The ability to track disease progression is important in any pathology, but it is particularly important in chronic diseases with poor prognoses. 

Tracking disease progression when a patient is expected to recover is different from tracking it when a patient’s condition is expected to worsen. For recoverable diseases, it is a matter of time until the patient becomes clinically well. For diseases for which there is still no cure, the ability to track progression means more opportunities to administer symptomatic relief and maximize quality of life. 

The unspoken rule in tackling untreatable diseases is this: offer support, both physical and mental/emotional, so that the patient is able to live a life as close to normal as possible. Secondly, conduct research into promising treatments that can prolong life and reduce the disease burden. Lastly and most importantly, invest in finding a permanent cure. 


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Neuromyelitis optica spectrum disorder (NMOSD), at present, falls under the category of “chronic diseases of poor prognosis.” Its more severe features include tonic spasms following transverse myelitis, neuropathic pain that can be more severe and disabling than in patients with multiple sclerosis, and mental health challenges. 

Read more about NMOSD etiology 

One of the most important aspects of treating NMOSD is to prevent relapses from occurring. “Disability in NMOSD patients is due to accrued damage from each relapse,” Holroyd and colleagues wrote in Current Opinions in Ophthalmology. “Prevention of recurrent attacks is therefore essential.”

A Diagnostic and Monitoring Tool

In Therapeutic Advances in Neurological Disorders, Solomon and colleagues proposed that magnetic resonance imaging (MRI) remains the most important tool in diagnosing and monitoring disease progression in NMOSD. 

Since its invention, MRI has played a central role in diagnostics, especially in soft tissue disease. There has been much medical research focused on finding ways to utilize it better. 

Let’s start with diagnosis. The value of MRI in diagnosing NMOSD is that it helps physicians exclude possible mimics. This is especially true in seronegative NMOSD. In about 50% to 85% of cases, brain lesions can be seen in patients with NMOSD. The characteristics of the lesions observed via MRI can help physicians differentiate NMOSD from multiple sclerosis and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD). 

Once a diagnosis is made, MRI can be used to help physicians decide on the most suitable treatment regimen. “MRI is used to evaluate presence of spinal cord atrophy, optic nerve and spinal cord lesion length” which “may inform treatment selection,” Solomon et al wrote. Spinal cord lesions in NMOSD are typically characterized as longitudinally extensive. 

Read more about NMOSD treatment 

Next, MRI can be used to track disease progression in NMOSD. It does so in a number of ways. For example, it can help physicians differentiate a relapse from a pseudo-relapse, which is important for management.

MRI can also allow physicians to detect subclinical disease activity. This is immensely useful since recurrent relapses in the same location in patients with pre-existing disability can be challenging to identify. For example, if a patient already suffers from vision loss, he or she may not notice new visual changes; hence, this symptom of clinical deterioration can easily be missed. “In these cases, MRI showing new enhancement may serve as a more sensitive marker to detect a relapse,” Solomon et al wrote. 

Informing Clinical Decisions

Because of all the reasons above, it is entirely reasonable for MRI to be used as a tool to inform treatment decision-making. Over the last few decades, medical advancements mean that targeted immunotherapies have been developed for NMOSD and other diseases. Currently, there is no set protocol for deciding on treatment options via MRI monitoring, but Solomon et al argued this should change.

“MRI monitoring of the brain and spinal cord could potentially help treating clinicians identify subclinical inflammation and allow them time to revise the treatment strategy before inflammation progresses to a full attack,” they wrote. “However, one of the challenges of routine imaging is that inflammation leading to a clinical relapse may develop rapidly, and unless timed well, MRI may not capture evolving inflammation early enough to prevent its progression.” 

The main point here is that we should not become so familiar with MRI that we forget its potency in helping us diagnose and monitor diseases. Solomon and colleagues make an excellent point in advocating for the more widespread use of MRI in the management of NMOSD. 

At the same time, researchers are looking into more incisive tools for NMOSD prognostication and disease monitoring. For now, radiological monitoring has an incredibly important role to play in flagging subclinical disease activity and offering physicians the opportunity to optimize therapy before a potentially disabling relapse occurs.

References

Huda S, Whittam D, Bhojak M, Chamberlain J, Noonan C, Jacob A. Neuromyelitis optica spectrum disorders. Clin Med (Lond). 2019;19(2):169-176. doi:10.7861/clinmedicine.19-2-169

Solomon JM, Paul F, Chien C, Oh J, Rotstein DL. A window into the future? MRI for evaluation of neuromyelitis optica spectrum disorder throughout the disease course. Ther Adv Neurol Disord. 2021;14:17562864211014389. doi:10.1177/17562864211014389 

Holroyd KB, Manzano GS, Levy M. Update on neuromyelitis optica spectrum disorder. Curr Opin Ophthalmol. 2020;31(6):462-468. doi:10.1097/ICU.0000000000000703