Showing papers by "Franz Fazekas published in 2015"

Evidence-based guidelines: MAGNIMS consensus guidelines on the use of MRI in multiple sclerosis--establishing disease prognosis and monitoring patients

Abstract: The role of MRI in the assessment of multiple sclerosis (MS) goes far beyond the diagnostic process. MRI techniques can be used as regular monitoring to help stage patients with MS and measure disease progression. MRI can also be used to measure lesion burden, thus providing useful information for the prediction of long-term disability. With the introduction of a new generation of immunomodulatory and/or immunosuppressive drugs for the treatment of MS, MRI also makes an important contribution to the monitoring of treatment, and can be used to determine baseline tissue damage and detect subsequent repair. This use of MRI can help predict treatment response and assess the efficacy and safety of new therapies. In the second part of the MAGNIMS (Magnetic Resonance Imaging in MS) network's guidelines on the use of MRI in MS, we focus on the implementation of this technique in prognostic and monitoring tasks. We present recommendations on how and when to use MRI for disease monitoring, and discuss some promising MRI approaches that may be introduced into clinical practice in the near future.

Evidence-based guidelines: MAGNIMS consensus guidelines on the use of MRI in multiple sclerosis - Clinical implementation in the diagnostic process

Abstract: The clinical use of MRI in patients with multiple sclerosis (MS) has advanced markedly over the past few years. Technical improvements and continuously emerging data from clinical trials and observational studies have contributed to the enhanced performance of this tool for achieving a prompt diagnosis in patients with MS. The aim of this article is to provide guidelines for the implementation of MRI of the brain and spinal cord in the diagnosis of patients who are suspected of having MS. These guidelines are based on an extensive review of the recent literature, as well as on the personal experience of the members of the MAGNIMS (Magnetic Resonance Imaging in MS) network. We address the indications, timing, coverage, reporting and interpretation of MRI studies in patients with suspected MS. Our recommendations are intended to help radiologists and neurologists standardize and optimize the use of MRI in clinical practice for the diagnosis of MS.

Nonconventional MRI and microstructural cerebral changes in multiple sclerosis.

Abstract: MRI has become the most important paraclinical tool for diagnosing and monitoring patients with multiple sclerosis (MS). However, conventional MRI sequences are largely nonspecific in the pathology they reveal, and only provide a limited view of the complex morphological changes associated with MS. Nonconventional MRI techniques, such as magnetization transfer imaging (MTI), diffusion-weighted imaging (DWI) and susceptibility-weighted imaging (SWI) promise to complement existing techniques by revealing more-specific information on microstructural tissue changes. Past years have witnessed dramatic advances in the acquisition and analysis of such imaging data, and numerous studies have used these tools to probe tissue alterations associated with MS. Other MRI-based techniques-such as myelin-water imaging, (23)Na imaging, magnetic resonance elastography and magnetic resonance perfusion imaging-might also shed new light on disease-associated changes. This Review summarizes the rapid technical progress in the use of MRI in patients with MS, with a focus on nonconventional structural MRI. We critically discuss the present utility of nonconventional MRI in MS, and provide an outlook on future applications, including clinical practice. This information should allow appropriate selection of advanced MRI techniques, and facilitate their use in future studies of this disease.

Connectivity-based parcellation of the thalamus in multiple sclerosis and its implications for cognitive impairment: A multicenter study

Abstract: © 2015 Wiley Periodicals, Inc. In this multicenter study, we performed a tractography-based parcellation of the thalamus and its white matter connections to investigate the relationship between thalamic connectivity abnormalities and cognitive impairment in multiple sclerosis (MS). Dual-echo, morphological and diffusion tensor (DT) magnetic resonance imaging (MRI) scans were collected from 52 relapsing-remitting MS patients and 57 healthy controls from six European centers. Patients underwent an extensive neuropsychological assessment. Thalamic connectivity defined regions (CDRs) were segmented based on their cortical connectivity using diffusion tractography-based parcellation. Between-group differences of CDRs and cortico-thalamic tracts DT MRI indices were assessed. A vertex analysis of thalamic shape was also performed. A random forest analysis was run to identify the best imaging predictor of global cognitive impairment and deficits of specific cognitive domains. Twenty-two (43%) MS patients were cognitively impaired (CI). Compared to cognitively preserved, CI MS patients had increased fractional anisotropy of frontal, motor, postcentral and occipital connected CDRs (0.002 < P < 0.02). They also experienced more pronounced atrophy in anterior thalamic regions and abnormal DT MRI indices of all cortico-thalamic tracts. Damage of specific cortico-thalamic tracts explained global cognitive dysfunction and impairment of selected cognitive domains better than all other MRI variables. Thalamic CDR DT MRI abnormalities were correlated with abnormalities of the corresponding cortico-thalamic tracts. Cortico-thalamic disconnection is, at various levels, implicated in cognitive dysfunction in MS. Thalamic involvement in CI MS patients is likely related to gray matter rather than white matter damage of thalamic subregions. Hum Brain Mapp 36:2809-2825, 2015.

