- Email: [email protected]
Aggressive course of cognitive impairment in multiple sclerosis: A new term for the management of patients
Journal of Clinical Neuroscience xxx (xxxx) xxx
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Opinion paper
Aggressive course of cognitive impairment in multiple sclerosis: A new term for the management of patients Abdorreza Naser Moghadasi ⇑, Mohammad Ali Sahraian Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
a r t i c l e
i n f o
Article history: Received 16 July 2019 Accepted 24 August 2019 Available online xxxx Keywords: Aggressive course Cognitive impairment Multiple sclerosis
a b s t r a c t Multiple sclerosis (MS) can create different kinds of symptoms by involving different fields of the central nervous system. Cognitive impairment (CI) is one of the symptoms that can be caused by the onset of the disease and provide a change in the patient’s quality of life. Considering the course of the disease, CI usually worsens increasingly, and there is usually a severe CI in patients with end stage of MS. However, progressing CI can be so fast and severe in a few patients that it can disrupt the daily affairs of the individual. This paper plans to define the aggressive course of CIs in MS patients according to the reported cases. This definition explains that, the aggressive course of CI in MS patients happens in less than 5 years from the onset of the disease, and during this time, it causes dementia in the patient. Ó 2019 Elsevier Ltd. All rights reserved.
1. Introduction Multiple sclerosis (MS) is a disease of the immune system that causes the various symptoms by involving the central nervous system. These symptoms include manifestations such as visual impairment, paresthesia, muscle weakness, and imbalance. Another important symptom is cognitive impairment (CI). Unfortunately, despite the significant effect that CI includes various aspects of MS patients’ life [1]; it has been reported less than motor disorders and physical weaknesses [2]. However, studies explain that, different aspects of cognitive functions can be disturbed in the early stages of disease diagnosis [3]. In the study conducted by DiGiuseppe et al., only 34.6% of participants with MS (whose disease diagnosis was not over one year) did not show CI [4]. Moreover, CIs was observed in pre-diagnosis stages of MS as in patients with clinically isolated syndrome (CIS) and radiologically isolated syndrome (RIS). In a study, 50% of patients with RIS and 48% of patients with CIS had at least one problem in one of the cognitive domains, which are significant rates [5]. Parameters such as male gender, higher age, and lower education are related to CI in MS patients [6]. CI is also related to anxiety [7] and depression [8]. In addition to all these data and considering the fact that CI can influence the patients’ quality of life and their various occupational ⇑ Corresponding author at: MS Research Center, Sina Hospital, Tehran University of Medical Sciences, Hasan Abad Sq., Tehran, Iran. E-mail address: [email protected] (A. Naser Moghadasi).
and social aspects [9], CI is not significantly considered, especially clinically and to treat the patients. In other field, many questions are unanswered according to the CI of MS patients. We still do not know whether the degree of CI and its involvement should be one of the medical objectives as the number of attacks or degrees of disability, or not. In other words, if no evidence of disease activity -4 (NEDA-4) is defined as the absence of attacks, the absence of disability increase, the absence of increase in the number of new or enhancing plaques in magnetic resonance imaging (MRI), and the absence of an increase in the amount of brain atrophy, and if the objective is to meet this in pharmaceutical trials, should we include CIs in this definition according to their high importance? In addition, if the CI of a patient is exacerbated but its physical condition does not change, should the MS drug be changed? These questions should be answered in future studies. However, this paper plans to answer another question: Is there an aggressive course considering the cognitive decline in MS patients? If this course can be determined, which approach should be taken? 2. Course of cognitive impairment in patients with multiple sclerosis The CI course in patients with MS has been examined in several studies. In a 10-year study, Amato et al. explained that a significant group (56%) of MS patients gradually develops CI [10]. They indicated that at early stages, the patients have problems related to the verbal memory and abstract reasoning in the linguistic process. The patients then suffer from attention deficit and short-term spa-
https://doi.org/10.1016/j.jocn.2019.08.104 0967-5868/Ó 2019 Elsevier Ltd. All rights reserved.
