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Background and ObjectivesCognitive impairment in multiple sclerosis (MS) is associated with functional connectivity abnormalities. While there have been calls to use functional connectivity measures as biomarkers, there remains to be a full understanding of why they are affected in MS. In this cross-sectional study, we tested the hypothesis that functional network regions may be susceptible to disease-related “wear and tear” and that this can be observable on co-occurring abnormalities on other magnetic resonance metrics. We tested whether functional connectivity abnormalities in cognitively impaired patients with MS co-occur with (1) overlapping, (2) local, or (3) distal changes in anatomic connectivity and cerebral blood flow abnormalities.MethodsMultimodal 3T MRI and assessment with the Brief Repeatable Battery of Neuropsychological tests were performed in 102 patients with relapsing-remitting MS and 27 healthy controls. Patients with MS were classified as cognitively impaired if they scored ≥1.5 SDs below the control mean on ≥2 tests (n = 55) or as cognitively preserved (n = 47). Functional connectivity was assessed with Independent Component Analysis and dual regression of resting-state fMRI images. Cerebral blood flow maps were estimated, and anatomic connectivity was assessed with anatomic connectivity mapping and fractional anisotropy of diffusion-weighted MRI. Changes in cerebral blood flow and anatomic connectivity were assessed within resting-state networks that showed functional connectivity abnormalities in cognitively impaired patients with MS.ResultsFunctional connectivity was significantly decreased in the anterior and posterior default mode networks and significantly increased in the right and left frontoparietal networks in cognitively impaired relative to cognitively preserved patients with MS (threshold-free cluster enhancement corrected at p ≤ 0.05, 2 sided). Networks showing functional abnormalities showed altered cerebral blood flow and anatomic connectivity locally and distally but not in overlapping locations.DiscussionWe provide the first evidence that functional connectivity abnormalities are accompanied by local cerebral blood flow and structural connectivity abnormalities but also demonstrate that these effects do not occur in exactly the same location. Our findings suggest a possibly shared pathologic mechanism for altered functional connectivity in brain networks in MS.

Background: Coping in multiple sclerosis (MS) refers to cognitive and behavioural efforts to manage stresses imposed by the illness. Existing generic and disease-specific coping scales do not meet modern guidelines for scale development and cannot produce interval-level metrics to allow for change scores. Objective: The main aim of this study was to develop a brief patient-reported outcome measure for coping in MS, capable of interval-level measurement. Methods: Qualitative work in 43 people with MS leads to a draft scale which was administered to 5747 participants, with longitudinal collection in 2290. A calibration sample of 1000 subjects split into development and validation sets was used to generate three scales consistent with Rasch model expectations. Results: The total Coping Index-MS (CI-MS-T), CI-MS-Internal (CI-MS-I) and CI-MS-External (CI-MS-E) cover total, internal and externally focused coping. All three scales are capable of interval-level measurement. Trajectory analysis of 9000 questionnaires showed two trajectories in CI-MS-T: Group 1 showed a low level of coping with slight decline over 40 months, while Group 2 had a better and stable level of coping due to improving CI-MS-I which compensated for the deteriorating CI-MS-E over time. CI-MS-T Conclusion: The CI-MS-T, CI-MS-I and CI-MS-E, comprising 20 items, provide interval-level measurement and are free-for-use in not-for-profit settings.

Spinocerebellar ataxia type 2 (SCA2) and amyotrophic lateral sclerosis (ALS) share a common molecular basis: both are associated with CAG-repeat expansion of ATXN2 and TDP-43-positive neuronal cytoplasmic inclusions. To date, the two disorders are viewed as clinically distinct with ALS resulting from 30-33 CAG-repeats and SCA2 from >34 CAG-repeats. We describe a 67-year old with a 32 CAG-repeat expansion of ATXN2 who presented with simultaneous symptoms of ALS and SCA2. Our case demonstrates that the clinical dichotomy between SCA2 and ATXN2-ALS is false. We suggest instead that CAG-repeat expansion length determines the timing of SCA2 clinical symptoms relative to onset of ALS; consistent with this age of onset of SCA2 but not ATXN2-ALS, is dependent upon expansion length. Review of the literature and our local cohort provides evidence for occurrence of ALS in late stage SCA2, which may be under-recognised by clinicians who think of the two diseases as distinct.

