. Barry Singer
All right, so what's a visual evidence potential, and how is that useful?
- [18:16]
Dr. Leora Freeman
I don't know about you, Barry, but I haven't ordered those in a really long time. I think back in the days where MRIs were not as good quality, we tended to order this more. So, in essence, the visual Evo potentials are tests that measure how long it takes the brain to respond to any stimulus that is sent to the eye. So people have shown a flashing chessboard pattern on a computer screen, and then they have electrodes on their scalp that's detecting brain activity. And in ms, we may notice a delay in the transmission of the nerve signal around those visual pathways. And that's what the visual evoked potential are aiming to detect.
- [18:53]
Dr. Barry Singer
Excellent. So, Leora, you just diagnosed someone with Ms. And you're in the clinic with them. What's your recommendations next?
- [19:00]
Dr. Leora Freeman
Navigating Ms. Can be extremely overwhelming. So for me, what's really key is to help build the proverbial village around my patients. And having the right care team is extremely important. First, having a doctor you trust, a care team with whom you're going to be able to communicate well and easily. It's really important for people with Ms. To have the right information about their treatment options. So I encourage them to connect with resources that are available to them. So give them some information from the National Ms. Society. Also, the Ms. Association of America has an excellent tool online that's called the Ultimate Treatment Guide where they can find unbiased information about Ms. Therapies. We have information about support groups in our community as well. All of this is really to build their understanding of the disease and the support that they can have.
- [19:55]
Dr. Barry Singer
Well, thank you so much, Dr. Freeman. Really some extraordinary insights that I think will help guide people in this process of getting diagnosed with Ms. It definitely helps to understand what your medical options are and what are the tests that are necessary to make sure you have a confident diagnosis of Ms.
- [20:13]
Dr. Leora Freeman
Awesome. Well, it was a pleasure to speak with you, Barry, and thank you for all the work that you do to really educate people with Ms. And their families and to raise awareness.
- [20:33]
Dr. Barry Singer
Really honored to have one of the leading global Ms. Experts join us next. Javier Montauban is Chair of Neurology at Valdebron University Hospital in Barcelona, Spain. He's also the Director of cemcat, the Multiple Sclerosis center of Catalonia, a leading global center for research and Ms. Care. Professor Multiban has served as Chair of the International Medical and Scientific Board of the Multiple Sclerosis International Federation and President of actromes, the European Committee for Treatment and Research in Multiple Sclerosis. Professor Multibon has been involved in the inception phases and on steering committees of numerous clinical trials related to multiple sclerosis. He's a leading researcher on MRI and biologic prognostic factors of disease evolution and treatment response. Welcome to the Podcast. Professor Monteman, thank you. So Dr. Freeman and I talked about early symptoms of Ms. And how difficult the disease can be to diagnose. Can you tell our audience why is early and accurate diagnosis so critical to our patients?
- [21:38]
Professor Xavier Montauban
By anticipating and facilitating the diagnosis of multiple sclerosis, we are now improving the prognosis in the long term. That's very clear. And in fact, fact, we published in 2021 in Neurology a paper showing that since we decreased by 77% the median time from first symptom suggestive of Ms. To Ms. Diagnosis, the probability of reaching an EDSS of 3 or higher at the age of 40 decreased from 0.86 to 0.2, which is really key. And this is the important factor for our patients.
- [22:15]
Dr. Barry Singer
Yeah. Just for our listeners to understand, we use this 10 point EDSS scale to measure disability for research purposes. And the point is that early diagnosis leads to early intervention and hopefully less disability over time.
- [22:29]
Professor Xavier Montauban
Absolutely, absolutely.
- [22:30]
Dr. Barry Singer
And if we get there early with our highly effective medications, we can change the whole future course for someone living with the disease. Right.
- [22:38]
Professor Xavier Montauban
You are completely right. In our clinical practice, we are now treating our patients first episodes with very high efficacy therapy. That means monoclonal antibodies, more than 75% of those. So we have changed our clinical practice very much.
- [22:53]
Dr. Barry Singer
Xavier, as you know, our diagnostic criteria for Ms. Has changed a lot over the years. One of the hallmarks of the disease that we looked for early in our careers was this concept of dissemination in space and time. What does that actually mean?
- [23:08]
Professor Xavier Montauban
Dissemination in space means that you want to have lesions in different locations. When we are using the mri, we are checking for lesions in some specific locations. We are checking the brainstem, we are checking the spinal cord, we will be checking the optic nerve in the next future as well. And I think this is the most important factor for diagnosing Ms. Nowadays. And then you have dissemination in time, which is, in my opinion, an old fashioned statement. Right. So dissemination in time means that you require to have different relapses over time or different MRI lesions over time. But now, as you said, we are using very high efficacy therapy from the very beginning. Our goal is not to have anything else. Right. We don't want to have relapses or new lesions. Hopefully this will be different in the new revision of the McDonald criteria.
- [24:07]
Dr. Barry Singer
So you mentioned the McDonald criteria, which we use today to diagnose Ms. But let's go back in time. In 1983, the poser criteria came out to diagnose Ms. Do you recall what was required then? To diagnose Ms. To be honest with.
