Literature Commentary

In this issue of Journal of Neuro-Ophthalmology, M. Tariq Bhatti, MD and Mark L. Moster, MD will discuss the following 6 articles: 1. Markus HS, Levi C, King A, Madigan J, Norris J; Cervical Artery Dissection in Stroke Study (CADISS) Investigators. Antiplatelet Therapy vs Anticoagulation Therapy in Cervical Artery Dissection: The Cervical Artery Dissection in Stroke Study (CADISS) Randomized Clinical Trial Final Results. JAMA Neurol. [published ahead of print February 25, 2019] doi: 10.1001/jamaneurol.2019.0072. 2. Cortese I, Muranski P, Enose-Akahata Y, Ha SK, Smith B, Monaco M, Ryschkewitsch C, Major EO, Ohayon J, Schindler MK, Beck E, Reoma LB, Jacobson S, Reich DS, Nath A. Pembrolizumab Treatment for Progressive Multifocal Leukoencephalopathy. N Engl J Med. 2019; 380:1597-1605. 3. Pittock SJ, Berthele A, Fujihara K, Kim HJ, Levy M, Palace J, Nakashima I, Terzi M, Totolyan N, Viswanathan S, Wang KC, Pace A, Fujita KP, Armstrong R, Wingerchuk DM. Eculizumab in Aquaporin-4-Positive Neuromyelitis Optica Spectrum Disorder. N Engl J Med. [published ahead of print May 3, 2019] doi: 10.1056/NEJMoa1900866. 4. Adler S, Reichenbach S, Gloor A, Yerly D, Cullmann JL, Villiger PM. Risk of relapse after discontinuation of tocilizumab therapy in giant cell arteritis. Rheumatology (Oxford). [published ahead of print March 26, 2019] doi: 10.1093/rheumatology/kez091. 5. Weber D, Sarva H, Weaver J, Wang F, Chou J, Cornes S, Nickels K, Safdieh JE, Poncelet A, Stern BJ. Current state of educational compensation in academic neurology: Results of a US national survey. Neurology. 2019;93:30-34. 6. Calabrese M, Gasperini C, Tortorella C, Schiavi G, Frisullo G, Ragonese P, Fantozzi R, Prosperini L, Annovazzi P, Cordioli C, Di Filippo M, Ferraro D, Gajofatto A, Malucchi S, Lo Fermo S, De Luca G, Stromillo ML, Cocco E, Gallo A, Paolicelli D, LanzilloR, Tomassini V, Pesci I, Rodegher ME, Solaro C; RIREMS group (Rising Italian Researchers in Multiple Sclerosis). "Better explanations" in multiple sclerosis diagnostic workup: A 3-year longitudinal study. Neurology. 2019;92:e2527-e2537. (C) 2019 by North American Neuro-Ophthalmology Society

Literature Commentary Section Editors: Mark L. Moster, MD M. Tariq Bhatti, MD Literature Commentary In this issue of Journal of Neuro-Ophthalmology, M. Tariq Bhatti, MD and Mark L. Moster, MD will discuss the following 6 articles: 1. Markus HS, Levi C, King A, Madigan J, Norris J; Cervical Artery Dissection in Stroke Study (CADISS) Investigators. Antiplatelet Therapy vs Anticoagulation Therapy in Cervical Artery Dissection: The Cervical Artery Dissection in Stroke Study (CADISS) Randomized Clinical Trial Final Results. JAMA Neurol. [published ahead of print February 25, 2019] doi: 10.1001/jamaneurol.2019.0072. 2. Cortese I, Muranski P, Enose-Akahata Y, Ha SK, Smith B, Monaco M, Ryschkewitsch C, Major EO, Ohayon J, Schindler MK, Beck E, Reoma LB, Jacobson S, Reich DS, Nath A. Pembrolizumab Treatment for Progressive Multifocal Leukoencephalopathy. N Engl J Med. 2019; 380:1597-1605. 3. Pittock SJ, Berthele A, Fujihara K, Kim HJ, Levy M, Palace J, Nakashima I, Terzi M, Totolyan N, Viswanathan S, Wang KC, Pace A, Fujita KP, Armstrong R, Wingerchuk DM. Eculizumab in Aquaporin-4-Positive Neuromyelitis Optica Spectrum Disorder. N Engl J Med. [published ahead of print May 3, 2019] doi: 10.1056/NEJMoa1900866. 4. Adler S, Reichenbach S, Gloor A, Yerly D, Cullmann JL, Villiger PM. Risk of relapse after discontinuation of tocilizumab therapy in giant cell arteritis. Rheumatology (Oxford). [published ahead of print March 26, 2019] doi: 10.1093/rheumatology/kez091. 5. Weber D, Sarva H, Weaver J, Wang F, Chou J, Cornes S, Nickels K, Safdieh JE, Poncelet A, Stern BJ. Current state of educational compensation in academic neurology: Results of a US national survey. Neurology. 2019;93:30-34. 6. Calabrese M, Gasperini C, Tortorella C, Schiavi G, Frisullo G, Ragonese P, Fantozzi R, Prosperini L, Annovazzi P, Cordioli C, Di Filippo M, Ferraro D, Gajofatto A, Malucchi S, Lo Fermo S, De Luca G, Stromillo ML, Cocco E, Gallo A, Paolicelli D, LanzilloR, Tomassini V, Pesci I, Rodegher ME, Solaro C; RIREMS group (Rising Italian Researchers in Multiple Sclerosis). "Better explanations" in multiple sclerosis diagnostic workup: A 3-year longitudinal study. Neurology. 