Background:\ud Neurodegeneration is the pathological substrate that causes major disability in secondary progressive multiple sclerosis. A synthesis of preclinical and clinical research identified three neuroprotective drugs acting on different axonal pathobiologies. We aimed to test the efficacy of these drugs in an efficient manner with respect to time, cost, and patient resource.\ud Methods:\ud We did a phase 2b, multiarm, parallel group, double-blind, randomised placebo-controlled trial at 13 clinical neuroscience centres in the UK. We recruited patients (aged 25–65 years) with secondary progressive multiple sclerosis who were not on disease-modifying treatment and who had an Expanded Disability Status Scale (EDSS) score of 4·0–6·5. Participants were randomly assigned (1:1:1:1) at baseline, by a research nurse using a centralised web-based service, to receive twice-daily oral treatment of either amiloride 5 mg, fluoxetine 20 mg, riluzole 50 mg, or placebo for 96 weeks. The randomisation procedure included minimisation based on sex, age, EDSS score at randomisation, and trial site. Capsules were identical in appearance to achieve masking. Patients, investigators, and MRI readers were unaware of treatment allocation. The primary outcome measure was volumetric MRI percentage brain volume change (PBVC) from baseline to 96 weeks, analysed using multiple regression, adjusting for baseline normalised brain volume and minimisation criteria. The primary analysis was a complete-case analysis based on the intention-to-treat population (all patients with data at week 96). This trial is registered with ClinicalTrials.gov, NCT01910259.\ud Findings:\ud Between Jan 29, 2015, and June 22, 2016, 445 patients were randomly allocated amiloride (n=111), fluoxetine (n=111), riluzole (n=111), or placebo (n=112). The primary analysis included 393 patients who were allocated amiloride (n=99), fluoxetine (n=96), riluzole (n=99), and placebo (n=99). No difference was noted between any active treatment and placebo in PBVC (amiloride vs placebo, 0·0% [95% CI −0·4 to 0·5; p=0·99]; fluoxetine vs placebo −0·1% [–0·5 to 0·3; p=0·86]; riluzole vs placebo −0·1% [–0·6 to 0·3; p=0·77]). No emergent safety issues were reported. The incidence of serious adverse events was low and similar across study groups (ten [9%] patients in the amiloride group, seven [6%] in the fluoxetine group, 12 [11%] in the riluzole group, and 13 [12%] in the placebo group). The most common serious adverse events were infections and infestations. Three patients died during the study, from causes judged unrelated to active treatment; one patient assigned amiloride died from metastatic lung cancer, one patient assigned riluzole died from ischaemic heart disease and coronary artery thrombosis, and one patient assigned fluoxetine had a sudden death (primary cause) with multiple sclerosis and obesity listed as secondary causes.\ud Interpretation:\ud The absence of evidence for neuroprotection in this adequately powered trial indicates that exclusively targeting these aspects of axonal pathobiology in patients with secondary progressive multiple sclerosis is insufficient to mitigate neuroaxonal loss. These findings argue for investigation of different mechanistic targets and future consideration of combination treatment trials. This trial provides a template for future simultaneous testing of multiple disease-modifying medicines in neurological medicine.\ud Funding:\ud Efficacy and Mechanism Evaluation (EME) Programme, an MRC and NIHR partnership, UK Multiple Sclerosis Society, and US National Multiple Sclerosis Society.

Cognitive impairment is common in multiple sclerosis (MS) and resting state functional MRI (rs-fMRI) functional connectivity (FC) is increasingly used to study its pathophysiology. However, results remain difficult to interpret, showing both high and low FC associated with cognitive impairment. We conducted a systematic review of rs-fMRI studies in MS to understand whether the direction of FC change relates to cognitive dysfunction, and how this may be influenced by the choice of methodology. Embase, Medline and PsycINFO were searched for studies assessing cognitive function and rs-fMRI FC in adults with MS. Fifty-seven studies were included in a narrative synthesis. Of these, 50 found an association between cognitive impairment and FC abnormalities. Worse cognition was linked to high FC in 18 studies, and to low FC in 17 studies. Nine studies found patterns of both high and low FC related to poor cognitive performance, in different regions or for different MR metrics. There was no clear link to increased FC during early stages of MS and reduced FC in later stages, as predicted by common models of MS pathology. Throughout, we found substantial heterogeneity in study methodology, and carefully consider how this may impact on the observed findings. These results indicate an urgent need for greater standardisation in the field – in the choice of MRI analysis and the definition of cognitive impairment. Through this we will be closer to using rs-fMRI FC as a biomarker in clinical studies, and as a tool to understand mechanisms underpinning cognitive symptoms in MS.Key pointsCognitive impairment in multiple sclerosis (MS) is increasingly being researched with advanced magnetic resonance imaging (MRI) measures, including resting state functional MRI (rs-fMRI)The rs-fMRI functional connectivity (FC) metric is associated with cognitive impairment, and has the potential to be a biomarker of cognitive decline.A main challenge to developing a FC biomarker is the lack of consistency in the direction of FC changes associated with cognitive impairment, with cognitive deficits associated with both lower and higher FC.FC changes don’t appear to be linked to clinical and methodological factors such as disease phenotype, disease duration and brain region or network studied.Overall, there is substantial heterogeneity in study methodology, suggesting an acute need to standardise the study of cognitive impairment in MS and its investigation by rs-fMRI methods.