Cerebral small vessel disease, cognitive reserve and cognitive dysfunction

Abstract: The concept of cognitive reserve describes differences between individuals in the ability to compensate age-related brain changes or pathology as a result of greater intellectual enrichment. Cerebral small vessel disease (CSVD) is a common age-related vascular disease of the brain associated with slowly accumulating tissue damage and represents a leading cause of functional loss, disability and cognitive decline in the elderly. The promotion of cognitive reserve might be a valuable possibility to moderate the negative impact of accumulating brain changes associated with CSVD on cognitive function and thus limit the functional consequences of CSVD. We here review existing studies investigating this topic in CSVD and provide conceptual considerations why future research is needed. Relevant studies were identified using the electronic databases PubMed and MEDLINE. Six studies including 7893 subjects were found that all focused on a single feature of CSVD only, i.e., white matter hyperintensities (WMH). We also included one study investigating 247 CADASIL patients. In general, they confirm that higher cognitive reserve (i.e., educational attainment) attenuates the negative impact of WMH on cognition. Further studies should attempt to replicate this association for all features of CSVD and to expand the concept to other areas of functional loss like disordered gait. Finally intervention studies will be needed to define when and how we can still increase our cognitive reserve and what kind and magnitude of protective effects this may offer.

Dynamics of brain iron levels in multiple sclerosis: A longitudinal 3T MRI study

Abstract: Objective: We investigated longitudinal changes in iron concentration in the subcortical gray matter (caudate nucleus, globus pallidus, putamen, thalamus) of patients with clinically isolated syndrome (CIS) and definite multiple sclerosis (MS) and their relation to clinical and other morphologic variables. Methods: We followed 144 patients (76 CIS; median Expanded Disability Status Scale [EDSS] 1.0 [interquartile range (IQR) 0.0–2.0]; 68 MS; median EDSS 2.0 [IQR 1.0–3.3]) clinically and with 3T MRI over a median period of 2.9 (IQR 1.3–4.0) years. Iron concentration was determined by R2* relaxometry at baseline and last follow-up. Results: At baseline, subcortical gray matter iron deposition was higher in MS compared to CIS. In CIS, R2* rates increased in the globus pallidus ( p p p p p p Conclusions: Iron accumulation in the basal ganglia is more pronounced in the early than later phases of the disease and occurs independent from other morphologic brain changes. Short-term changes in iron concentration are not associated with disease activity or changes in disability.

MRI in Leber's hereditary optic neuropathy: the relationship to multiple sclerosis

Abstract: Background Leber’s hereditary optic neuropathy (LHON) and a multiple sclerosis (MS)-like illness appear to coexist 50 times more frequently than would be expected by chance This association of LHON and MS (LMS) raises an important question about whether there could be a common pathophysiological mechanism involving mitochondrial dysfunction Objective The primary aim was to define MRI features of LMS and LHON, and to assess the proportions of individuals displaying features typical of MS Secondarily, we investigated the effect of gender on the risk of developing white matter lesions in the context of LHON Methods A blinded standardised review of conventional brain MRIs of 30 patients with MS, 31 patients with LHON and 11 patients with LMS was conducted by three independent experts in the field MS-like MRI features were assessed Results All patients with LMS and 26% of patients with LHON had white matter lesions Of these, all patients with LMS and 25% with LHON were found to have an MRI appearance typical of MS Female patients with LHON had a significantly greater risk of having white matter lesions consistent with MS compared with male patients (relative risk 83) Conclusions A blinded review of conventional brain MRIs shows that patients with LMS have a scan appearance indistinguishable from MS Mitochondrial dysfunction could be a common pathophysiological pathway in the formation of white matter lesions There appears to be a strong female influence on the radiological appearance as well as clinical development of MS in patients with LHON

Physical activity in the elderly is associated with improved executive function and processing speed: the LADIS Study.