2019;92:e2527-e2537. Markus HS, Levi C, King A, Madigan J, Norris J; Cervical Artery Dissection in Stroke Study (CADISS) Investigators. Antiplatelet therapy vs anticoagulation therapy in cervical artery dissection: the cervical artery dissection in stroke study (CADISS) randomized clinical trial final results. JAMA Neurol. [published ahead of print February 25, 2019] doi: 10.1001/ jamaneurol.2019.0072. Importance: Extracranial carotid and vertebral artery dissection is an important cause of stroke, particularly in younger individuals. In some but not all observational studies, it has been associated with a high risk of recurrent stroke. Both antiplatelet agents (APs) and anticoagulants (ACs) are used to reduce stroke risk, but whether 1 treatment strategy is more effective is unknown. Objective: To determine whether AP or AC therapy is more effective in preventing stroke in cervical dissection and the risk of recurrent stroke in a randomized clinical trial setting. A secondary outcome was to determine the effect on arterial imaging outcomes. Design, Setting, and Participants: Randomized, prospective, open-label international multicenter parallel design study with central blinded review of both clinical and imaging end points. Recruitment was conducted in 39 stroke and Moster and Bhatti: J Neuro-Ophthalmol 2019; 39: 429-436 neurology secondary care centers in the United Kingdom and 7 centers in Australia between February 24, 2006, and June 17, 2013. One-year follow-up and analysis was conducted in 2018. Two hundred fifty participants with extracranial carotid and vertebral dissection with symptom onset within the past 7 days were recruited. Follow-up data at 1 year were available for all participants. Interventions: Randomization to AP or AC (heparin followed by warfarin) for 3 months, after which the choice of AP and AC agents was decided by the local clinician. Main Outcomes and Measures: The primary end point was ipsilateral stroke and death. A planned per-protocol (PP) analysis was performed in patients meeting the inclusion criteria after central review of imaging to confirm the diagnosis of dissection. A secondary end point was angiographic recanalization in those with imaging confirmed dissection. Results: Two hundred fifty patients were randomized (118 carotid and 132 vertebral), 126 to AP and 124 to AC. Mean (SD) age was 49 (12) years. Mean (SD) time to randomization was 3.65 (1.91) days. The recurrent stroke rate at 1 year was 6 of 250 (2.4%) on ITT analysis and 5 of 197 (2.5%) on PP analysis. There were no significant differences between treatment groups for any outcome. Of the 181 patients with confirmed dissection and complete imaging at baseline and 3 months, there was no difference in the presence of residual narrowing or occlusion between those receiving AP (n = 56 of 92) vs those receiving AC (n = 53 of 89) (P = 0.97). 429 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Literature Commentary Conclusions and Relevance: During 12 months of follow-up, the number of recurrent strokes was low. There was no difference between treatment groups in outcome events or the rate of recanalization. Trial Registration: ISRCTN.com Identifier: CTN44555237. COMMENTS This final report of the Cervical Artery Dissection in Stroke Study is a follow-up to the 3-month results of the randomized open-label study comparing the efficacy of antiplatelet (AP) to anticoagulant (AC) on the rate of stroke in patients with extracranial carotid and vertebral artery dissections (1). Just as a reminder, the first article found that within 3 months, there was no difference in the rate of stroke between patients who were treated with AP (3/126 [2%]) compared with AC (1/124 [1%]) within 7 days of symptom onset. This study provides the 12-month results of all the original 250 patients enrolled. One hundred eighteen patients had a carotid dissection, and 132 had a vertebral dissection. One hundred twenty-six patients were randomized to AP and 124 to AC. In terms of primary outcome (ipsilateral stroke and death), there were more cases in the AP group (4/126 [3.2%]) compared with the AC group (2/124 [1.6%]), but