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Professor Xavier Montauban
You, I never learned those criteria very well. They were quite complicated. You had a combination of clinical relapses, you know, abnormalities in the examination, then CSF study and then clinical evidence. So it was quite complex. Nowadays it's much, much simpler.
- [24:40]
Dr. Barry Singer
Back then, you really had to have two relapses at least a month apart, with evidence of dissemination space. So two lesions in the nervous system. But really, this was 1983, so MRI wasn't even part of the criteria. Spinal fluid was sometimes helpful in making the diagnosis correct. So what is clinically isolated syndrome? How do you explain that to our audience?
- [25:03]
Professor Xavier Montauban
Yeah, so clinically isolated syndrome is a first episode suggestive of demyelinating disease, suggestive of multiple sclerosis. That means noptic neuritis or amyelitis or a brainstem syndrome. It's a very bad name because means nothing clinically. But we haven't been able to find a better one.
- [25:23]
Dr. Barry Singer
So when we think about clinically isolated syndrome, do you have to have lesions on your brain to be a clinically isolated syndrome, or can you have optic neuritis with no lesions and still be clinically isolated sometimes?
- [25:34]
Professor Xavier Montauban
Well, this is a very important question. There is some confusion about that. You may have patients with clinically isolated syndrome and with a perfectly normal brain and spinal cord MRI. In fact, we have a prospective cohort of CIS patients since 1995, and 35% of our patients with CIS they had a normal brain MRI at that time. So CIS is just the definition and nothing else.
- [26:01]
Dr. Barry Singer
Javier, so can a patient with CIS be immediately diagnosed with MS?
- [26:07]
Professor Xavier Montauban
Absolutely. If a patient with a CIS, that means first episode suggestive of Ms. Has an abnormal MRI or fulfills the criteria of MS, they have Ms. And that happens in 60, 65% of patients with CIS. And that has clinical consequences, of course.
- [26:26]
Dr. Barry Singer
And how do you make that diagnosis? Like, what is going to distinguish someone that just has isolated optic neuritis from someone that optic rhinitis in the setting of ms?
- [26:35]
Professor Xavier Montauban
Right. We, of course perform a brain and a spinal cord mri. Then we look for the typical lesions in the typical topographies. We have now five typical topographies, spinal cord, juxtacortical, cortical, perventricular, brainstem and also optic nerve. Very soon, then you may look for other factors. For instance, the presence of oligogonal bands in the csf.
- [26:59]
Dr. Barry Singer
So we look for antibodies in the spinal fluid that are detected as actual visible bands on a lab test having two or more oligoclonal bands in the spinal fluid that are not present in the blood is consistent with multiple sclerosis.
- [27:12]
Professor Xavier Montauban
Yes.
- [27:13]
Dr. Barry Singer
Can you clarify what you meant by topography?
- [27:16]
Professor Xavier Montauban
I'm talking about the specific location. It's very important to highlight that not every white spot in the brain is going to be multiple sclerosis. So you're looking for, for typical lesions and you are looking those lesions in specific areas of the brain and in the spinal cord. That's very important.
- [27:34]
Dr. Barry Singer
Right. So you mentioned juxtaportical, which is right near the surface of the gray matter in the cortex, in the gray matter of the brain and then around the fluid filled spaces of the brain called the ventricles.
- [27:45]
Professor Xavier Montauban
Yes. In the brain stem as well and in the spinal cord. And the optic nerve? The optic nerve will be here very soon.
- [27:54]
Dr. Barry Singer
So to diagnose people, you mentioned McDonald criteria and that's evolved over time. How do you see that moving forward? In terms of helping us to make a diagnosis earlier of MS, we had.
- [28:06]
Professor Xavier Montauban
Five revisions of the McDonald criteria. Each time we modify something. One of the most important One was the 2001, of course, because we incorporated the MRI into the diagnostic criteria. I think another important Revision was in 2010 when we consider dissemination in time. When you have one single scan with gut and enhancing and non enhancing lesions, that was also quite key. And then in the last revision in 2017, we incorporated the polygonal bands in the CSF. They are very helpful to make the diagnosis of multiple sclerosis in quite a number of patients as well. So the different diagnostic criteria revisions have allowed us to make make the diagnosis of Ms. Earlier and earlier, therefore treating our patients earlier and earlier, improving the long term prognosis.
- [28:58]
Dr. Barry Singer
Yeah, I remember a time where a lot of people were not treated with clinically isolated syndrome, even though they, looking back, probably met the criteria of Ms. So it took a long time.
- [29:07]
Professor Xavier Montauban
Correct? Correct, yes.
- [29:09]
Dr. Barry Singer
So can you have Ms. Without neurologic symptoms?
- [29:12]
Professor Xavier Montauban
That's another important question. Of course. Yes, you can. In fact, we have ris, radiologically isolated syndrome, which means that you have a very typical MRI or a typical MRI with typical lesions, but don't have any typical symptom of Ms. And you can see patients who get an MRI due to headache, head trauma, number of reasons, and then you look to the MRI and you see the typical lesions. But now in the new revision of the McDonald criteria that we did just a few months ago, some of the RIS patients, some of the patients were with no typical symptoms, but with typical MRI and fulfilling other criteria will be considered multiple sclerosis and I think this is important as well.