Abstract: Objectives Physical activity reduces the risk of cognitive decline but may affect cognitive domains differently. We examined whether physical activity modifies processing speed, executive function and memory in a population of non-dementia elderly subjects with age-related white matter changes (ARWMC). Methods Data from the Leukoaraiosis And DISability (LADIS) study, a multicenter, European prospective cohort study aimed at examining the role of ARWMC in transition to disability, was used. Subjects in the LADIS study were clinically assessed yearly for 3 years including MRI at baseline and 3-year follow-up. Physical activity was assessed at baseline, and cognitive compound scores at baseline and 3-year assessment were used. Results Two-hundred-eighty-two subjects (age, y (mean (SD)): 73.1 (±5.1); gender (f/m): 164/118); MMSE (mean (SD)): 28.3 (±1.7)) who had not progressed to MCI or dementia, were included. Multiple variable linear regression analysis with baseline MMSE, education, gender, age, stroke, diabetes and ARWMC rating as covariates revealed that physical activity was associated with better scores at baseline and 3-year follow-up for executive function (baseline: β: 0.39, 95% CI: 0.13–0.90, p = 0.008; follow-up: β: 0.24, 95% CI: 0.10–0.38, p = 0.001) and processing speed (baseline: β: 0.48, 95% CI: 0.14–0.89, p = 0.005; follow-up: β: 0.15, 95% CI: 0.02–0.29, p = 0.02) but not memory. When including baseline cognitive score as a covariate in the analysis of 3-year follow-up scores, executive function remained significant (β: 0.11, 95% CI: 0–0.22, p = 0.04). Conclusion Our findings confirm previous findings of a positive effect of physical activity on cognitive functions in elderly subjects, and further extends these by showing that the association is also present in patients with ARWMC. Copyright © 2014 John Wiley & Sons, Ltd.

Brain Magnetic Resonance Imaging Findings Fail to Suspect Fabry Disease in Young Patients With an Acute Cerebrovascular Event

Abstract: Background and Purpose—Fabry disease (FD) may cause stroke and is reportedly associated with typical brain findings on magnetic resonance imaging (MRI). In a large group of young patients with an acute cerebrovascular event, we wanted to test whether brain MRI findings can serve to suggest the presence of FD. Methods—The Stroke in Young Fabry Patients (SIFAP 1) study prospectively collected clinical, laboratory, and radiological data of 5023 patients (18–55 years) with an acute cerebrovascular event. Their MRI was interpreted centrally and blinded to all other information. Biochemical findings and genetic testing served to diagnose FD in 45 (0.9%) patients. We compared the imaging findings between FD and non-FD patients in patients with at least a T2-weighted MRI of good quality. Results—A total of 3203 (63.8%) patients had the required MRI data set. Among those were 34 patients with a diagnosis of FD (1.1%), which was definite in 21 and probable in 13 cases. The median age of patients with FD was slightl...

Contribution of Convexal Subarachnoid Hemorrhage to Disease Progression in Cerebral Amyloid Angiopathy

Abstract: Background and Purpose—Cerebral amyloid angiopathy–related cortical superficial siderosis (cSS) seems to indicate an increased risk of subsequent intracerebral hemorrhage (ICH). We wanted to identify the mechanisms and sequence of hemorrhagic events which are responsible for this association. Methods—During a 9-year-period, we identified patients with spontaneous convexal subarachnoid hemorrhage (cSAH) and performed a careful longitudinal analysis of clinical and neuroimaging data. A close imaging–histopathologic correlation was performed in one patient. Results—Of 38 cSAH patients (mean age, 77±11 years), 29 (76%) had imaging features of cerebral amyloid angiopathy on baseline magnetic resonance imaging. Twenty-six (68%) had cSS. Sixteen subjects underwent postcontrast magnetic resonance imaging. Extravasation of gadolinium at the site of the acute cSAH was seen on all postcontrast scans. After a mean of 24±22 (range 1–78) months of follow-up, 15 (39%) had experienced recurrent cSAHs and 14 (37%) had suf...