the difference was not statistically significant (P = 0.51). I want to point out a few other interesting findings in the study: Total stroke and transient ischemic attack events were more common in the first 3 months of the study than after 3 months (10 vs 3, respectively). There was only 1 death in the study and that occurred after 3 months in the AP group. There was only 1 major bleeding event and that occurred within the first 3 months in the AC group. I think it is important to highlight the fact that this was not a controlled and blinded study, but, rather, an unblinded, open-label, prospective study that allowed patients to take a variety of AP therapies (aspirin, clopidogrel, or dipyridamole alone or in any combination thereof). The author stated was "a pragmatic treatment trial." Therefore, this study does not meet criteria for Class 1 evidence (2), but it is the best evidence we currently have for the optimum treatment of extracranial cervical and vertebral artery dissections. -M. Tariq Bhatti, MD REFERENCES 1. CADISS trial investigators, Markus HS, Hayter E, Levi C, Feldman A, Venables G, Norris J. Antiplatelet treatment compared with anticoagulation treatment for cervical artery dissection (CADISS): a randomised trial. Lancet Neurol. 2015;14:361-367. Erratum in: Lancet Neurol. 2015 Jun;14(6):566. 2. American Acadey of Neurology. Classification of Evidence. Available at: https://qibawiki.rsna.org/images/3/33/ 430 American_Academy_of_Neurology_Classification_of_Evidence20100504.doc. Accessed May 2019. The relatively good prognosis in these patients with either AP or AC therapy is welcome news. I do share your concerns about the flexibility in the treatment decision by the treating physician. Additional concerns are the authors' statement that in 20%, the diagnosis could not be confirmed radiographically because of poor quality or the "diagnostic criteria were not rigorously applied and other causes of angiographic abnormalities were mistakenly diagnosed as dissection." It turns out that those who had strokes during the study had a previous stroke already at the time of diagnosis of the dissection, so that the prognosis may be even better for those without ischemic presentations. -Mark L. Moster, MD Cortese I, Muranski P, Enose-Akahata Y, Ha SK, Smith B, Monaco M, Ryschkewitsch C, Major EO, Ohayon J, Schindler MK, Beck E, Reoma LB, Jacobson S, Reich DS, Nath A. Pembrolizumab treatment for progressive multifocal leukoencephalopathy. N Engl J Med. 2019; 380:1597-1605. Background: Progressive multifocal leukoencephalopathy (PML) is an opportunistic brain infection that is caused by the JC virus and is typically fatal unless immune function can be restored. Programmed cell death protein 1 (PD-1) is a negative regulator of the immune response that may contribute to impaired viral clearance. Whether PD-1 blockade with pembrolizumab could reinvigorate anti-JC virus immune activity in patients with PML was unknown. Methods: We administered pembrolizumab at a dose of 2 mg per kilogram of body weight every 4-6 weeks to 8 adults with PML, each with a different underlying predisposing condition. Each patient received at least 1 dose but no more than 3 doses. Results: Pembrolizumab induced downregulation of PD-1 expression on lymphocytes in peripheral blood and in cerebrospinal fluid (CSF) in all 8 patients. Five patients had clinical improvement or stabilization of PML accompanied by a reduction in the JC viral load in the CSF and an increase in in vitro CD4+ and CD8+ anti-JC virus activity. In the other 3 patients, no meaningful change was observed in the viral load or in the magnitude of antiviral cellular immune response, and there was no clinical improvement. Conclusions: Our findings are consistent with the hypothesis that in some patients with PML, pembrolizumab reduces JC viral load and increases CD4+ and CD8+ activity against the JC virus; clinical improvement or stabilization occurred in 5 of the 8 patients who received pembrolizumab. Further study of immune checkpoint inhibitors in the treatment of PML is warranted (Funded by the National Institutes of Health [NIH]). Moster and Bhatti: J Neuro-Ophthalmol 2019; 39: 429-436 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Literature