Spinocerebellar ataxia type 2 (SCA2) and amyotrophic lateral sclerosis (ALS) share a common molecular basis: both are associated with CAG-repeat expansion of

Longitudinal studies among people with Multiple Sclerosis (pwMS) have shown that self-efficacy is linked to physical, cognitive and psychological functioning.To determine the distribution of self-efficacy in a large sample of pwMS, examining whether there are distinct groups which show different self-efficacy trajectories over time, and the health status characteristics of any groups identified.Participants completed serial questionnaire packs, including Unidimensional Self-efficacy-MS (USE-MS) scale, for the Trajectories of Outcome in Neurological Conditions-MS (TONiC-MS) study over an average 46-month period. The resulting longitudinal data were analysed by a group-based trajectory model.5887 pwMS were studied: mean age 50.2 years (SD 12.0); 73.6% female; Relapsing Remitting MS (61.8%), Secondary Progressive (22.9%), Primary Progressive (11.1%), Rapidly Evolving Relapsing Remitting MS (4.2%). Four distinct self-efficacy trajectories emerged, with declining, slightly declining, stable or improving self-efficacy, each showing different patterns of health status indicators such as EQ-5D-5L, disability and depression. USE-MS ≤ 18 at baseline detected all participants in the two declining groups.Future trials on interventions for self-efficacy should assume a priori that those with low levels of self-efficacy (USE-MS ≤ 18 at baseline) are likely to be on a declining trajectory and may need different interventions from those with stable self-efficacy.

Natalizumab is one of the most effective therapies for relapsing-remitting multiple sclerosis. One complication is progressive multifocal leucoencephalopathy, a viral brain infection caused by John Cunningham virus (JCV). Monitoring of neurological symptoms, JCV serology and regular brain imaging are required to ensure safe use of this therapy. Local audit data from 2015 indicated poor compliance with safety monitoring: under 25% of investigations were within recommended timeframes. Subsequently, a protocol was implemented to improve monitoring, with specialist nurses coordinating requests for MRI scans and arranging JCV serology, with frequency determined according to JCV index. A re-audit assessed the impact of this protocol (n=155). Some 97.4% of patients were appropriately tested for JCV and 88.4% were imaged within the recommended interval. Additional work with the informatics and virology team ensured serology results became more easily accessible. The use of a standardised, nurse-led operating procedure has resulted in marked improvement in the safety monitoring of natalizumab.

B-cell depleting anti-CD20 monoclonal antibody therapies are being increasingly used as long-term maintenance therapy for neuroinflammatory disease compared to many non-neurological diseases where they are used as remission-inducing agents. While hypogammaglobulinaemia is known to occur in over half of patients treated with medium to long-term B-cell-depleting therapy (in our cohort IgG 38, IgM 56 and IgA 18%), the risk of infections it poses seems to be under-recognised. Here, we report five cases of serious infections associated with hypogammaglobulinaemia occurring in patients receiving rituximab for neuromyelitis optica spectrum disorders. Sixty-four per cent of the whole cohort of patients studied had hypogammaglobulinemia. We discuss the implications of these cases to the wider use of anti-CD20 therapy in neuroinflammatory disease.

Background\ud In March 2020, the United Kingdom Multiple Sclerosis Register (UKMSR) established an electronic case return form, designed collaboratively by MS neurologists, to record data about COVID-19 infections in people with MS (pwMS).\ud \ud Objectives\ud Examine how hospital admission and mortality are affected by disability, age and disease modifying treatments (DMTs) in people with Multiple Sclerosis with COVID-19.\ud \ud Methods\ud Anonymised data were submitted by clinical teams. Regression models were tested for predictors of hospitalisation and mortality outcomes. Separate analyzes compared the first and second ‘waves’ of the pandemic.\ud \ud Results\ud Univariable analysis found hospitalisation and mortality were associated with increasing age, male gender, comorbidities, severe disability, and progressive MS; severe disability showed the highest magnitude of association. Being on a DMT was associated with a small, lower risk. Multivariable analysis found only age and male gender were significant. Post hoc analysis demonstrated that factors were significant for hospitalisation but not mortality. In the second wave, hospitalisation and mortality were lower. Separate models of the first and second wave using age and gender found they had a more important role in the second wave.\ud \ud Conclusions\ud Features associated with poor outcome in COVID-19 are similar to other populations and being on a DMT was not found to be associated with adverse outcomes, consistent with smaller studies. Once in hospital, no factors were predictive of mortality. Reassuringly, mortality appears lower in the second wave.