- [29:59]
Dr. Barry Singer
So if you have radiologically isolated syndrome, do you have to have positive spinal fluid to be diagnosed with ms?
- [30:06]
Professor Xavier Montauban
Well, not necessarily. Of course, this is one of the criteria to have oligoconal bands in the csf. But also you may have dissemination in time, so some GAD lesions, and then you may consider that patient to have Ms. As well. The new criteria will be presented in Copenhagen very soon, in fact.
- [30:24]
Dr. Barry Singer
Excellent. That's great. What about the Ms. Prodrome? So we know some people, before they have their first neurologic symptom, they do have other symptoms, whether it be GI problems or anxiety and depression or skin manifestations. And Helen Tremlett and others have well characterized this prodrome that people have. Do you think, think we're going to be able to detect Ms. Before that attack?
- [30:48]
Professor Xavier Montauban
Well, I have my doubts because those symptoms are quite common in the general population, as you said, fatigue, headache, mood abnormalities, et cetera. You don't want to do an MRI in all these patients. Right. So perhaps you may consider family members of patients with multiple sclerosis and these symptoms, but not in the general population. I do believe that the main fact is to have an abnormal mri. I think that we need to have that. One aspect that we haven't mentioned is that that in the poster criteria, and in fact, in the 2017 revision of the McDonald criteria, you're able to make the diagnosis of Ms. Without anything, just a clinical diagnosis. You don't require to have an mri. Right. But this is going to be different in the future, of course.
- [31:35]
Dr. Barry Singer
Yeah. You mentioned family members. So we don't really have a protocol in place now for screening family members on a regular basis. And maybe identical twins have a much higher risk. Do you see that coming in the future?
- [31:47]
Professor Xavier Montauban
Future? No, not really. Unless one of these members have prodomal symptoms, as you said.
- [31:54]
Dr. Barry Singer
Sergio Berenzini used artificial intelligence to compare the spoke database of 40 million items to medical barcodes of patients. And artificial intelligence predicted who would get Ms. In three years by 83% accuracy. So do you see artificial intelligence helping us diagnose Ms. Sooner?
- [32:15]
Professor Xavier Montauban
You know where I see that artificial intelligence can play a role in those centers? Around the world. They do have good MRI machines, perhaps, but they don't have enough expertise from neuroradiology or from neurologists. And having a good AI validated program may help them. Right. So I think this is going to be one area of research. We are also doing some projects on the that.
- [32:43]
Dr. Barry Singer
So are there any other advances that you're excited about biomarkers or some other way that we're going to be able to diagnose Ms. Sooner?
- [32:50]
Professor Xavier Montauban
I think what you mentioned about the concept of dissemination in time, the inclusion of the optic nerve as well the ris. So not necessarily you need clinical symptoms to make the diagnosis of Ms. I think these are key. Perhaps I can mention the role of kappa free light change in the CSF as an optional tool as well. Instead of the organal bands that can be technically demanding. I think these are the most important ones.
- [33:18]
Dr. Barry Singer
Great. Anything else that you're working on that you're excited to share with our audience here? We have a global audience listening in.
- [33:25]
Professor Xavier Montauban
We are all excited with the improvement of the prognosis of our patients with ms, but still, as you know, we have a gap there with the neurodegeneration and we are now trying to fight against that. Let's see how it goes.
- [33:38]
Dr. Barry Singer
Excellent. Excellent.
- [33:39]
Professor Xavier Montauban
Yep.
- [33:40]
Dr. Barry Singer
Hopefully we'll have some good news coming up here at ectrims. All right, well, thank you very much Professor Maltraban for being in the Ms. Living well podcast and your leadership in the field of Ms. And particularly diagnosing Ms.
- [33:51]
Professor Xavier Montauban
Thank you very much, Barry. My pleasure.
- [33:54]
Dr. Barry Singer
Thanks to our listeners for downloading this episode of the Ms. Living well Podcast on Diagnosing Multiple Sclerosis. We know that early intervention in the treatment of multiple multiple sclerosis is a key factor in the long term health and wellness of people living with the disease. But in order to be treated, you first have to be diagnosed. Thankfully, my colleagues, like neurologists Drs. Freeman and Maltapon are leading the way to develop the tools for an earlier and more accurate diagnosis. Thanks again to TG Therapeutics and Neurax Pharm for sponsoring this episode. Keep in mind mind the topics we discuss on the show are strictly informational and not medical advice. Any change in your treatment should be discussed directly with your healthcare providers first. Our show is Hosted by me, Dr. Barry Singer, produced by Karate Harmon and audio editing by Frank Garza. Our theme music is the Gold Lining by Broke for Free. If you like the show, please share it with others living with that. Appreciate a positive review on Apple Podcasts. It helps more people find out about the show. You can follow me on Axe at Dr. Barry Singer. More information about our guests and the websites can be found in the show Notes for this episode in the blog section of mslivingwhale.org thanks so much for listening. This has been an Ms. Living Whale podcast.