Commentary COMMENTS Progressive multifocal leukoencephalopathy (PML) can be a devastating disease and is invariably seen in immunocompromised patients. Treatment is geared toward re-establishing the immune system, most often with plasma exchange. In the introduction, the authors provide the biological basis for using pembrolizumab, which is a monoclonal antibody targeting the programmed cell death protein 1 (PD-1) found on T cells. Also known as an immune checkpoint inhibitor, it releases the breaks on the immune system and has been successfully used in a variety of aggressive cancers. This article reports on 8 patients who were involved in 2 NIH studies but were given pembrolizumab on a compassionate use basis. The underlying diseases were HIV infection (2), chronic lymphocytic leukemia (2), Hodgkin lymphoma (1), non-Hodgkin lymphoma (1), and idiopathic lymphopenia (2). In terms of the degree of disability, 2 patients were classified as mild, 2 as moderate, and 4 severe. Four patients were noted to have either cortical visual impairment or hemianopia. All patients received intravenous (IV) pembrolizumab at a dose of 2 mg/kg, every 4-6 weeks for up to 3 doses. A variety of laboratory tests were performed including detection of PD-1 on lymphocytes in the blood and CSF and JC viral load in the CSF. In addition, all the patients underwent brain MRI. The clinical course information was provided on each patient in descriptive form and quantitated using the modified Rankin scale. Two patients had clinical improvement, 3 patients stabilized, 1 patient had no benefit, and 2 patients worsened with both resulting in death. No patient had normalization of the brain MRI. I reviewed the supplemental appendix to see if I could find any specific information on the visual outcomes. All that I could find was this: Patient 1: "Cortical blindness also improved with ability to identify colors and objects; with improvement of cortical visual impairment, dense left hemianopia became apparent as residual deficit Patient 5: ".and vision improved with regained ability to recognize objects, finger count, identify colors as well as read large text. Left hemianopia persisted as did some degree of simultagnosia and visual ataxia." In terms of adverse events, 1 patient developed a psoriatic mouth rash and another developed a recurrence of a maculopapular rash. One patient (Patient 2) had initial worsening of his clinical symptoms in addition to progression on MRI that was believed to be due to the PML and not from the immune reconstitution inflammatory syndrome. Eventually, the patient stabilized. Along with this study, there were 2 case reports published in the same issue on the use of immune checkpoint inhibitors (one with nivolumab and the other with pembrolizumab) for PML (1,2). In addition, an editorial accompanied all these articles, highlighting some important points: (3) Moster and Bhatti: J Neuro-Ophthalmol 2019; 39: 429-436 Decrease in lesion size on MRI may not represent treatment efficacy but rather white matter atrophy from tissue destruction by PML. Case reports of immune checkpoint inhibitor-associated PML. JC virus-specific T cells in the blood are needed for immune checkpoint inhibitors to be effective. A controlled trial is needed to determine the true effect of immune checkpoint inhibitors in the treatment of PML. Let me end Mark, by giving you a fun fact about immune checkpoint inhibitors. The 2018 Nobel Prize in Physiology and Medicine was awarded to James P. Allison (University of Texas MD Anderson Cancer Center, Houston, TX) (4) and Tasuku Honjo (Kyoto University, Kyoto, Japan) (5) "for their discovery of cancer therapy by inhibition of negative immune regulation." -M. Tariq Bhatti, MD 1. Walter O, Treiner E, Bonneville F, Mengelle C, Vergez F, Lerebours F, Delobel P, Liblau R, Martin-Blondel G; Immune Checkpoint inhibitors in PML Study Group. Treatment of progressive multifocal leukoencephalopathy with nivolumab. N Engl J Med. 2019;380:1674-1676. 2. Rauer S, Marks R, Urbach H, Warnatz K, Nath A, Holland S, Weiller C, Grimbacher B. Treatment of progressive multifocal leukoencephalopathy with pembrolizumab. N Engl J Med. 2019;380:1676-1677. 