Gait disability in people with progressive multiple sclerosis (MS) is difcult to quantify using existing clinical tools. This study aims to identify reliable and objective gait-based biomarkers to monitor progressive multiple sclerosis (MS) in clinical settings. During routine clinical visits, 57 people with secondary progressive MS and 24 healthy controls walked for 6minutes wearing three inertial motion sensors. Fifteen gait measures were computed from the sensor data and tested for between-session reliability, for diferences between controls and people with moderate and severe MS disability, and for correlation with Expanded Disability Status Scale (EDSS) scores. The majority of gait measures showed good to excellent between-session reliability when assessed in a subgroup of 23 healthy controls and 25 people with MS. These measures showed that people with MS walked with signifcantly longer step and stride durations, reduced step and stride regularity, and experienced difculties in controlling and maintaining a stable walk when compared to controls. These abnormalities signifcantly increased in people with a higher level of disability and correlated with their EDSS scores. Reliable and objective gait-based biomarkers using wearable sensors have been identifed. These biomarkers may allow clinicians to quantify clinically relevant alterations in gait in people with progressive MS within the context of regular clinical visits. This work was supported by the Mobilise-D project, that has received funding from the Innovative Medicines Initiative 2 Joint Undertaking under grant agreement No. 820820. This Joint Undertaking receives support from the European Union's Horizon 2020 research and innovation program and the European Federation of Pharmaceutical Industries and Associations (EFPIA). Content in this publication reflects the authors’ view and neither IMI nor the European Union, EFPIA, or any Associated Partners are responsible for any use that may be made of the information contained herein.&nbsp

BackgroundRemote ischaemic preconditioning (RIPC) is the exposure of body parts to brief periods of circulatory occlusion and reperfusion. Recent studies have also shown that RIPC can improve exercise performance in healthy individuals.ObjectiveThis study aimed to assess the effect of RIPC on walking in people with multiple sclerosis (MS).MethodsThis was a double-blind randomised controlled clinical trial. We used three cycles of RIPC delivered by occluding the upper arm with a blood pressure (BP) cuff inflated to a pressure of 30 mm Hg above the systolic BP. In patients in the sham intervention group, the BP cuff was inflated only to 30 mm Hg below diastolic BP. Outcome measures included the Six-Minute Walk Test (6MWT), gait speed, the Borg rate of perceived exertion (RPE) scale, the tolerability of the RIPC using a Numerical Rating Scale for discomfort from 0 to 10, and adverse events. We identified responders meeting the minimal clinically important difference (MCID) established in the literature in each group.ResultsSeventy-five participants completed the study (RIPC: 38 and Sham: 37). The distance walked during the 6MWT improved by 1.9% in the sham group and 5.7% in the RIPC group (p=0.012). The number of responders meeting MCID criteria in the RIPC group was significantly greater compared with the sham intervention group. No serious adverse events occurred.ConclusionSingle cycle of RIPC resulted in immediate improvement in walking distances during 6MWT in people with MS.Trial registration numbersNCT03153553

Papilloedema and raised intracranial pressure have been frequently reported with hypoparathyroidism, but very rarely optic neuritis. We report a case of a 54-year-old male patient who presented with classical optic neuritis which is believed to be secondary to primary hypoparathyroidism.

MRI has long been established as the most sensitive in vivo technique for detecting multiple sclerosis (MS) lesions. The 2010 revisions of the McDonald Criteria have simplified imaging criteria, such that a diagnosis of MS can be made on a single contrast-enhanced MRI scan in the appropriate clinical context. New disease-modifying therapies have proven effective in reducing relapse rate and severity. Several of these therapies, most particularly natalizumab, but also dimethyl fumarate and fingolimod, have been associated with progressive multifocal leukoencephalopathy (PML). PML-immune reconstitution inflammatory syndrome (IRIS) has been recognized in patients following cessation of natalizumab owing to PML, and discontinuation for other reasons can lead to the phenomenon of rebound MS. These complications often provide a diagnostic dilemma and have implications for imaging surveillance of patients. We demonstrate how the updated McDonald Criteria aid the diagnosis of MS and describe the imaging characteristics of conditions such as PML and PML-IRIS in the context of MS. Potential imaging surveillance protocols are considered for the diagnosis and assessment of complications. We will explain how changes in MS treatment are leading to new imaging demands in order to monitor patients for disease progression and treatment-related complications.

Objective:The objective of this paper is to inform the pathophysiology of medial longitudinal fasciculus (MLF) axonal dysfunction in patients with internuclear ophthalmoplegia (INO) due to multiple sclerosis (MS), and develop a composite structural-functional biomarker of axonal and myelin integrity in this tract.Methods:Eighteen patients with definite MS and clinically suspected INO underwent electrical vestibular stimulation and search-coil eye movement recording. Components of the electrically evoked vestibulo-ocular reflex (eVOR) were analyzed to probe the latency and fidelity of MLF axonal conduction. The MLF and T2-visible brainstem lesions were defined by high-resolution MRI. White matter integrity was determined by diffusion-weighted imaging metrics.Results:eVOR onset latency was positively correlated with MLF lesion length (left: r = 0.66, p = 0.004; right: r = 0.75, p = 0.001). The mean conduction velocity (±SD) within MLF lesions was estimated at 2.72 (±0.87) m/s. eVOR onset latency correlated with normalized axial diffusivity ( r = 0.66, p < 0.001) and fractional anisotropy ( r = 0.44, p = 0.02) after exclusion of cases with ipsilateral vestibular root entry zone lesions.Conclusions:Axonal conduction velocity through lesions involving the MLF was reduced below levels predicted for natively myelinated and remyelinated axons. Composite in vivo biomarkers enable delineation of axonal from myelin processes and may provide a crucial role in assessing efficacy of novel reparative therapies in MS.