Please cite this article as: A. Naser Moghadasi and M. A. Sahraian, Aggressive course of cognitive impairment in multiple sclerosis: A new term for the management of patients, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2019.08.104
2
A. Naser Moghadasi, M.A. Sahraian / Journal of Clinical Neuroscience xxx (xxxx) xxx
tial memory impairment. Another study was published by Achiron et al. in 2005 [11] in this field. Unlike Amato et al., the study conducted by Achiron et al. was not cohort, but it was a cross-sectional study. They classified the patients into two groups according to the duration of the disease, less than 5 years and more than 5 years. They realized that verbal memory and verbal fluency are among the first cognitive areas that get impaired in patients with MS. Subsequently, with increased duration of involvement, visuospatial involvement occurs, recall is delayed, attention is lost, and the speed of data processing is decreased. They indicated that cognitive decline in patients with MS follows a specific pattern over time. It was indicated in another study conducted by Barbu et al. that although cognitive rehabilitation can improve the cognitive status of patients during the time, this improvement is lower compared to the control participants [12].
3. Severe cognitive impairment of patients with multiple sclerosis As previously mentioned, cognitive impairment can be occurred in different forms and levels in MS patients. This disorder sometimes occurs in one cognitive field, and sometimes includes several cognitive domains. In terms of definition, CI occurs in one patient when his/her cognitive ability in two or more domains is scored 2 standard deviations (z < 2) below the mean of healthy control group [13]. However, this definition does not undoubtedly cover the severe cases. There are seldom reports of severe CI in some patients. Considering these cases can help us to define a severe cognitive impairment. In 2003, Zarei et al. introduced six MS patients whose beginning of the disease was associated with CI. These six cases had progressive dementia with other cortical symptoms and gradual addition of physical symptoms [14]. Staff et al., reported 23 patients who had CI as their initial complaint, which was so high that caused problems in their daily lives [15]. They applied the Short Test of Mental Status (STMS) test which includes 38 items. The score 38.31 or less with a sensitivity of 86.4% and a specificity of 93.5% in patients younger than 50 years old explains dementia. All reported cases had no other neurological impairments (such as visual and sensorimotor problems), or they had these disorders at minimal levels. In 74% of these patients, cognitive impairment was the first clinical manifestation of the disease, and the rest referred to other symptoms such as optic neuritis and paresthesia. Nine patients developed relapsing-remitting symptoms. Eleven participants were patients with primary progressive and three were patients with secondary progressive. The score range was 3 to 35 with median score of 25. The important point was the different development course of CI in these patients. Fourteen patients had developed cognitive impairment slowly and progressively up to this level, while nine patients had several intense cognitive attacks. In another study, Mendes et al. examined four patients who had developed severe cognitive impairment during the first five years after diagnosis. This study used Mini-Mental State Examination (MMSE) test, the controlled oral word association test, and a complete review of cortical functions. All four patients developed relapsing-remitting symptoms. All patients had severe dementia according to the MMSE criteria (the scores were below 14) [16]. As previously mentioned, CI happens in one patient when his/ her cognitive ability in two or more domains is scored 2 standard deviations (z < 2) below the mean of healthy control group. On the other hand, as the mentioned studies explain, severe CI can be defined as a CI which causes dementia in any time of the disease. Mild to moderate CI can be defined as a CI without dementia.
