Cerebrospinal fl uid (CSF) in the diagnosis of MS Florian Deisenhammer Harald Hegen Dept. of Neurology Innsbruck Medical University
Peer reviewed by ParadigMS
www.paradigms.foundation
Abstract The diagnosis of multiple sclerosis (MS) is a complicated process, requiring the condition to be differentiated from other MS mimics – diseases that might appear similar at first to MS but which are distinguished by their own set of specific characteristics. As analytical techniques have evolved, the cerebrospinal fluid (CSF) has become a highly specific and sensitive tool to support the diagnosis of MS. In this ParadigMS Foundation presentation, Professor Florian Deisenhammer shares his knowledge of the use of specific biomarkers in CSF such as oligoclonal bands and kappa free light chains to demonstrate the chronic inflammatory nature of MS. This workshop will serve as an excellent educational resource for all neurologists aiming to further their knowledge and skill in relation to the diagnosis, care and management of MS patients.
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ParadigMS’ Peer Review Process All ParadigMS slide decks are presented and peer reviewed at expert meetings. Once the peer review process is completed, the slide deck is published on the ParadigMS website and used in educational and training activities. The experts and board members of ParadigMS
Laura Airas (Finland, University of Turku) Raed Al Roughani (Kuwait, MS clinic at Ibn-Sina hospital & Amiri Hospitals Kuwait) Mona Alkhawajah (Saudi Arabia, King Faisal Specialist Hospital & Research Centre Riyadh) Thomas Berger (Austria, Medical University of Vienna) Alexey Boyko (Russia, Russian State Medical University and MS Center) Lou Brundin (Sweden, Karolinska Institutet Stockholm) Andrew Chan (Switzerland, University Hospital Bern) Florian Deisenhammer (Austria, Medical University of Innsbruck) Paolo Gallo (Italy, University of Padova) Nikolaos Grigoriadis (Greece, Aristotle University of Thessaloniki) Hans-Peter Hartung (Germany, Heinrich-Heine-University Dusseldorf) Christoph Kleinschnitz (Germany, Essen University Hospital) Ralf Linker (Germany, University of Regensburg) Melinda Magyari (Denmark, Danish Multiple Sclerosis Center) Celia Oreja-Guevara (Spain, Hospital Clinico San Carlos Madrid) Carlo Pozzilli (Italy, University of Roma La Sapienza) Veronica Popescu (Belgium, University MS Center Pelt –Hasselt) Maura Pugliatti (Italy, University of Ferrara) Bart Van Wijmeersch (Belgium, University MS Center Pelt -Hasselt) Patrick Vermersch (France, University of Lille) Bassem Yamout (Lebanon, American University of Beirut Medical Center) Magd Zakaria (Egypt, Egyptian Society of Multiple Sclerosis) Tjalf Ziemssen (Germany, Carl Gustav Carus University Hospital Dresden)
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A short history Criteria
Requirements
Diagnosis of RR-MS
Timepoint 1
Details
Timepoint 2
episode no.1
+ relapse no.1
Clinical diagnosis Two relapses affecting two separate sites within the CNS
Poser 1983
episode no.1
+ relapse no.1
Laboratory-assisted diagnosis Positive CSF and evidence for paraclinical abnormalities (MRI or VEP) at a separate site replaces second relapse
McDonald 2001/2005/2010
episode no.1
Schumacher 1965
+
MRI
DIS
DIT
MRI-assisted diagnosis MRI evidence for DIS and DIT replaces second relapse
Definitions: CNS: central nervous system; CSF: cerebrospinal fluid; DIS: dissemination in space; DIT: dissemination in time; MRI: magnetic resonance imaging; VEP: visual evoked potential
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What’s positive CSF? McDonald Criteria Ann Neurol 2001;50:121-7
CSF abnormality: – OCB (preferably by IEF) and/or – Elevated IgG Index – WBC < 50/mm3 – State of the art technology
Definitions: CSF: cerebrospinal fluid; IEF: isoelectric focusing; Ig: immunoglobulin; OCB: oligoclonal bands; WBC: white blood cell
Positive CSF • In context with MS “positive CSF” means detection of intrathecal synthesis of immunoglobulins as a surrogate of chronic immune activation DIT • Surrogates of acute inflammation, i.e. elevated cell counts are not suggestive of a “positive CSF”
Definitions: CSF: cerebrospinal fluid; DIT: dissemination in time
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Intrathecal immunoglobulin synthesis Blood-CSF-barrier Blood
CSF
Albumin IgG IgA
Filtration
Intrathecal Ig synthesis
IgM
Definitions: CSF: cerebrospinal fluid; Ig: immunoglobulin
Semiquantitative total IgG
•
IgG Index=
IgG CSF : IgG Serum Alb CSF : Alb Serum
Normal: <0.7
Definitions: Alb: albumin; Ig: immunoglobulin.