Neuroaxonal loss is a major substrate of irreversible disability in multiple sclerosis, however, its cause is not understood. In multiple sclerosis there may be intracellular sodium accumulation due to neuroaxonal metabolic dysfunction, and increased extracellular sodium due to expansion of the extracellular space secondary to neuroaxonal loss. Sodium magnetic resonance imaging measures total sodium concentration in the brain, and could investigate this neuroaxonal dysfunction and loss in vivo. Sodium magnetic resonance imaging has been examined in small cohorts with relapsing-remitting multiple sclerosis, but has not been investigated in patients with a progressive course and high levels of disability. We performed sodium magnetic resonance imaging in 27 healthy control subjects, 27 patients with relapsing-remitting, 23 with secondary-progressive and 20 with primary-progressive multiple sclerosis. Cortical sodium concentrations were significantly higher in all subgroups of multiple sclerosis compared with controls, and deep grey and normal appearing white matter sodium concentrations were higher in primary and secondary-progressive multiple sclerosis. Sodium concentrations were higher in secondary-progressive compared with relapsing-remitting multiple sclerosis in cortical grey matter (41.3 ± 4.2 mM versus 38.5 ± 2.8 mM, P = 0.008), normal appearing white matter (36.1 ± 3.5 mM versus 33.6 ± 2.5 mM, P = 0.018) and deep grey matter (38.1 ± 3.1 mM versus 35.7 ± 2.4 mM, P = 0.02). Higher sodium concentrations were seen in T₁ isointense (44.6 ± 7.2 mM) and T1 hypointense lesions (46.8 ± 8.3 mM) compared with normal appearing white matter (34.9 ± 3.3 mM, P < 0.001 for both comparisons). Higher sodium concentration was observed in T₁ hypointense lesions in secondary-progressive (49.0 ± 7.0 mM) and primary-progressive (49.3 ± 8.0 mM) compared with relapsing-remitting multiple sclerosis (43.0 ± 8.5 mM, P = 0.029 for both comparisons). Independent association was seen of deep grey matter sodium concentration with expanded disability status score (coefficient = 0.24, P = 0.003) and timed 25 ft walk speed (coefficient = -0.24, P = 0.01), and of T1 lesion sodium concentration with the z-scores of the nine hole peg test (coefficient = -0.12, P < 0.001) and paced auditory serial addition test (coefficient = -0.081, P < 0.001). Sodium concentration is increased within lesions, normal appearing white matter and cortical and deep grey matter in multiple sclerosis, with higher concentrations seen in secondary-progressive multiple sclerosis and in patients with greater disability. Increased total sodium concentration is likely to reflect neuroaxonal pathophysiology leading to clinical progression and increased disability.

Background R 2 ′ is an MRI measure of microscopic magnetic field inhomogeneity, and is increased by the paramagnetic effect of iron and the diamagnetic effect of myelin. R 2 ′ may detect features of multiple sclerosis (MS) not evident with conventional MRI. Methods Multiecho T 2 and T 2 * weighted sequences were obtained from 21 healthy controls (nine men, 12 women; mean age 36 years) and 28 MS patients (seven men, 21 women; 18 relapsing remitting, 10 secondary progressive; mean age 42 years). T 2 and T 2 * relaxation time maps were created from the multiecho sequences, and R 2 ′ maps were created using the formula R 2 ′ = R 2 *−R 2 = 1/T 2 *−1/T 2 . R 2 ′ was measured in MS white matter lesions and in regions of interest in normal appearing white matter (NAWM) and grey matter in all subjects. Results R 2 ′ was reduced in NAWM in MS compared with controls (9.5/s vs 10.1/s, p=0.05). R 2 ′ was additionally reduced in lesions, both T 1 isointense (8.5/s vs 9.5/s, p=0.02) and T 1 hypointense (7.7/s vs 9.5/s, p=0.003) compared with NAWM. R 2 ′ tended to be higher in the basal ganglia of MS patients compared with controls, and was significantly higher in the caudate nucleus in secondary progressive MS (12.9/s vs 10.9/s, p=0.03). Increased T 2 lesion volume predicted an increase in R 2 ′ in the caudate (β=0.412, p=0.02). Conclusions Reduction in R 2 ′ in NAWM and lesions is consistent with a decreases in myelin, tissue iron and/or deoxyhaemoglobin. Increased caudate R 2 ′ in patients with secondary progressive MS is consistent with increased iron deposition, as corroborated by other techniques.