Periventricular lesions correlate with cortical thinning in multiple sclerosis

Abstract: Objective It has been suggested recently that cortical pathology in multiple sclerosis (MS) may, at least partly, be caused by factors in cerebrospinal fluid (CSF). We thus hypothesized that MS-related tissue changes in compartments close to the CSF, such as periventricular lesions, might correlate with cortical pathology. Methods We investigated a cohort of 160 patients, comprising 91 with a clinically isolated syndrome (CIS) and 69 with relapsing-remitting MS (RRMS; mean age: CIS: 31.4 ± 9.0; RRMS: 33.0 ± 8.7 years; mean disease duration: CIS: 7.2 ± 15 months; RRMS: 8.0 ± 6.5 years, Expanded Disability Status Scale (median, min-max): CIS: 1, 0–3.5; RRMS: 1.25, 0–4) with 3.0T magnetic resonance imaging. MS lesions were segmented semiautomatically on fluid-attenuated inversion recovery images. To quantify periventricular lesion load (PV-LL), we generated ventricle masks and dilated them by a voxel factor of 3. Lesions within the dilated ventricle margin were classified as periventricular. Cortical thinning was assessed by cortical mean thickness (CMT) and compared to data from 58 healthy controls (HCs; mean age: 29.1 ± 7.4 years). Results Compared to HC, CIS and (even more so) RRMS patients demonstrated significantly reduced CMT. Even after controlling for ventricular volume and total lesion load, increased periventricular lesion occupancy (percentage of PV-LL) significantly correlated with decreased CMT in RRMS (r = –0.295; p = 0.015), but not in CIS (r = 0.032; p = 0.768) patients. Interpretation The correlation between increased periventricular lesion burden and decreased CMT indicative of subpial cortical pathology supports the concept that common CSF-mediated factors might play a role in the accumulation of damage to gray and white matter in MS. Ann Neurol 2015;78:530–539

Iron mapping using the temperature dependency of the magnetic susceptibility.

Abstract: Purpose The assessment of iron content in brain white matter (WM) is of high importance for studying neurodegenerative diseases While R2* mapping and quantitative susceptibility mapping is suitable for iron mapping in gray matter, iron mapping in WM still remains an unsolved problem We propose a new approach for iron mapping, independent of diamagnetic contributions of myelin by assessing the temperature dependency of the paramagnetic susceptibility Theory and Methods We used unfixed human brain slices for relaxometry and calculated R2′ as a measure for microscopic susceptibility variations at several temperatures (4°C–37°C) at 3 Tesla The temperature coefficient of R2′ (TcR2p) was calculated by linear regression and related to the iron concentration found by subsequent superconducting quantum interference device (SQUID) magnetometry and by inductively coupled plasma mass spectrometry Results In line with SQUID measurements, R2′ mapping showed a linear temperature dependency of the bulk susceptibility with the highest slope in gray matter Even in WM, TcR2p yielded a high linear correlation with the absolute iron concentration Conclusion According to Curie's law, only paramagnetic matter exhibits a temperature dependency while the diamagnetism shows no effect We have demonstrated that the temperature coefficient (TcR2p) can be used as a measure of the paramagnetic susceptibility despite of an unknown diamagnetic background Magn Reson Med 73:1282–1288, 2015 © 2014 Wiley Periodicals, Inc

Early-Stage White Matter Lesions Detected by Multispectral MRI Segmentation Predict Progressive Cognitive Decline

Abstract: White matter lesions (WML) are the main brain imaging surrogate of cerebral small-vessel disease. A new MRI tissue segmentation method, based on a discriminative clustering approach without explicit model-based added prior, detects partial WML volumes, likely representing very early-stage changes in normal-appearing brain tissue. This study investigated how the different stages of WML, from a "pre-visible" stage to fully developed lesions, predict future cognitive decline. MRI scans of 78 subjects, aged 65-84 years, from the Leukoaraiosis and Disability (LADIS) study were analyzed using a self-supervised multispectral segmentation algorithm to identify tissue types and partial WML volumes. Each lesion voxel was classified as having a small (33%), intermediate (66%), or high (100%) proportion of lesion tissue. The subjects were evaluated with detailed clinical and neuropsychological assessments at baseline and at three annual follow-up visits. We found that voxels with small partial WML predicted lower executive function compound scores at baseline, and steeper decline of executive scores in follow-up, independently of the demographics and the conventionally estimated hyperintensity volume on fluid-attenuated inversion recovery images. The intermediate and fully developed lesions were related to impairments in multiple cognitive domains including executive functions, processing speed, memory, and global cognitive function. In conclusion, early-stage partial WML, still too faint to be clearly detectable on conventional MRI, already predict executive dysfunction and progressive cognitive decline regardless of the conventionally evaluated WML load. These findings advance early recognition of small vessel disease and incipient vascular cognitive impairment.

