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Full Disclosure Forms Radiologically isolated syndrome in children Clinical and radiologic outcomes Naila Makhani, MD, ABSTRACT MPH Objective: To describe clinical and radiologic outcomes of children with incidental findings on neu- Christine Lebrun, MD, roimaging suggestive of CNS demyelination (termed “radiologically isolated syndrome” or RIS). PhD Methods: Clinical and radiologic data were obtained from a historical cohort of children with no Aksel Siva, MD symptoms of demyelinating disease who had MRI scans that met the 2010 MRI criteria for dis- David Brassat, MD semination in space for MS. Clarisse Carra Dallière, MD Results: We identified 38 children (27 girls and 11 boys) with RIS now being prospectively fol- Jérôme de Seze, MD lowed at 16 sites in 6 countries. The mean follow-up time was 4.8 6 5.3 years. The most common Wei Du, MS reason for initial neuroimaging was headache (20/38, 53%). A first clinical event consistent with Françoise Durand Dubief, CNS demyelination occurred in 16/38 children (42%; 95% confidence interval [CI]: 27%–60%) MD in a median of 2.0 years (interquartile range [IQR] 1.0–4.3 years). Radiologic evolution developed Orhun Kantarci, MD in 23/38 children (61%; 95% CI: 44%–76%) in a median of 1.1 years (IQR 0.5–1.9 years). The Megan Langille, MD presence of $2 unique oligoclonal bands in CSF (hazard ratio [HR] 10.9, 95% CI: 1.4–86.2, p 5 Sona Narula, MD 0.02) and spinal cord lesions on MRI (HR 7.8, 95% CI: 1.4–43.6, p 5 0.02) were associated with Jean Pelletier, MD an increased risk of a first clinical event after adjustment for age and sex. Juan Ignacio Rojas, MD Conclusions: We describe the clinical characteristics and outcomes of children with incidental Eugene D. Shapiro, MD MRI findings highly suggestive of CNS demyelination. Children with RIS had a substantial risk Robert T. Stone, MD of subsequent clinical symptoms and/or radiologic evolution. The presence of oligoclonal bands Mar Tintoré, MD in CSF and spinal cord lesions on MRI were associated with an increased risk of a first clinical Ugur Uygunoglu, MD event. Neurol Neuroimmunol Neuroinflamm 2017;4:e395; doi: 10.1212/NXI.0000000000000395 Patrick Vermersch, MD Evangeline Wassmer, MD GLOSSARY Darin T. Okuda, MD CI 5 confidence interval; DIS 5 dissemination in space; HR 5 hazard ratio; IQR 5 interquartile range; RIS 5 radiologically Daniel Pelletier, MD isolated syndrome. On behalf of Observatoire Francophone de la The incidental finding of abnormalities on MRI scans of the brain and spinal cord has become Sclérose en Plaques more common due to the increasing use of MRI in the evaluation of a wide range of medical 1,2 (OFSEP), Société conditions in children. Some of these abnormalities are highly suggestive of CNS demyelin- Francophone de la ation based on their size, location within the white matter, and shape. This finding has pre- Sclérose en Plaques viously been described in adults and has been termed “radiologically isolated syndrome” or (SFSEP), and the RIS.3–5 Criteria for RIS in adults were proposed in 2009 and require both clinical and imaging Radiologically Isolated factors including the incidental detection of MRI abnormalities meeting the following criteria: Syndrome Consortium (1) ovoid and well-circumscribed homogenous foci with or without involvement of the corpus (RISC) callosum, (2) T2 hyperintensities $3 mm in diameter fulfilling at least 3 of the 4 Barkhof MRI criteria for dissemination in space (DIS), as adopted in the 2005 diagnostic criteria for MS,6 and 3 Correspondence to (3) the CNS abnormalities are not consistent with a vascular pattern. We recently reported Dr. Makhani: a teenager with such incidental white matter abnormalities detected on brain MRI.7 However, [email protected] Supplemental data at Neurology.org/nn Author affiliations are provided at the end of the article. Coinvestigators are listed at Neurology.org/nn. Funding information and disclosures are provided at the end of the article. Go to Neurology.org/nn for full disclosure forms. The Article Processing Charge was funded by the authors. This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License 4.0 (CC BY-NC-ND), which permits downloading and sharing the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Neurology.org/nn Copyright © 2017 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology. 