Background and aims: Although the incidence of falls and syncope increase with age, the underlying mechanisms are not fully understood, particularly in very old patients. We report diagnostic outcomes of tilt table and carotid sinus massage (TT/CSM) testing in a population of older old subjects (82% over 80 years of age) referred for TT/CSM from a falls clinic for assessment of syncope or unexplained falls. Methods: Prospective observational study between January 1, 2001 and January 1, 2005 involving 290 consecutive subjects undergoing TT/CSM testing according to European Society of Cardiology guidelines for the diagnosis and management of syncope. Results: Combination of TT/CSM provided a positive result in 62% of subjects, and was significantly more likely to be positive in subjects over the age of 80 (68% vs 50%, p=0.001). Carotid sinus syndrome (CSS) was the most common diagnosis, and was significantly more common in subjects over 80 (48% vs 34%, p=0.022) particularly due to a higher incidence of mixed CSS (16% vs 7%, p=0.023). There was no significant difference in the diagnosis of subjects referred due to falls and those reporting syncope (p=0.93). No cardiovascular or neurological adverse events occurred. Conclusions: In our cohort of very elderly patients, the diagnostic accuracy of tilt testing and carotid sinus massage was high and adverse incidents absent when testing was indicated by a geriatrician experienced in the assessment of falls and syncope. We advocate the use of TT/CSM testing as part of a comprehensive falls/syncope assessment for the diagnostic evaluation of older patients presenting with unexplained falls and/or syncope in whom structured assessment has not identified a cause for their symptoms.

Energy failure is an emerging concept in multiple sclerosis research. Pathological studies have indicated that axonal modifications in response to demyelination may increase neuronal energy demand. At the same time, soluble mediators of inflammation may impair mitochondrial function, and brain perfusion may also be decreased. Insufficient energy production for demand can lead to intracellular sodium accumulation, calcium influx and cell death. Magnetic resonance (MR) is a promising technique to investigate these pathology driven hypotheses in vivo. MR spectroscopy can inform on mitochondrial function with measures of N acetyl aspartate (NAA), and requirement for extra-mitochondrial glycolysis via measurement of lactate. MR measurement of phosphorous ((31)P) and sodium ((23)Na) allows direct assessment of energy availability and axonal sodium handling. MR techniques for imaging perfusion can quantify oxygen delivery and nascent MR techniques that exploit the paramagnetism of deoxyhaemaglobin may be able to quantify oxygen utilization. This report reviews the physical principles underlying these techniques, their implementation for human in vivo imaging, and their application in neurological conditions with an emphasis on multiple sclerosis. Combination of these techniques to obtain a comprehensive picture of oxygen delivery, energy production and utilization may provide new insights into the pathophysiology of multiple sclerosis and may provide outcome measures for trials of novel treatments.

A 44-year-old, right-handed woman presented with a 2 year history of intermittent burning and numbness over the left side of her face which had become continuous for the past 9 months. Over the past 7 months she had experienced spasms characterised by a sensation that the left side of her mouth was being pulled tight, associated with spontaneous flexed posturing of the left elbow and wrist with clawing of the hand. The spasms lasted for approximately 15 s and were extremely painful. They occurred in paroxysms lasting up to 2 h, several times a week. One month prior to presentation, she developed double vision on looking to the left with vertical separation of the images, and vertigo. She also reported fatigue, dry mouth and dry eyes over the previous 2 years. There was no previous medical history and she was taking no medications. Family history was unremarkable. Examination showed a markedly dry mouth. There was no skin rash or joint inflammation. On left lateral gaze the left eye deviated upwards in comparison with the right, a left hypertropia. Eye movements were otherwise normal. There was subjective reduction in sensation over the left side of the face in all trigeminal nerve divisions, consistent with a sensory trigeminal neuropathy, with preservation of the corneal reflex. Neurological examination was otherwise unremarkable. Routine biochemistry and haematology were normal. P and C antineutrophil cytoplasmic antibodies, rheumatoid factor, tissue autoantibodies, extractable nuclear antigen antibodies, anti-scl-70, anticentromere, antiphospholipid, anti-Jo1, anti-Ro, anti-La, anti-RNP and anti-Sm antibodies were all consistently negative. Antinuclear antibodies were slightly raised at a titre of 1 in 40 but double stranded DNA antibodies were negative. MRI of brain and cervical spine with contrast was normal. Lumbar puncture showed normal opening pressure, protein, glucose and cell count, and was negative for oligoclonal bands. Chest x …