3. Koralnik IJ. Can immune checkpoint inhibitors keep JC virus in check? N Engl J Med. 2019;380:1667-1668. 4. The Nobel Prize. James P Allison Facts. Available at: https:// www.nobelprize.org/prizes/medicine/2018/allison/facts/. Accessed May 2019. 5. The Nobel Prize. Tasuku Honjo Facts. Available at: https://www. nobelprize.org/prizes/medicine/2018/honjo/facts/. Accessed May 2019. This anecdotal report on the compassionate use of pembrolizumab for PML is encouraging, with 5 of the 8 patients stabilized or improved. Therefore, further clinical trials are warranted. As you noted, the Nobel Prize was given for the discovery of these checkpoint inhibitors, which are a huge advancement in cancer treatment. I wonder whether we will see similar complications in these immunosuppressed patients with PML treated with these agents as we see in patients with healthier immune systems being treated for cancer (e.g., optic neuritis and myasthenia gravis). -Mark L. Moster, MD Pittock SJ, Berthele A, Fujihara K, Kim HJ, Levy M, Palace J, Nakashima I, Terzi M, Totolyan N, Viswanathan S, Wang KC, Pace A, Fujita KP, Armstrong R, Wingerchuk DM. Eculizumab in aquaporin-4-positive neuromyelitis optica spectrum disorder. N Engl J Med. [published ahead of print May 3, 2019] doi: 10.1056/NEJMoa1900866. Background: Neuromyelitis optica spectrum disorder (NMOSD) is a relapsing, autoimmune, inflammatory 431 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Literature Commentary disorder that typically affects the optic nerves and spinal cord. At least two-thirds of cases are associated with aquaporin-4 antibodies (AQP4-IgG) and complementmediated damage to the central nervous system. In a previous small, open-label study involving patients with AQP4IgG-positive disease, eculizumab, a terminal complement inhibitor, was shown to reduce the frequency of relapse. Methods: In this randomized, double-blind, time-to-event trial, 143 adults were randomly assigned in a 2:1 ratio to receive either IV eculizumab (at a dose of 900 mg weekly for the first 4 doses starting on Day 1, followed by 1,200 mg every 2 weeks starting at Week 4) or matched placebo. The continued use of stable-dose immunosuppressive therapy was permitted. The primary end point was the first adjudicated relapse. Secondary outcomes included the adjudicated annualized relapse rate (ARR), quality-of-life measures, and the score on the Expanded Disability Status Scale (EDSS), which ranges from 0 (no disability) to 10 (death). Results: The trial was stopped after 23 of the 24 prespecified adjudicated relapses, given the uncertainty in estimating when the final event would occur. The mean (±SD) ARR in the 24 months before enrollment was 1.99 ± 0.94; 76% of the patients continued to receive their previous immunosuppressive therapy during the trial. Adjudicated relapses occurred in 3 of 96 patients (3%) in the eculizumab group and 20 of 47 (43%) in the placebo group (hazard ratio, 0.06; 95% confidence interval [CI], 0.02-0.20; P , 0.001). The adjudicated ARR was 0.02 in the eculizumab group and 0.35 in the placebo group (rate ratio, 0.04; 95% CI, 0.01- 0.15; P , 0.001). The mean change in the EDSS score was 20.18 in the eculizumab group and 0.12 in the placebo group (least-squares mean difference, 20.29; 95% CI, 20.59 to 0.01). Upper respiratory tract infections and headaches were more common in the eculizumab group. There was 1 death from pulmonary empyema in the eculizumab group. Conclusions: Among patients with AQP4-IgG-positive NMOSD, those who received eculizumab had a significantly lower risk of relapse than those who received placebo. There was no significant between-group difference in measures of disability progression (funded by Alexion Pharmaceuticals; PREVENT ClinicalTrials.gov number, NCT01892345; EudraCT number, 2013-001150-10). COMMENTS Before, I spout out my thoughts, let me provide some basic information about the trial. Eculizumab is a humanized monoclonal antibody that targets complement protein C5, thereby preventing it from dividing into its 2 active forms: C5b, which is proinflammatory, and C5b, which is important in membrane attack complex formation. This was a randomized, double-blind, placebo-controlled study that enrolled a total of 143 adult patients