Reiber formula QAlb
IgG Index
IgA Index
IgM Index
5 10 20 40 80 100
0,65 0,68 0,72 0,76 0,78 0,78
0,46 0,46 0,53 0,61 0,66 0,67
0,22 0,28 0,39 0,49 0,56 0,58
Intrathecal Ig concentration IgLoc = [ QIg – (a/b √(QAlb)2 + b2 – c) ] x IgSerum
[mg/l]
Intrathecal Ig fraction IgIF = [ 1 – (a/b √(QAlb)2 + b2 – c) / QIg ] x 100
Definitions: Alb: albumin; Ig: immunoglobulin.
[%]
Auer & Hegen formula
Auer M, et al. Eur J Neurol. 2016 Apr;23(4):713-21
Diagnostic performance of quantitative formulae
73 95
At onset
Definite MS
Bourahoui A, et al. Eur J Neurol. 2004 Aug;11(8):525-9; Freedman MS, et al. Arch Neurol. 2005 Jun;62(6):865-70.
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IgG Index vs. OCB 647 patients with IgG index > 0.6 100
DMD IND OND Borr. Total
% of OCB
80 60 40
SAH excluded!
20 0
demyelinating neurol. diseases (n=295) inflammatory neurol. diseases (n=197) other neurol. diseases (n=137) neuroborreliosis (n=18)
0.600.63
0.630.67
0.680.76
0.760.89
0.901.18
1.191.1.96
2.007.75
IgG index
Ig: immunoglobulin; OCB: oligoclonal bands; SAH: subarachnoid haemorrhage Mayringer I, et al. Eur J Neurol. 2005
In 30% of MS patients clonal expansion occurs without elevated total IgG!
IEF patterns CSF
Ser
IEF followed by immunostaining for IgG Definitions: CSF: cerebrospinal fluid; IEF: isoelectric focusing; Ig: immunoglobulin
Sensitivity and specificity of oligoclonal bands
Deisenhammer F, et al. Eur J Neurol. 2006 Sep;13(9):913-22
CSF in diagnostic criteria 2005 and 2010
If imaging or other tests (for instance, CSF) are undertaken and are negative, extreme caution needs to be taken before making a diagnosis of MS, and alternative diagnoses must be considered.
CSF: cerebrospinal fluid Polman CH, et al. Ann Neurol. 2011 Feb;69(2):292-302
Normal CSF!
CSF: cerebrospinal fluid Solomon AJ, et al. Neurology. 2016 Sep 27;87(13):1393-9
2017 diagnostic MS criteria in RMS
CSF: cerebrospinal fluid; DIS: dissemination in space; DIT: dissemination in time; MRI: magnetic resonance imaging; Thompson AJ, et al. Lancet Neurol. 2018 Feb;17(2):162-173
Predictive value of OCB Clinically isolated syndromes (CIS): evidence that + IgG OB pose a risk for presenting a 2 nd attack independently of MRI findings:
CDMS: clinically definite MS; CIS: clinically isolated syndrome; Ig: immunoglobulin; MRI: magnetic resonance imaging; OB: oligoclonal bands; DMT: disease-modifying therapy Tintore M et al. Neurology. 2008;70:1079-1083. Tintore M et al. Brain. 2015;138:1863-1874.
