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Different MRI patterns in MS worsening after stopping fingolimod
Caterina Lapucci1, Damiano Baroncini1, Maria Cellerino1
1Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics (C.L., M.C., G.B., M.P., G.N., G.L.M., A.U., M.I.), Maternal and Child Health (DiNOGMI), University of Genoa; Multiple Sclerosis Centre (D.B., A.G., M.Z.), Gallarate Hospital, ASST of Valle Olona, Gallarate; Department of Neurology (M.C., G.B., M.P., G.L.M., A.U.), Ospedale Policlinico San Martino-Sistema Sanitario Regione; Liguria -Istituto di Ricovero e Cura a Carattere Scientifico per l'Oncologia; IRCCS Foundation C. Mondino National Neurological Institute (I.C.), Pavia; Department of Health Sciences (DISSAL) (M.P.S., L. R.), Ospedale Policlinico San Martino IRCCS, Genoa, Italy; Department of Radiology and Neuroscience (M.I.), Icahn School of Medicine at Mount Sinai, New York; and Department of Neuroradiology (L.R.), Ospedale Policlinico San Martino IRCCS, Genoa, Italy.
Objective:
To analyze MRI images in patients with MS who experienced worsening of neurologic status (WNS) after stopping fingolimod (FTY).
Methods:
In this retrospective study, demographic, clinical, and radiologic data of patients with MS who experienced WNS after stopping FTY were retrospectively collected. We introduced the "δExpanded Disability Status Scale (EDSS)-ratio" to identify patients who, after FTY withdrawal, showed an inflammatory flare-up exceeding the highest lifetime disease activity level. Patients with δEDSS-ratio > 1 were enrolled in the study.
Results:
Eight patients were identified. The mean (SD) age of the 8 (7 female) patients was 35.3 (4.9) years. The mean FTY treatment duration was 3.1 (0.8) years. The mean FTY discontinuation-WNS interval was 4 (0.9) months. The 4 patients with δEDSS-ratio ≥ 2 developed severe monophasic WNS (EDSS score above 8.5), characterized by clinical features and MRI findings not typical of MS, which we classified as "tumefactive demyelination pattern" (TDL) and "Punctuated pattern" (PL). Conversely, patients whose δEDSS-ratio was between 1 and 2 had clinical features and brain MRI compatible with a more typical, even if aggressive, MS relapse. In patients with TDL and PL, the flare-up of inflammatory activity led to severe tissue damage resulting in T2 but also T1 lesion volume increase at 6-month follow-up.
Conclusions:
Peculiar MRI features (TDL and PL), different from a typical MS flare-up, might occur in some patients who experienced WNS after stopping FTY. Further studies, also involving immunologic biomarkers, are necessary to investigate TDL or PL pathophysiology.
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