Measuring Gray Matter and White Matter Damage in MS: Why This is Not Enough

Abstract: Over the past years, progress in cerebral magnetic resonance imaging (MRI) technology has increased the possibilities to quantify MS-related tissue changes, starting from lesion assessment in the white matter (WM) to the quantification of microstructural changes of the whole brain (1). This was expected to give full insight into the causes of MS patients’ deficits but despite all achievements, the current plethora of MRI metrics still provides no complete explanation for the clinical condition on a group (2) and even less so on an individual level. However, within the scope of personalized medicine, this remains an important goal to better understand and ultimately minimize the functional impact of MS-related tissue damage. In this context, functional cerebral changes including adaptation and plasticity are strong contributors to the apparent clinical consequences of MS and are likely to explain part of the “morphological-clinical gap” (3), notwithstanding ongoing controversies what patient deficits to consider and how to assess them. Against this background, we critically review the development and current state of techniques to assess gross MS-related morphologic damage and their contribution to understand the clinical consequences of MS (disability, and also cognitive problems and fatigue) and the obvious modulating roles of cerebral adaptation and plasticity as unraveled by functional MRI (fMRI). From existing data, we suggest that it is unlikely to ever achieve a satisfactory level of explanation and prediction of an individual patient’s condition-based solely on morphologic information, although such insights might be better suited to define disease progression than clinical assessment.

Cervical Artery Dissection in Young Adults in the Stroke in Young Fabry Patients (sifap1) Study

Abstract: Background: Patients with carotid artery dissection (CAD) have been reported to have different vascular risk factor profiles and clinical outcomes to those with v

Morphological MRI characteristics of recent small subcortical infarcts

Abstract: BackgroundNew imaging criteria for recent small subcortical infarcts have recently been proposed, replacing the earlier term ‘lacunar infarction’, but their applicability and impact on lesion selec...

Family History in Young Patients With Stroke

Abstract: Background and Purpose—Family history of stroke is an established risk factor for stroke. We evaluated whether family history of stroke predisposed to certain stroke subtypes and whether it differed by sex in young patients with stroke. Methods—We used data from the Stroke in Fabry Patients study, a large prospective, hospital-based, screening study for Fabry disease in young patients (aged <55 years) with stroke in whom cardiovascular risk factors and family history of stroke were obtained and detailed stroke subtyping was performed. Results—A family history of stroke was present in 1578 of 4232 transient ischemic attack and ischemic stroke patients (37.3%). Female patients more often had a history of stroke in the maternal lineage (P=0.027) than in the paternal lineage. There was no association with stroke subtype according to Trial of Org 10172 in Acute Stroke Treatment nor with the presence of white matter disease on brain imaging. Patients with dissection less frequently reported a family history of ...

IV thrombolysis in patients with ischemic stroke and alcohol abuse

Abstract: Objective: To determine whether chronic alcohol consumption or acute alcohol intoxication affects the rate of IV thrombolysis (IVT) and associated risk of symptomatic intracranial hemorrhage (SICH) in patients with acute ischemic stroke (IS). Methods: We analyzed data from the nationwide Austrian Stroke Unit Registry for all patients with IS admitted to one of 35 stroke units between 2004 and 2014. We compared demographic and clinical characteristics for patients with chronic alcohol consumption (>2 drinks/d) or acute intoxication and for patients without these factors and their rates of IVT and associated SICH. Results: We identified 47,422 patients with IS. Of these patients, 3,999 (8.5%) consumed alcohol chronically and 216 (0.5%) presented with acute intoxication. Alcohol abusers were younger, more frequently men, and less often functionally disabled before the index event. Stroke severity was comparable between alcoholic and nonalcoholic IS patients. Nevertheless, patients who abused alcohol were less likely to receive IVT (16.6% vs 18.9%) and this difference remained after accounting for possible confounders. Rates of SICH after IVT were not increased in patients who abused alcohol (2.1% vs 3.7%, p = 0.04). Multivariate analysis including age, NIH Stroke Scale score, and time from symptom onset to IVT treatment showed that alcohol abuse was not an independent risk factor for SICH and was not protective (odds ratio 0.73, 95% confidence interval 0.43–1.25, p = 0.2). Conclusions: IS patients with chronic alcohol consumption or acute intoxication have decreased likelihood of receiving IVT and are not at an increased risk of associated SICH. This supports current practice guidelines, which do not list chronic alcohol consumption or acute intoxication as an exclusion criterion.