These definitions can help us to distinguish severe CI from aggressive CI which will be introduced in next section. 4. Aggressive course of cognitive impairment in multiple sclerosis Although CI can be significant at the start of the disease, there is a severe cognitive impairment mostly in advanced stages of the disease, especially in chronic and progressive patients. Therefore, the time and the time duration that a person achieves this degree of CI from the start of the disease are very important to define the aggressive course of CI in MS. As far as the authors of this study are considered, there is no study conducted in this field, but as previous reports explain, the five-year period seems to be logical. According to Achiron et al. [11], this time is fair enough to allow CI develops in the affected persons; however, it is not too long to allow a person to enter the progressive phase. In Mendes et al. however, it was assumed the time interval to be 5 years after the start of the disease in the definition for patients with severe CI [16]. The next issue is which level of the CI is considered significant so that the disorder is considered as aggressive during 5 years? As the reports on severe cognitive impairment explain, it should be as much as is covered in the definition of dementia and thus disrupts the daily affairs of the individual [14–16]. This remember a very important point to us, that is, to use the cognitive tests to measure the patients validated to define the dementia, tests which are definitely used for MS patients, should be validated to screen the dementia. As available studies explain, only two MMSE and STMS tests are proper enough to be applied in this field. At the same time, one of the most trustworthy cognitive tests used for MS patients, i.e. the minimal assessment of cognitive function in multiple sclerosis (MACFIMS), does not have these features and must be certainly validated to explain dementia in MS patients. Moreover, since this decrement rate in cognitive domains is unseemly to occur during the first 5 years of the disease, all medical or psychiatric causes that could justify this decline should be examined. According to the above discussion, the aggressive course of CI in patients with MS can be defined as follows: 1. Cognitive impairment happens within 5 years of the start of the disease. 2. It is so severe that disrupts daily affairs. 3. According to the criteria of assessment tests, it is considered dementia 4. Other possible medical and psychological causes have been rejected. 5. Is there any need to change the medicine at the aggressive course of the disease? To the best of the authors’ knowledge, no study has been conducted in this regard. Even in NEDA-4, which is considered as a therapeutic goal, CI has not been considered. However, since CI at such an extreme level significantly disrupts the daily affairs of the patient, if this disorder is attributed to the disease itself, the change in medication may be logical, particularly, if it is along with other parameters indicating the disease progression. For example, an increase in the degree of disability or a new neurological symptom makes this change unavoidable. However, the problem happens at the time when the only disorder is CI. Whether or not there is a need to change the medication, and to what extent the drug change will help patients require more examinations. It will be logical to change the medication if there is an increase in the number of plaques in the T2 or enhancing plaque is available in
Please cite this article as: A. Naser Moghadasi and M. A. Sahraian, Aggressive course of cognitive impairment in multiple sclerosis: A new term for the management of patients, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2019.08.104
A. Naser Moghadasi, M.A. Sahraian / Journal of Clinical Neuroscience xxx (xxxx) xxx
the simultaneous MRI. It is not known whether atrophy in the MRI scanning or progressive atrophy in these patients can also be a criterion to change the drug. Although, the absence of atrophy is one of the criteria in NEDA-4, it has not still become a parameter to change the drug. However, various studies have indicated the relationship between CI and atrophy of various brain regions in MRI [17]. Therefore, it can be possible to change the drug in patients with the aggressive course of CI and progressive atrophy. 6. Conclusion Cognitive impairment is one of the significant symptoms of MS, which, despite its high prevalence, is highly neglected in treatment of patients. In this paper, we propose that sever cognitive impairment should be defined and validated in future studies and considered as one of the escalating parameters to prevent more disability. References: [1] Ruet A, Deloire M, Hamel D, Ouallet JC, Petry K, Brochet B. Cognitive impairment, health-related quality of life and vocational status at early stages of multiple sclerosis: a 7-year longitudinal study. J Neurol 2013;3:776–84. [2] Rahn K, Slusher B, Kaplin A. Cognitive impairment in multiple sclerosis: a forgotten disability remembered cognitive impairment in multiple sclerosis: a forgotten disability remembered. Cerebrum 2012;2012:14. [3] McNicholas N, O’Connell K, Yap SM, Killeen RP, Hutchinson M, McGuigan C. Cognitive dysfunction in early multiple sclerosis: a review. QJM 2018;111 (6):359–64. [4] DiGiuseppe G, Blair M, Morrow SA. Short report: prevalence of cognitive impairment in newly diagnosed relapsing-remitting multiple sclerosis. Int J MS Care 2018;20(4):153–7.