DIS: dissemination in space; DIT: dissemination in time; OB: oligoclonal bands; Tintore M et al. Neurology. 2008;70:1079-1083. Tintore M et al. Brain. 2015;138:1863-1874. Arrambide G et al. Brain. 2018;141:1075-1084
Prognostic value of OCB in CIS
OCB+ in 60-70% of CIS patients
Conversion to CDMS best investigated in ON: – –
Nilsson et al., J Neurol 2005: Risk for CDMS after 15 years in OCB+ 49% vs. 23% in OCB- (p=0.02) Soderstrom et al., Neurology 1998 (n= 143, 72% OCB+)
fig: Probability not to develop MS OCB+ (n=103) vs. OCB- (n=40) OCB+ sensitivity for CDMS 96% specificity 42% PPV 49% NPV 95%
CDMS: clinically definite MS; CIS: clinically isolated syndrome; NPV: negative predictive value; OCB: oligoclonal bands; PPV: positive predictive value;
OC-IgM-B in MS Author
year
n Analyte
OCMB+
EDSS
Villar
2002
65 OCMB
30 (46%)
+
Villar
2003
29 OCMB
11 (38%)
+
Mandrioli
2008
64 OCMB
30 (47%)
+
Villar
2008
54
myelin lipid spec. OCMB
Thangarajh
2008
81
lipid spec. OCMB
Method: IEF
Conversion to SPMS
+
+ 24 (30%)
+
+
New development
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Intrathecal B cell activity in MS Blood-CSF barrier Blood
CSF
Albumin Ig
Filtration VL
Intrathecal synthesis
CL
VL
FLC
CL
B
C
CL
L
VL
VL
• Immunoglobulins and Free Light Chains (FLC) accumulate in CSF in case of an intrathecal B cell activity • Besides intact immunoglobulins, terminally differentiated B cells (plasma cells) produce Light Chains in excess.
• 3 IgG isotypes: IgG, IgA, IgM • 2 subtypes: 𝜿-FLC & 𝝀-FLC
CSF: cerebrospinal fluid; Ig: immunoglobulin Hegen H, et al. Wien Med Wochenschr. 2022 Nov;172(15-16):337-345
Meta anlysis k-FLC – diagnostic value for MS
FLC: free light chains; OCB: oligoclonal bands Hegen H, et al. Mult Scler. 2023 Feb;29(2):169-181
Marker
Sensitivity (range)
Specificity (range)
k-FLC
88 (52-100)%
89 (69-100)%
OCB
85 (37-100)%
92 (74-100)%
Mean difference
2
-4
Very similar findings in PPMS
FLC: free light chains Hegen et al. submitted
kFLC index is superior to other formulae
CSF: cerebrospinal fluid; FLC: free light chains; IF: intrathecal fraction; Ig: immunoglobulin Hegen H, et al. Clin Chem Lab Med. 2019 Sep 25;57(10):1574-1586
k-FLC index cutpoint (range: 2.4 – 20)
FLC: free light chains Hegen H, et al. Mult Scler. 2023 Feb;29(2):169-181
Heterogenicity of study populations mimics assay related performance
N Latex
FLC: free light chains; OCB: oligoclonal bands Hegen H, et al. Mult Scler. 2023 Feb;29(2):169-181
Freelite
KFLC and OCB concordance rates
The concordance was higher between OB and KFLC indexes compared to OB / KFLC indexes and IgG index The highest concordance occurred between OB and KFLC-6.6, followed by OB and KFLC-5.9
FLC: free light chains; Ig: immunoglobulin; OB: oligoclonal bands Arrambide G et al. Brain. 2022;45:3931-3942.
KFLC cutpoints by differentials Multicentric: MS n=675, CIS n=90, OIND n=297, NINDC n=559 (no MRI data available) KFLC index cut-offs:
Diagnostic performance, KFLC index vs OB
-MS/CIS vs NINDC: 8.92 -MS/CIS vs OIND: 11.56
The KFLC perform slightly better than OB
CIS: clinically isolated syndrome; KFLC: kappa free light chains; Ig: immunoglobulin; OCB: oligoclonal bands; OIND: other inflammatory CNS disorders; NINDC: noninflammatory CNS disorder controls Levraut M et al. Neurol Neuroimmunol Neuroinflamm. 2022;10:e200049.
OIND MOGAD (n=26) NMOSD (n=18) ADEM (n=10) idiopathic myelitis (n=29); Idiopathic optic neuritis (n=29) Neurosarcoidosis (n=17) CNS vasculitis (n=21); Sjögren syndrome (n=5) Neurolupus (n=5) Behçet’s disease (n=5) Idiopathic LETM (n=10) Undefined demyelinating disease (n=17) Autoimmune encephalitis (n=72);
Pachy/Leptomeningitis (n=7) Aseptic meningitis/meningoradiculitis (n=10) TolosaHunt (n=4) Vogt-Koyanagi-Harada syndrome (n=3); CAAri (n=6) Relapsing meningoencephalomyelitis (n=2); Hypophysitis (n=1
Levraut M et al. Neurol Neuroimmunol Neuroinflamm. 2022;10:e200049.