Clinically Relevant Depressive Symptoms in Young Stroke Patients - Results of the sifap1 Study

Abstract: Background: Although post-stroke depression is widely recognized, less is known about depressive symptoms in the acute stage of stroke and especially in young str

Cortical Superficial Siderosis and Risk of Bleeding after Thrombolysis for Ischemic Stroke

Abstract: Background: Cortical superficial siderosis (CSS) is a neuroimaging marker of cerebral amyloid angiopathy and has been associated with a high risk for early subsequent major intracranial hemorrhage (ICH). Therefore, many experts recommend withholding of antithrombotic medication to patients with CSS. In this study, we sought to investigate the prevalence of CSS and the associated risk of ICH in the setting of intravenous thrombolysis (IVT) for ischemic stroke. Methods: We retrospectively searched the medical documentation system of our primary and tertiary care university clinic for all patients with ischemic stroke that received IVT from 2009 to December 2014. All available imaging data were reviewed in a standardized manner and blinded to any clinical data for the presence of CSS and ICH. CSS was defined as linear signal loss along the cerebral cortex on gradient echo T2*-weighted sequences. A stroke neurologist, who was blinded to the neuroimaging data, extracted the corresponding clinical data including follow-up information. Results: We identified 298 patients that received IVT and had undergone brain MRI (mean age 67.6 ± 12.6 years, 59.4% male). Cerebral MRI was performed in 116 patients (38.9%) before and in 182 patients (61.1%) after IVT (median time from stroke symptom onset to MRI: 1 day; range 0-7 days). Only 3 patients (2 females and 1 male aged 90, 76 and 73 years, respectively) had CSS (1%). All of them had a middle cerebral artery (MCA) stroke with a corresponding vessel occlusion. The 76-year-old female patient had extensive CSS and numerous cerebral microbleeds and received another IVT treatment for recurrent MCA stroke 8 months after the first event. After both IVTs, she had clinically asymptomatic small ICH outside the ischemic infarct and distant from CSS. The 2 other patients had only mild to moderate CSS and did not experience any ICH on postthrombolytic imaging. Conclusions: The prevalence of CSS in a clinical cohort of stroke patients that received IVT was low and thus does not appear to pose a substantial risk for symptomatic ICH although this may occur in individual patients. However, such analysis also needs to be extended to the very old stroke patients in whom IVT is increasingly used.

Levodopa-responsive Holmes' Tremor Caused by a Single Inflammatory Demyelinating Lesion.

Abstract: Background : Holmes’ tremor is characterized by a combination of rest, postural, and kinetic tremor that is presumably caused by interruption of cerebello-thalamo-cortical and nigrostriatal pathways. Medical treatment remains unsatisfactory. Case Report : A 16-year-old girl presented with Holmes’ tremor caused by a transient midbrain abnormality on magnetic resonance imaging (MRI). To explore the discrepancy between persistent tremor and resolved MRI changes, we performed dopamine transporter single-photon emission computed tomography (DaT-SPECT) with a 123I-ioflupane that revealed nearly absent DaT binding in the right striatum. Levodopa dramatically improved the tremor. Discussion : This is only the second report of a transient midbrain MRI abnormality disrupting nigrostriatal pathways. The case highlights the sometimes limited sensitivity of morphologic imaging for identifying the functional consequences of tissue damage and confirms that DaT imaging may serve as a predictor for levodopa responsiveness in Holmes’ tremor.

What is new in MS spasticity research? Poster session highlights

Abstract: Each year at the Experts Summit, recent relevant research in the field of multiple sclerosis spasticity is featured in the poster sessions. Highlights of the 2015 poster session are presented.

Country break-out session highlights.

Abstract: Individuals with multiple sclerosis (MS) spasticity present a wide range of symptoms and disability levels that are frequently challenging to manage. At the MS Experts Summit 2015, five country breakout sessions were conducted in parallel, and mainly in the native language, to examine various aspects about the management of treatment-resistant MS spasticity. Topics covered included video documentation of MS spasticity management (Germany), use of cannabinoid medicines in daily practice (Italy), multidisciplinary approach to MS spasticity care (France), titration and adherence to treatments for MS spasticity (Spain) and management of MS symptoms (Norway/Rest of World). For the benefit of all attendees, session highlights were collated and presented in a Plenary Session which is summarized herein.