3
[5] Labiano-Fontcuberta A, Martínez-Ginés ML, Aladro Y, et al. A comparison study of cognitive deficits in radiologically and clinically isolated syndromes. Mult Scler 2016;22(2):250–3. [6] Johnen A, Bürkner PC, Landmeyer NC, et al. Can we predict cognitive decline after initial diagnosis of multiple sclerosis? Results from the German National early MS cohort (KKNMS). J Neurol 2019;266(2):386–97. [7] Ribbons K, Lea R, Schofield PW, Lechner-Scott J. Anxiety levels are independently associated with cognitive performance in an Australian multiple sclerosis patient cohort. J Neuropsychiatry Clin Neurosci 2017;29 (2):128–34. [8] Karadayi H, Arisoy O, Altunrende B, Boztas MH, Sercan M. The relationship of cognitive impairment with neurological and psychiatric variables in multiple sclerosis patients. Int J Psychiatry Clin Pract 2014;18(1):45–51. [9] Cotter J, Firth J, Enzinger C, et al. Social cognition in multiple sclerosis: a systematic review and meta-analysis. Neurology 2016;87(16):1727–36. [10] Amato MP, Ponziani G, Siracusa G, Sorbi S. Cognitive dysfunction in early-onset multiple sclerosis: a reappraisal after 10 years. Arch Neurol 2001;58 (10):1602–6. [11] Achiron A, Polliack M, Rao SM, Barak Y, Lavie M, Appelboim N, et al. Cognitive patterns and progression in multiple sclerosis: construction and validation of percentile curves. J Neurol Neurosurg Psychiatry 2005;76(5):744–9. [12] Barbu RM, Berard JA, Gresham LM, Walker LAS. Longitudinal stability of cognition in early-phase relapsing-remitting multiple sclerosis: does cognitive reserve play a role? Int J MS Care 2018;20(4):173–9. [13] Eijlers AJ, Meijer KA, Wassenaar TM, et al. Increased default-mode network centrality in cognitively impaired multiple sclerosis patients. Neurology 2017;88(10):952–60. [14] Zarei M, Chandran S, Compston A, Hodges J. Cognitive presentation of multiple sclerosis: evidence for a cortical variant. J Neurol Neurosurg Psychiatry 2003;74(7):872–7. [15] Staff NP, Lucchinetti CF, Keegan BM. Multiple sclerosis with predominant, severe cognitive impairment. Arch Neurol 2009;66(9):1139–43. [16] Mendes MF, Finkelsztejn A, Gomes S, Fragoso YD. Early and severe cognitive impairment in multiple sclerosis. Dement Neuropsychol 2012;6(1):48–52. [17] Rojas JI, Patrucco L, Miguez J, Cristiano E. Brain atrophy in multiple sclerosis: therapeutic, cognitive and clinical impact. Arq Neuropsiquiatr 2016;74 (3):235–43.
Please cite this article as: A. Naser Moghadasi and M. A. Sahraian, Aggressive course of cognitive impairment in multiple sclerosis: A new term for the management of patients, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2019.08.104
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Opinion paper
Aggressive course of cognitive impairment in multiple sclerosis: A new term for the management of patients Abdorreza Naser Moghadasi ⇑, Mohammad Ali Sahraian Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
a r t i c l e
i n f o
Article history: Received 16 July 2019 Accepted 24 August 2019 Available online xxxx Keywords: Aggressive course Cognitive impairment Multiple sclerosis
a b s t r a c t Multiple sclerosis (MS) can create different kinds of symptoms by involving different fields of the central nervous system. Cognitive impairment (CI) is one of the symptoms that can be caused by the onset of the disease and provide a change in the patient’s quality of life. Considering the course of the disease, CI usually worsens increasingly, and there is usually a severe CI in patients with end stage of MS. However, progressing CI can be so fast and severe in a few patients that it can disrupt the daily affairs of the individual. This paper plans to define the aggressive course of CIs in MS patients according to the reported cases. This definition explains that, the aggressive course of CI in MS patients happens in less than 5 years from the onset of the disease, and during this time, it causes dementia in the patient. Ó 2019 Elsevier Ltd. All rights reserved.
1. Introduction Multiple sclerosis (MS) is a disease of the immune system that causes the various symptoms by involving the central nervous system. These symptoms include manifestations such as visual impairment, paresthesia, muscle weakness, and imbalance. Another important symptom is cognitive impairment (CI). Unfortunately, despite the significant effect that CI includes various aspects of MS patients’ life [1]; it has been reported less than motor disorders and physical weaknesses [2]. However, studies explain that, different aspects of cognitive functions can be disturbed in the early stages of disease diagnosis [3]. In the study conducted by DiGiuseppe et al., only 34.6% of participants with MS (whose disease diagnosis was not over one year) did not show CI [4]. Moreover, CIs was observed in pre-diagnosis stages of MS as in patients with clinically isolated syndrome (CIS) and radiologically isolated syndrome (RIS). In a study, 50% of patients with RIS and 48% of patients with CIS had at least one problem in one of the cognitive domains, which are significant rates [5]. Parameters such as male gender, higher age, and lower education are related to CI in MS patients [6]. CI is also related to anxiety [7] and depression [8]. In addition to all these data and considering the fact that CI can influence the patients’ quality of life and their various occupational ⇑ Corresponding author at: MS Research Center, Sina Hospital, Tehran University of Medical Sciences, Hasan Abad Sq., Tehran, Iran. E-mail address: [email protected] (A. Naser Moghadasi).