Natalizumab is one of the most effective therapies for relapsing-remitting Multiple Sclerosis. One complication is Progressive Multifocal Leucoencephalopathy (PML), a viral brain infection in patients already infected with JC virus. Monitoring of neurological symptoms, JC virus serology and regular brain imaging are required to ensure safe use of this therapy. Local audit data from 2015 indicated poor compliance with safety monitoring, with less than 25% of patients undergoing required investigations within the recommended time intervals. Subsequently a protocol was implemented to improve monitoring, with specialist nurses coordinating the requests for MRI scans and arranging JC virus serology, the frequency of which was determined according to the JC virus index. The records of all patients receiving Natalizumab at the centre were audited to assess the impact of this protocol (n=155). 99.2% of patients were appropriately tested for JC virus and 95.3% were imaged within the recommended interval. Additional work with the informatics and virology team ensured serology results became more easily accessible. The use of a standardised nurse-led operating procedure has resulted in marked improvement in the safety monitoring of Natalizumab.

In the original article, the co-author's family name has been published incorrectly. The correct family name should be Constantinescu.

This case describes the case of a young woman with a relapsing and remitting neurological disorder but with features atypical of multiple sclerosis, including prominent cognitive features during relapses, large lesions on MRI, and continuing expansion of lesions despite treatment. We outline her clinical journey, including complications of an early lumbar puncture, through to a brain biopsy which was able to confirm her diagnosis. We then discuss the rationale for our eventual choice of treatment and discuss monitoring for the development of progressive multifocal leucoencephalopathy. Finally, we discuss her likely future prognosis based upon case series of patients with similar clinical features.

Summary Background Acute demyelinating optic neuritis, a common feature of multiple sclerosis, can damage vision through neurodegeneration in the optic nerve and in its fibres in the retina. Inhibition of voltage-gated sodium channels is neuroprotective in preclinical models. In this study we aimed to establish whether sodium-channel inhibition with phenytoin is neuroprotective in patient with acute optic neuritis. Methods We did a randomised, placebo-controlled, double-blind phase 2 trial at two UK academic hospitals in London and Sheffield. Patients with acute optic neuritis aged 18–60 years, presenting within 2 weeks of onset, with visual acuity of 6/9 or worse, were randomly assigned (1:1) by minimisation via a web-based service to oral phenytoin (maintenance dose 4 mg/kg per day if randomised before or on July 16, 2013, and 6 mg/kg per day if randomised on or after July 17, 2013) or placebo for 3 months, stratified by time from onset, centre, previous multiple sclerosis diagnosis, use of disease-modifying treatment, and use of corticosteroids for acute optic neuritis. Participants and treating and assessing physicians were masked to group assignment. The primary outcome was retinal nerve fibre layer (RNFL) thickness in the affected eye at 6 months, adjusted for fellow-eye RNFL thickness at baseline, analysed in a modified intention-to-treat population of all randomised participants who were followed up at 6 months. Safety was analysed in the entire population, including those who were lost to follow-up. The trial is registered with ClinicalTrials.gov, number NCT 01451593. Findings We recruited 86 participants between Feb 3, 2012, and May 22, 2014 (42 assigned to phenytoin and 44 to placebo). 29 were assigned to phenytoin 4 mg/kg and 13 to phenytoin 6 mg/kg. Five participants were lost to follow-up, so the primary analysis included 81 participants (39 assigned to phenytoin and 42 to placebo). Mean 6-month RNFL thickness in the affected eye at 6 months was 81·46 μm (SD 16·27) in the phenytoin group (a mean decrease of 16·69 μm [SD 13·73] from baseline) versus 74·29 μm (15·14) in the placebo group (a mean decrease of 23·79 μm [13·97] since baseline; adjusted 6-month difference of 7·15 μm [95% CI 1·08–13·22]; p=0·021), corresponding to a 30% reduction in the extent of RNFL loss with phenytoin compared with placebo. Treatment was well tolerated, with five (12%) of 42 patients having a serious adverse event in the phenytoin group (only one, severe rash, was attributable to phenytoin) compared with two (5%) of 44 in the placebo group. Interpretation These findings support the concept of neuroprotection with phenytoin in patients with acute optic neuritis at concentrations at which it blocks voltage-gated sodium channels selectively. Further investigation in larger clinical trials in optic neuritis and in relapsing multiple sclerosis is warranted. Funding US National Multiple Sclerosis Society, Multiple Sclerosis Society of Great Britain and Northern Ireland, Novartis, UK National Institute for Health Research (NIHR), and NIHR UCLH/UCL Biomedical Research Centre.