KFLC as prognostic marker independent of OCB status KFLC index in pati ents with CIS (Multi centre, n=88)
KFLC index: similar levels if OB negative, regardless of clinical status (CIS-CIS vs CIS-MS) Berek K et al. Neurol Neuroimmunol Neuroinflamm. 2021;8:e1005.
KFLC as a prognostic marker Single centre, n= 214 CIS. Results: General characteristics
Definitions: CIS: clinically isolated syndrome; DIS: dissemination in space; DIT: dissemination in time; KFLC: kappa free light chains; MRI: magnetic resonance imaging Arrambide G et al. Brain. 2022;45:3931-3942
KFLC vs OCB as a prognostic marker
The risk for second attack was very similar between KFLC-5.0 and KFLC-6.6 The highest risk for DIS and DIT was demonstrated for KFLC-5.9 Definitions: DIS: dissemination in space; DIT: dissemination in time; KFLC: kappa free light chains; OCB oligoclonal bands Arrambide G et al. Brain. 2022;45:3931-3942.
KFLC vs OCB as a prognostic marker
Both KFLC-5.0 and KFLC-6.6 had the highest sensitivity and a better specificity, with a slightly higher accuracy than OB Although the IgG index had the highest specificity, its sensitivity was lower than that of OB and KFLC indexes, yielding the lowest accuracy. Its NPV was also the lowest although the PPV was similar to that of OB and KFLC indexes DIS: dissemination in space; DIT: dissemination in time; Ig: immunoglobulin; KFLC: kappa free light chains; NPV: negative predictive value; OB oligoclonal bands; PPV: positive predictive value; Arrambide G et al. Brain. 2022;45:3931-3942.
Prognostic value by KFLC index Results: Estimating cut-offs by outcome
KFLC index cut-offs vary according to the outcome
DIS: dissemination in space; DIT: dissemination in time; KFLC: kappa free light chains; NPV: negative predictive value; PPV: positive predictive value; Arrambide G et al. Brain. 2022;45:3931-3942.
Free light chains in CSF combine advantages of OCB and total IgG measurements Intrathecal Ig synthesis
Intrathecal k-FLC synthesis
Qualitative
Quantitative Non-linear Function • Reiber1 / • Auer & Hegen2
Quantitative Different approaches
Oligoclonal IgG Bands3 •
•
Absolute CSF concentration
• • • •
Metric Easy & fast Rater-independent High diagnostic sensitivity
% IF
• • • •
Metric Easy & fast Rater-independent Moderate diagnostic sensitivity
• Nominal • Labour-intensive • Rater-dependent • High diagnostic sensitivity
CSF: cerebrospinal fluid; Ig: immunoglobulin; KFLC: kappa free light chains; OCB oligoclonal bands 1Reiber H. J Neurol Sci. 1994 Apr;122(2):189-203; 2 Auer M, et al. Eur J Neurol. 2016 Apr;23(4):713-21; 3 Freedman MS, et al. Arch Neurol. 2005 Jun;62(6):865-70
Steroids do not impact 𝜅-FLC in CSF 𝜅-FLC index
CSF 𝜅-FLC concentration
CSF: cerebrospinal fluid; KFLC: kappa free light chains Konen FF, et al. Cells. 2020 Mar 31;9(4):842. doi: 10.3390/cells9040842
Conclusion and take home messages • CSF is a highly specific and sensitive tool for the diagnosis of MS • The CSF diagnostic criteria (“positive CSF”) for MS apply for patients with a typical clinical demyelinating syndrome AFTER (!) exclusion of differentials (i.e. no better explanation) • The cut-off points for “positive CSF” – 2 or more CSF restricted OCB or elevated kFLC are made to demonstrate the chronic inflammatory nature of MS. These are NOT made to differentiate between MS and other inflammatory CNS disease • Of course, CSF can be useful for differential diagnosis, but other diagnostic criteria apply for the respective diseases • The primary purpose is to support the diagnosis (DIT criteria); however, there is also a prognostic value • New markers (kFLC) will increase availability, prognostic value and diagnostic performance • Many other biomarkers are discussed currently, but none have been used as MS diagnostic markers to date CSF: cerebrospinal fluid; DIT: dissemination in time; Ig: immunoglobulin; KFLC: kappa free light chains; OCB oligoclonal bands
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