and social aspects [9], CI is not significantly considered, especially clinically and to treat the patients. In other field, many questions are unanswered according to the CI of MS patients. We still do not know whether the degree of CI and its involvement should be one of the medical objectives as the number of attacks or degrees of disability, or not. In other words, if no evidence of disease activity -4 (NEDA-4) is defined as the absence of attacks, the absence of disability increase, the absence of increase in the number of new or enhancing plaques in magnetic resonance imaging (MRI), and the absence of an increase in the amount of brain atrophy, and if the objective is to meet this in pharmaceutical trials, should we include CIs in this definition according to their high importance? In addition, if the CI of a patient is exacerbated but its physical condition does not change, should the MS drug be changed? These questions should be answered in future studies. However, this paper plans to answer another question: Is there an aggressive course considering the cognitive decline in MS patients? If this course can be determined, which approach should be taken? 2. Course of cognitive impairment in patients with multiple sclerosis The CI course in patients with MS has been examined in several studies. In a 10-year study, Amato et al. explained that a significant group (56%) of MS patients gradually develops CI [10]. They indicated that at early stages, the patients have problems related to the verbal memory and abstract reasoning in the linguistic process. The patients then suffer from attention deficit and short-term spa-
https://doi.org/10.1016/j.jocn.2019.08.104 0967-5868/Ó 2019 Elsevier Ltd. All rights reserved.
Please cite this article as: A. Naser Moghadasi and M. A. Sahraian, Aggressive course of cognitive impairment in multiple sclerosis: A new term for the management of patients, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2019.08.104
2
A. Naser Moghadasi, M.A. Sahraian / Journal of Clinical Neuroscience xxx (xxxx) xxx
tial memory impairment. Another study was published by Achiron et al. in 2005 [11] in this field. Unlike Amato et al., the study conducted by Achiron et al. was not cohort, but it was a cross-sectional study. They classified the patients into two groups according to the duration of the disease, less than 5 years and more than 5 years. They realized that verbal memory and verbal fluency are among the first cognitive areas that get impaired in patients with MS. Subsequently, with increased duration of involvement, visuospatial involvement occurs, recall is delayed, attention is lost, and the speed of data processing is decreased. They indicated that cognitive decline in patients with MS follows a specific pattern over time. It was indicated in another study conducted by Barbu et al. that although cognitive rehabilitation can improve the cognitive status of patients during the time, this improvement is lower compared to the control participants [12].
3. Severe cognitive impairment of patients with multiple sclerosis As previously mentioned, cognitive impairment can be occurred in different forms and levels in MS patients. This disorder sometimes occurs in one cognitive field, and sometimes includes several cognitive domains. In terms of definition, CI occurs in one patient when his/her cognitive ability in two or more domains is scored 2 standard deviations (z < 2) below the mean of healthy control group [13]. However, this definition does not undoubtedly cover the severe cases. There are seldom reports of severe CI in some patients. Considering these cases can help us to define a severe cognitive impairment. In 2003, Zarei et al. introduced six MS patients whose beginning of the disease was associated with CI. These six cases had progressive dementia with other cortical symptoms and gradual addition of physical symptoms [14]. Staff et al., reported 23 patients who had CI as their initial complaint, which was so high that caused problems in their daily lives [15]. They applied the Short Test of Mental Status (STMS) test which includes 38 items. The score 38.31 or less with a sensitivity of 86.4% and a specificity of 93.5% in patients younger than 50 years old explains dementia. All reported cases had no other neurological impairments (such as visual and sensorimotor problems), or they had these disorders at minimal levels. In 74% of these patients, cognitive impairment was the first clinical manifestation of the disease, and the rest referred to other symptoms such as optic neuritis and paresthesia. Nine patients developed relapsing-remitting symptoms. Eleven participants were patients with primary progressive and three were patients with secondary progressive. The score range was 3 to 35 with median score of 25. The important point was the different development course of CI in these patients. Fourteen patients had developed cognitive impairment slowly and progressively up to this level, while nine patients had several intense cognitive attacks. In another study, Mendes et al. examined four patients who had developed severe cognitive impairment during the first five years after diagnosis. This study used Mini-Mental State Examination (MMSE) test, the controlled oral word association test, and a complete review of cortical functions. All four patients developed relapsing-remitting symptoms. All patients had severe dementia according to the MMSE criteria (the scores were below 14) [16]. As previously mentioned, CI happens in one patient when his/ her cognitive ability in two or more domains is scored 2 standard deviations (z < 2) below the mean of healthy control group. On the other hand, as the mentioned studies explain, severe CI can be defined as a CI which causes dementia in any time of the disease. Mild to moderate CI can be defined as a CI without dementia.
