Corticosteroid Effects on Asymptomatic Gadolinium-enhancing Lesions in Multiple Sclerosis

Investigators perform a study on 104 consecutive patients with a diagnosis of RR-MS. Participants will be selected for the study if they meet all of the following inclusion criteria: (1) a baseline MRI scan with at least one CEL on contrast-enhanced T1-weighted images (performed either at the time of the diagnosis or during the routine MRI monitoring of the disease) and (2) a follow-up MRI scan performed at least 6 months later in the same hospital site. Participants were then divided into two groups by block randomization (the Block size will be 4): (1) participants with asymptomatic CELs, treated with a single cycle of high-dose IVMP after baseline MRI (group A) and (2) participants with asymptomatic CELs for clinical relapse and, therefore, not exposed to IVMP after baseline MRI (group B).

• Microsoft Excel software will be used for block randomization with a group of 4.
• Number the participants from 1 to 102.
• In a group of 2, the possible combinations of blocks are:(A=Group1 and B=Group2)

• ABBA 2. ABAB 3. BBAA 4. ABAB 5. BAAB 6. BABA

To determine the sample size for this study we used the result of Maria Di Gregorio and et al.

This study will be double-blind patients and radiologist clinicians unaware of types of interventions.

MRI examinations were performed with a 1.5 T magnet (General Electric Medical Systems, Milwaukee, WI, USA) with a standard head coil. The MRI protocol used in our Neuroradiology Section included the following sequences: (1) a T2-weighted-fluid-attenuated inversion recovery (FLAIR) sequence with an inversion time (TI) of 2400 ms, an echo time (TE) of 120 ms, and a repetition time (TR) of 8000 ms; (2) a T2-weighted fast spin-echo (FSE) sequence with a TE of 90 ms and a TR of 6600 ms; and (3) a spin-echo (SE) sequence for T1-weighted images with a TR of 500 ms and a TE of 20 ms Post-contrast images were obtained with a scan delay of 5 min after the injection of gadoterate (Dotarem, Guerbet group, Roissy, France) at 0.2 mmol/kg. 3-mm thick contiguous slices were obtained.

In the baseline MRI, the following characteristics of CELs were recorded: (1) number; (2) maximum diameter (≤ or > 5 mm); (3) pattern of enhancement (homogeneous or ring enhancement); (4) hypointensity as compared to normal-appearing surrounding white matter in baseline T1-weighted images acute black hole (aBH); and (5) the fact of being symptomatic, as established by an experienced neurologist (MDG) on the basis of CELs' localization and clinical characteristics of the concomitant relapse. The follow-up MRI was performed with the same 1.5 T magnet and using the same MRI protocol. At the follow-up MRI, the presence of persistent black holes (pBHs) was recorded. Specifically, pBHs were defined as non-enhancing T1 lesions hypointense with respect to the surrounding normal-appearing white matter and concordant with hyperintense T2 lesions [10]. Three investigators (MDG, AP, and GR) in agreement with a senior experienced neuro-radiologist (PF) revised baseline CELs and follow-up pBHs' characteristics. The three investigators and the neuroradiologist were blinded to the exposure of the patients to IVMP treatment

Inclusion criteria

• All patients with a diagnosis of RR-MS
• with a baseline MRI scan with at least one asymptomatic CEL on contrast-enhanced T1-weighted images

Exclusion criteria

• Pulse therapy 3 months ago,
• More than 6 months ago slowly progressive disease
• Systemic infections, including fungal infection
• Uncontrolled hypertension
• With known hypersensitivity to the steroid preparation