1 outcomes following the detection of RIS in routine clinical practice at 16 collaborating MS centers in 6 coun- children are not known, and there are no cri- tries between December 1, 1995, and March 15, 2016 (table e-1 at Neurology.org/nn). A detailed clinical history and neurologic teria for RIS in children. examination were performed on all children. Tests to exclude Adults identified with RIS have a 34% risk other infectious, inflammatory, rheumatologic, and metabolic of developing a first clinical event consistent diseases (e.g., erythrocyte sedimentation rate, C-reactive protein with CNS demyelination within 5 years.8,9 Fac- level, antinuclear antibody screen, rheumatoid factor level, double- stranded DNA testing, vitamin B12 level, angiotensin-converting tors associated with the development of a first enzyme level, anticardiolipin antibodies, and Lyme disease serol- clinical event in adults with RIS include age ogy) were performed based on local practice. CSF analysis and ,37 years, male sex, and the presence of spinal determination of serum 25-hydroxyvitamin D levels were ob- tained at the discretion of the treating neurologist at non- cord lesions on MRI. Radiologic evolution standardized time points and tested using local methods. occurred in 59% of adult RIS subjects after 3 Neuroimaging. All children underwent MRI on either 1.5T or amedianof2.7years. The risk of developing 3T MRI scanners. All brain and spinal cord MRI studies included either a first clinical event consistent with CNS T1- and T2-weighted spin-echo sequences in multiple planes of demyelination or radiologic evolution in chil- view (axial and sagittal, with coronal images for brain studies) dren (age ,18 years) with RIS is unknown. with or without gadolinium. MRI abnormalities were first identified by a clinical neurora- The objectives of this historical cohort diologist and then confirmed by at least 1 MS specialist at each study in children newly enrolled in a multicen- site to ensure that the 2010 DIS criteria were met on initial scans. ter longitudinal observational cohort study of The presence or absence of radiologic evolution, defined as any of $1 new T2 lesion, $1 newly enlarging T2 lesion, or $1 newly outcomes following pediatric RIS were there- enhancing lesion in either the brain or spinal cord, was similarly fore (1) to propose criteria for RIS in children, determined.8,9 (2) to determine the clinical and radiologic Standard protocol approvals and patient consents. Institu- outcomes of children with RIS over time, tional ethical approval was obtained from all sites. Written and (3) to determine whether any clinical, informed consent was obtained from parents/guardians, and chil- MRI, or laboratory marker was associated with dren provided assent. an increased risk of either clinical or radiologic Statistical analysis. Clinical and MRI data were collected using evolution. a standard template. We report mean values (6SD) and/or me- dians (with interquartile ranges, IQRs) for continuous variables METHODS Study participants. We identified a historical and frequency (percentage) for categorical variables. We created cohort of children aged ,18 years with incidental MRI abnor- Kaplan-Meier survival curves to illustrate time to either a first malities consistent with CNS demyelination that met the 2010 clinical event consistent with CNS demyelination (defined as $ criteria for DIS for MS on MRI.10 All children are now being a new neurologic symptom and sign lasting 24 hours) or prospectively followed. Inclusion and exclusion criteria are shown radiologic evolution where zero time was the date of the initial in table 1. Children were identified and followed according to scan that met the 2010 criteria for DIS. We used Mann-Whitney U tests (continuous variables) and Fisher’s exact tests (categorical variables) to examine the statistical significance of unadjusted Table 1 Study inclusion and exclusion criteria associations between the outcomes of either a first clinical event or radiologic evolution, and demographic variables (e.g., age, sex, Inclusion criteria Exclusion criteria and race), MRI variables (e.g., number of brain lesions, presence 1. RIS subjects <18 years of age 1. MRI date ,1990 of enhancing lesions, presence of periventricular, infratentorial, or spinal cord lesions), and laboratory-based variables (e.g., presence 2. Incidental anomalies identified on brain 2. Incomplete medical history or $ MRI with the primary reason for the acquired radiologic data of 2 unique oligoclonal bands in CSF). We created multivari- MRI resulting from evaluation of a condition able Cox proportional hazards models for the time to either a first other than suspected CNS demyelination clinical event or radiologic evolution. Multivariable models 3. CNS white matter abnormalities meeting 3. History of remitting symptoms consistent included predictors found to have significant associations with the following MRI criteria: with MS lasting .24 hours prior to first MRI demonstrating anomalies suggestive of MS our outcomes in unadjusted analyses as well as age (modeled continuously in years) and sex, which we felt were clinically rel- Ovoid, well-circumscribed, and homogenous foci with or without evant variables. The proportional hazards assumption was as- involvement of the corpus callosum sessed using graphical methods. We report hazard ratios (HRs) T2 hyperintensities measuring ‡3mm2 with 95% confidence intervals (CIs). We considered 2-sided fulfilling the 2010 criteria for p values ,0.05 as statistically significant.
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