These definitions can help us to distinguish severe CI from aggressive CI which will be introduced in next section. 4. Aggressive course of cognitive impairment in multiple sclerosis Although CI can be significant at the start of the disease, there is a severe cognitive impairment mostly in advanced stages of the disease, especially in chronic and progressive patients. Therefore, the time and the time duration that a person achieves this degree of CI from the start of the disease are very important to define the aggressive course of CI in MS. As far as the authors of this study are considered, there is no study conducted in this field, but as previous reports explain, the five-year period seems to be logical. According to Achiron et al. [11], this time is fair enough to allow CI develops in the affected persons; however, it is not too long to allow a person to enter the progressive phase. In Mendes et al. however, it was assumed the time interval to be 5 years after the start of the disease in the definition for patients with severe CI [16]. The next issue is which level of the CI is considered significant so that the disorder is considered as aggressive during 5 years? As the reports on severe cognitive impairment explain, it should be as much as is covered in the definition of dementia and thus disrupts the daily affairs of the individual [14–16]. This remember a very important point to us, that is, to use the cognitive tests to measure the patients validated to define the dementia, tests which are definitely used for MS patients, should be validated to screen the dementia. As available studies explain, only two MMSE and STMS tests are proper enough to be applied in this field. At the same time, one of the most trustworthy cognitive tests used for MS patients, i.e. the minimal assessment of cognitive function in multiple sclerosis (MACFIMS), does not have these features and must be certainly validated to explain dementia in MS patients. Moreover, since this decrement rate in cognitive domains is unseemly to occur during the first 5 years of the disease, all medical or psychiatric causes that could justify this decline should be examined. According to the above discussion, the aggressive course of CI in patients with MS can be defined as follows: 1. Cognitive impairment happens within 5 years of the start of the disease. 2. It is so severe that disrupts daily affairs. 3. According to the criteria of assessment tests, it is considered dementia 4. Other possible medical and psychological causes have been rejected. 5. Is there any need to change the medicine at the aggressive course of the disease? To the best of the authors’ knowledge, no study has been conducted in this regard. Even in NEDA-4, which is considered as a therapeutic goal, CI has not been considered. However, since CI at such an extreme level significantly disrupts the daily affairs of the patient, if this disorder is attributed to the disease itself, the change in medication may be logical, particularly, if it is along with other parameters indicating the disease progression. For example, an increase in the degree of disability or a new neurological symptom makes this change unavoidable. However, the problem happens at the time when the only disorder is CI. Whether or not there is a need to change the medication, and to what extent the drug change will help patients require more examinations. It will be logical to change the medication if there is an increase in the number of plaques in the T2 or enhancing plaque is available in
Please cite this article as: A. Naser Moghadasi and M. A. Sahraian, Aggressive course of cognitive impairment in multiple sclerosis: A new term for the management of patients, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2019.08.104
A. Naser Moghadasi, M.A. Sahraian / Journal of Clinical Neuroscience xxx (xxxx) xxx
the simultaneous MRI. It is not known whether atrophy in the MRI scanning or progressive atrophy in these patients can also be a criterion to change the drug. Although, the absence of atrophy is one of the criteria in NEDA-4, it has not still become a parameter to change the drug. However, various studies have indicated the relationship between CI and atrophy of various brain regions in MRI [17]. Therefore, it can be possible to change the drug in patients with the aggressive course of CI and progressive atrophy. 6. Conclusion Cognitive impairment is one of the significant symptoms of MS, which, despite its high prevalence, is highly neglected in treatment of patients. In this paper, we propose that sever cognitive impairment should be defined and validated in future studies and considered as one of the escalating parameters to prevent more disability. References: [1] Ruet A, Deloire M, Hamel D, Ouallet JC, Petry K, Brochet B. Cognitive impairment, health-related quality of life and vocational status at early stages of multiple sclerosis: a 7-year longitudinal study. J Neurol 2013;3:776–84. [2] Rahn K, Slusher B, Kaplin A. Cognitive impairment in multiple sclerosis: a forgotten disability remembered cognitive impairment in multiple sclerosis: a forgotten disability remembered. Cerebrum 2012;2012:14. [3] McNicholas N, O’Connell K, Yap SM, Killeen RP, Hutchinson M, McGuigan C. Cognitive dysfunction in early multiple sclerosis: a review. QJM 2018;111 (6):359–64. [4] DiGiuseppe G, Blair M, Morrow SA. Short report: prevalence of cognitive impairment in newly diagnosed relapsing-remitting multiple sclerosis. Int J MS Care 2018;20(4):153–7.
