The edition · Neurology
Prognosis at the first attack in MS, and a brain-age score that helps only before impairment
Eight outcomes predicted from the first demyelinating event in 1,288 patients, brain-predicted age tested against visual rating, demyelination quantified in cervical myelopathy, and network disruption that forecasts seizure recurrence years after surgery.
The edition in brief
Spider-MS predicts eight separate outcomes at the time of a first demyelinating attack — McDonald diagnosis, second attack, new T2 lesion rate, relapse-associated worsening, confirmed disability worsening, progression independent of relapse activity and reaching EDSS 3.0 — from age, sex, attack topography, brain and cord lesions, oligoclonal bands and time on effective treatment. Built in 1,180 patients in Barcelona and validated in 108 in Melbourne, accuracy was moderate to high (Harrell's C 0.653-0.823 internally, 0.623-0.766 externally). In 799 memory clinic patients with subjective cognitive decline or mild cognitive impairment, MRI-derived brain-predicted age difference predicted progression to dementia (hazard ratio 1.04 per year) and added to visual rating scales — but only in subjective cognitive decline (hazard ratio 1.09), not in mild cognitive impairment (1.01), where it added nothing. A meta-analysis of 27 studies found demyelination a prominent feature of degenerative cervical myelopathy, with magnetization transfer ratio most reduced in the ventral column and correlated with baseline neurological function. The practice-changer comes from 175 patients with drug-resistant temporal lobe epilepsy followed a mean 5.4 years after surgery: a multimodal connectome model of disruption in normative brain hubs achieved 80% specificity for predicting long-term seizure recurrence, implicating hippocampi and dorsal attention network hubs that temporal lobe surgery does not target.
Eight prognoses from a first demyelinating attack
At a first demyelinating attack, capture cord imaging, lesion counts and oligoclonal bands — they are the inputs any individualised prognosis will need.
Brain age adds something in subjective decline, and nothing in MCI
If brain-age reaches practice, it will be a tool for reassuring the worried patient with normal cognition — not for staging those already impaired.
Degenerative cervical myelopathy is a demyelinating disease too
Nothing changes today — but a myelin-sensitive measure that tracks neurological function opens the question of whether some deficit in cervical myelopathy is recoverable.
At a first demyelinating attack, image the cord and tap the CSF
Get cord imaging and oligoclonal bands at the first attack, while the patient is still in front of you — both carry prognostic weight, not just diagnostic.
Network disruption predicts who relapses years after epilepsy surgery
Tell patients before temporal lobe surgery that long-term relapse is common and partly determined by network disruption outside the resection — do not present early seizure freedom as the end of the story.
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