認知測驗與MRI可預測MS病程


  July 30, 2009 — 研究者報告指出,認知測驗與影像檢查有助醫師預測多發性硬化症(multiple sclerosis,MS)的短期改變。該研究線上發表於7月29日的神經學(Neurology)期刊,認為神經生理檢測在診斷MS病患上越顯重要。
  
  共同作者、義大利佛羅倫斯大學的Maria Pia Amato醫師在新聞稿中表示,我們的研究強調認知檢測對於看似健康之良性多發性硬化症病患的重要性。此訊息對於調整病患的治療也很重要。
  
  紐約州立大學水牛城醫學院的Ralph Benedict醫師和奧地利Graz大學的Franz Fazekas醫師,在編輯評論中對此觀點提出回應。他們指出,如果病患有所謂的良性疾病而有認知缺損,且認知缺損是疾病惡化的重要風險,就應對這些看似健康的病患多加注意偵測與預防。
  
  編輯們呼籲更重視MS病患的評估。
  
  加拿大多發性硬化症協會的發言代表、臨床計畫助理副總裁Aprile Royal表示同意。多發性硬化症的生理發現有諸多重點,現在有越來越多有關認知篩檢的訊息,以及認知篩檢能有實際幫助的訊息。
  
  【強調心智健康】
  研究者探究63名良性多發性硬化症病患。研究者表示,良性疾病的定義是有爭論的,他們的看法是,擴展殘疾狀況評分表(EDSS)之評分達3分以上且疾病期間至少15年。
  
  由同樣來自佛羅倫斯大學的Emilio Portaccio醫師所領導的研究團隊,注重在Rao's Brief Repeatable Neuropsychological Battery以及Stroop Test這兩項的神經生理評估。
  
  他們評估傳統腦部磁振造影與磁轉移影像(magnetization transfer imaging)的結果。評估白質病灶負載、整體與局部腦容量、以及磁轉移比率。研究者發現,將近30%的良性多發性硬化症患者在5年內顯著惡化,且分類不再為良性,發生EDSS分數4.0以上的次級漸進病程。
  
  兩項以上認知測驗失敗者,有20%機率更可能隨著時間惡化。相較於女性,良性疾病的男性後來經歷多發性硬化症徵兆的機率達3倍。MRI顯示較多T-1加權病灶者,也比較可能被分類為不再良性。
  
  【與MS惡化成不再良性狀態有關的因素】

因素

風險比

95% CI

P

男性

2.9

1.2 – 7.5

.02

神經生理檢測失敗數

1.4

1.1 – 1.7

.003

T1 加權病灶數

1.3

1.1 – 1.5

.002


  他們指出,使用這3個變項的模式中,不再良性之狀態的預測準確率為82%。
  
  Amato醫師表示,我們的發現強調,一個人的性別、認知狀態、腦部病灶數量等,是預測MS惡化的重要因素。
  
  在Medscape Neurology的訪問中,Royal醫師形容這是重要的研究,並且推崇該研究與其作者。但是她也指出,研究樣本太少。
  
  Benedict醫師和Fazekas醫師寫道,該研究有其觀察價值。它確認了神經生理功能是腦部完整性的重要測量。
  
  義大利多發性硬化症協會支付本研究費用。主要作者Emilio Portaccio醫師報告接受Merck Serono、Biogen Dompe、Bayer Schering以及Sanofi-Aventis等研究支持。共同作者、Pia Amato醫師接受Biogen Idec、Merck Serono、Bayer Schering以及Sanofi-Aventis等研究支持。
  

Cognitive Testing and MRI May Predict MS Progression

By Allison Gandey
Medscape Medical News

July 30, 2009 — Cognitive testing and imaging may help clinicians predict short-term disease evolution in multiple sclerosis (MS), report researchers. The study, published online July 29 in Neurology, suggests that neuropsychological testing may become increasingly important in diagnosing MS patients.

"Our study highlights the importance of cognitively testing people with benign multiple sclerosis who appear to be healthy," coauthor Maria Pia Amato, MD, from the University of Florence, in Italy, said in a news release. "This information might be important in tailoring the patient's treatment."

In an accompanying editorial, Drs. Ralph Benedict, from the State University of New York, Buffalo School of Medicine, and Franz Fazekas, from the Medical University of Graz, in Austria, echoed this view. "If some patients with so-called benign-disease course have cognitive impairment, and if cognitive impairment is a significant risk of disease progression," they note, "much more attention should be devoted to detecting and preventing such pathology in these otherwise healthy-appearing patients."

The editorialists call for a more comprehensive evaluation of MS patients.

Speaking on behalf of the Multiple Sclerosis Society of Canada, Aprile Royal, assistant vice president of clinical programs, said she agreed. "A lot of emphasis has been on physical findings in multiple sclerosis, and now we're hearing more and more about cognitive screening and how it can be really helpful when used early on."

Emphasizing Mental Health

Investigators looked at 63 patients with benign multiple sclerosis. The researchers acknowledge that the definition of benign disease is controversial and based their assessment on an Expanded Disability Status Score (EDSS) of 3 or more and disease duration of at least 15 years.

The research team, led by Emilio Portaccio, MD, also from the University of Florence, looked at neuropsychological assessments from the Rao's Brief Repeatable Neuropsychological Battery and the Stroop Test.

They evaluated results from conventional brain magnetic resonance imaging and magnetization transfer imaging. They assessed white-matter lesion load, global and regional brain volumes, and magnetization transfer ratio.

Researchers found that nearly 30% of people with benign multiple sclerosis significantly worsened over 5 years and were classified as "no longer benign," having developed a secondary progressive course defined as an EDSS of 4.0 or higher.

People who failed more than 2 cognitive tests were 20% more likely to progress over time. Men with benign disease were nearly 3 times more likely to later experience signs of multiple sclerosis compared with women. People with more T-1 weighted lesions on MRI were also more likely to be classified as no longer benign.

Factors Associated With MS Progression to "No-Longer-Benign" Status
Factors Hazard Ratio 95% CI P
Male sex 2.9 1.2 – 7.5 .02
Neuropsychological tests failed, n 1.4 1.1 – 1.7 .003
T1-weighted lesions, n 1.3 1.1 – 1.5 .002

In a model using all 3 of these variables, no-longer-benign status was predicted with an accuracy of 82%, they note.

"Our findings strongly suggest that a person's gender, cognitive state, and amount of lesions on the brain are important factors for predicting MS progression," Dr. Amato said.

During an interview with Medscape Neurology, Royal called this important work and complimented the study and its authors. But she also noted the study's small numbers.

Drs. Benedict and Fazekas write that the study presents a valuable observation. "It confirms neuropsychological functioning as another important measure of brain integrity."

This study was paid for by the Italian Multiple Sclerosis Association. Lead author Dr. Emilio Portaccio reports receiving research support from Merck Serono, Biogen Dompe, Bayer Schering, and Sanofi-Aventis. Coauthor Dr. Pia Amato receives research support from Biogen Idec, Merck Serono, Bayer Schering, and Sanofi-Aventis.

Neurology. 2009;73:498-503.

    
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