3
[5] Labiano-Fontcuberta A, Martínez-Ginés ML, Aladro Y, et al. A comparison study of cognitive deficits in radiologically and clinically isolated syndromes. Mult Scler 2016;22(2):250–3. [6] Johnen A, Bürkner PC, Landmeyer NC, et al. Can we predict cognitive decline after initial diagnosis of multiple sclerosis? Results from the German National early MS cohort (KKNMS). J Neurol 2019;266(2):386–97. [7] Ribbons K, Lea R, Schofield PW, Lechner-Scott J. Anxiety levels are independently associated with cognitive performance in an Australian multiple sclerosis patient cohort. J Neuropsychiatry Clin Neurosci 2017;29 (2):128–34. [8] Karadayi H, Arisoy O, Altunrende B, Boztas MH, Sercan M. The relationship of cognitive impairment with neurological and psychiatric variables in multiple sclerosis patients. Int J Psychiatry Clin Pract 2014;18(1):45–51. [9] Cotter J, Firth J, Enzinger C, et al. Social cognition in multiple sclerosis: a systematic review and meta-analysis. Neurology 2016;87(16):1727–36. [10] Amato MP, Ponziani G, Siracusa G, Sorbi S. Cognitive dysfunction in early-onset multiple sclerosis: a reappraisal after 10 years. Arch Neurol 2001;58 (10):1602–6. [11] Achiron A, Polliack M, Rao SM, Barak Y, Lavie M, Appelboim N, et al. Cognitive patterns and progression in multiple sclerosis: construction and validation of percentile curves. J Neurol Neurosurg Psychiatry 2005;76(5):744–9. [12] Barbu RM, Berard JA, Gresham LM, Walker LAS. Longitudinal stability of cognition in early-phase relapsing-remitting multiple sclerosis: does cognitive reserve play a role? Int J MS Care 2018;20(4):173–9. [13] Eijlers AJ, Meijer KA, Wassenaar TM, et al. Increased default-mode network centrality in cognitively impaired multiple sclerosis patients. Neurology 2017;88(10):952–60. [14] Zarei M, Chandran S, Compston A, Hodges J. Cognitive presentation of multiple sclerosis: evidence for a cortical variant. J Neurol Neurosurg Psychiatry 2003;74(7):872–7. [15] Staff NP, Lucchinetti CF, Keegan BM. Multiple sclerosis with predominant, severe cognitive impairment. Arch Neurol 2009;66(9):1139–43. [16] Mendes MF, Finkelsztejn A, Gomes S, Fragoso YD. Early and severe cognitive impairment in multiple sclerosis. Dement Neuropsychol 2012;6(1):48–52. [17] Rojas JI, Patrucco L, Miguez J, Cristiano E. Brain atrophy in multiple sclerosis: therapeutic, cognitive and clinical impact. Arq Neuropsiquiatr 2016;74 (3):235–43.
Please cite this article as: A. Naser Moghadasi and M. A. Sahraian, Aggressive course of cognitive impairment in multiple sclerosis: A new term for the management of patients, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2019.08.104