This study aims to inform the pathophysiology of axonal dysfunction in the medial longitudinal fasciculus (MLF) in patients with internuclear ophthalmoplegia (INO) in multiple sclerosis (MS), and develop a composite functional-structural biomarker that indirectly distinguishes demyelination from remyelination in this tract. Eighteen patients with definite MS and clinically suspected INO underwent electrical vestibular stimulation and search-coil eye movement recording. Components of the electrically evoked vestibulo-ocular reflex (eVOR) were analyzed to probe the latency and fidelity of MLF axonal conduction. Using a semi-automated technique, the MLF and T2-visible brainstem lesions involving the central vestibular pathways were defined by high-resolution MRI. White matter integrity was determined by diffusion-weighted imaging metrics. INO was associated with a T2-visible lesion within the MLF in all cases. Vestibular root entry zone (VREZ) lesions were observed in five patients (three bilateral, two unilateral). eVOR onset latency was positively correlated with MLF lesion length (left: r = .66, p = .004; right: r = .75, p = .001). Mathematical modelling estimated mean conduction velocity (± standard deviation) within MLF lesions of 2.72 (± 0.87) m/s. eVOR onset latency correlated with normalized axial diffusivity (r = .66, p

Introduction Neuroaxonal loss is the major pathological substrate of irreversible disability in Multiple Sclerosis (MS). Sodium is maintained at lower concentration within the intra–axonal space by the Na/K/ATPase pump. In MS, failure of the pump secondary to neuroaxonal metabolic dysfunction increases the intracellular sodium concentration, which in turn leads to neuroaxonal loss by causing intra–axonal calcium import. 1 Since sodium is at higher concentration within the extracellular space, neuroaxonal loss and replacement with extracellular fluid also increases sodium concentration. Sodium (23Na) magnetic resonance imaging enables quantitation of total sodium concentration in the brain, and could help to quantify the extent neuroaxonal dysfunction and loss in different tissue types and different MS subgroups in vivo, and their association with clinical disability. Previous studies have shown increased sodium concentration in lesions, normal appearing white matter (NAWM) and grey matter in patients with relapsing remitting MS (RRMS) 2 3 however whether similar increases are seen in patients with primary progressive MS (PPMS) and secondary progressive MS (SPMS) and whether sodium accumulation is associated with disability in these patients is not known. Methods We performed 23Na MRI imaging on 27 healthy controls, 27 patients with RRMS, 23 patients SPMS and 20 patients with PPMS. Sodium concentration was quantified in segmented NAWM, cortical grey matter, basal ganglia and T2 hyperintense, T1 hypointense and T1 isointense lesions. Results Cortical sodium concentrations were significantly higher in all subgroups of MS compared to controls, and NAWM and basal ganglia sodium concentrations were higher in PPMS and SPMS compared to controls. T2 hyperintense, T1 hypointense and T1 isointense lesion sodium concentrations were higher than NAWM. Sodium concentrations were higher in SPMS compared to RRMS in cortical grey matter (mean 41.3±4.2mM vs. 38.5±2.8 mM, p=0.028), NAWM (36.1±3.5 mM vs. 33.6±2.5 mM, p Conclusions Significant increases in sodium were seen in lesions and normal appearing brain tissues in MS. Increased concentration of sodium in lesions, cortical grey matter, NAWM and basal ganglia in SPMS versus RRMS indicates greater neuroaxonal metabolic dysfunction and/or loss in the former group. MRI measurement of sodium concentration in vivo is likely to reflect clinically relevant neuroaxonal pathophysiology and may be a useful outcome measure in trials of putative neuroprotective treatments.

A B S T R A C T Background: Midodrine hydrochloride has been shown to be effective in the management of syncope in adults with reflex syncope, orthostatic hypotension and orthostatic intolerance syndromes; however, its use, tolerability and side effects have not been monitored specifically in the older old, particularly not over a prolonged period of time. Objectives: We aim to document changes in patients’ symptoms, drug dosages employed and adverse drug reactions to midodrine therapy in older adults with a diagnosis of neurocardiogenic syncope assessed and managed at a specialist falls and syncope outpatient unit. Methods: Prospective observational study of 135 consecutive subjects with a mean age of 84 years started on midodrine after comprehensive geriatric assessment, structured falls evaluation, positive tilt table testing (TT) or a mixed/vasodepressor response to carotid sinus massage (CSM). Results: Ninety-seven individuals (71%) commenced on midodrine treatment and followed up for a mean of 2.7 years, reported either significant improvement or abolition of symptoms across all TT/CSM diagnosis. Forty-nine percent of individuals achieved sustained clinical improvement after an initial dosage of 2.5 mg three times per day and only four patients required dosages above 7.5 mg three times daily. One hundred and one individuals (75%) continued midodrine until the end of the monitoring period, and although 19 subjects developed adverse drug reactions, most were minor and only six resulted in drug withdrawal. Conclusions: Midodrine hydrochloride appears to be safe and well tolerated in older adults and should be considered, independent of age, in the management of patients with symptomatic orthostatic hypotension, vasovagal syncope and vasodepressor or mixed carotid sinus syndrome. This observation requires further confirmation by larger multicenter randomised control studies.