with aquaporin-4 antibody (AQP4-IgG)-positive neuromyelitis optic spectrum disorder (NMSOD). Patients were required to have at least 2 relapses in the previous 12 months or 3 relapses in the previous 24 months and could be entered into the study if they were receiving stable doses of immunosuppressive 432 medications. Patients who were previously treated with mitoxantrone or rituximab during the previous 3-month, IV immune globulin during the previous 3 weeks or prednisone (.20 mg/day or the other corticosteroid equivalent) were excluded. Patients were enrolled in a 2:1 ratio resulting in 96 receiving eculizumab and 47 placebo. The primary end point of the study was first relapse. The frequency of adjudicated relapses was 3% (3/96) for the eculizumab group and 43% (20/47) for the placebo group (P , 0.001). The ARR was 0.02 in the eculizumab group and 0.35 in the placebo group (P, 0.001). However, there was no statistical difference in the EDSS between the 2 groups (20.18 for eculizumab and 0.12 for placebo). More patients in the eculizumab group than the placebo group discontinued the trial (16 vs 3, respectively). Of the 16 patients who discontinued, 12 withdrew, 3 were lost to follow-up, and 1 died. In the 12 patients who withdrew from the eculizumab group, only 4 had no adverse events. In the supplemental Table S2, it states the reasons for withdrawal in the eculizumab group were: "moving away from the trial site (four patients); unwilling to continue participating in a clinical trial (two patients); economic reasons (one patient); employment (one patient); ongoing adverse event and difficult venous access (one patient). The reasons why the three remaining patients withdrew are not known." In terms of adverse events, 92% of patients in the eculizumab had any adverse event and 91% in the placebo group. The adverse event rate was also calculated using events per 100 patient years, which was 745 for the eculizumab group and 1,127 for the placebo group. I was curious to know the exact types of relapses, which I found in the supplemental Table S3. In the eculizumab group, 1 had myelitis and 2 had bilateral optic neuritis. In the placebo group, 17 had myelitis, 1 had area postrema syndrome, and 2 had unilateral optic neuritis. It appears patient's visual status was assessed only with the Snellen eye chart and not the Early Treatment Diabetic Retinopathy Study chart or a low contrast chart. Also, I do not believe optical coherence tomography or automated visual field testing was performed. If these had been performed, I suspect the neurological disability of the patients would have been worse than what the EDSS indicated. I found a couple of things a bit unusual about this study. The sponsor (Alexion Pharmaceuticals, New Haven, CT) made the final decision to terminate the study before the prespecified 24 relapses. The sponsor changed the hierarchy of the statistical analysis plan. For the first 88 patients, relapses were not adjudicating. However, following that for all patients, 2 neurologists and 1 neuro-ophthalmologist adjudicated the physician-determined relapse. Of the 45 relapses that were adjudicated, 47% were deemed not be relapses. I wonder what the true number of relapses would have been if the adjudication process had been implemented from the beginning of the study? Moster and Bhatti: J Neuro-Ophthalmol 2019; 39: 429-436 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Literature Commentary Finally, let me say that I find it interesting that despite being the preferred treatment of NMO, to-date rituximab has not been studied in a placebo-controlled trial. So, I curbsided my neuroimmunology colleague Eoin Flanagan here at Mayo about any ongoing or completed rituximab placebo-controlled trials, and this is what he had to say: "The completed phase 3 placebo-controlled study of Medi 551 (a.k.a. inebilizumab) a CD 19 blocker in NMOSD attack prevention was a positive trial presented at the American Academy of Neurology (AAN), I believe that was submitted but not published. Probably works similar to rituximab, possibly slightly better. I use rituximab in my patients but only supported by retrospective data." -M. Tariq Bhatti, MD Thanks, Tariq for spouting! At the AAN meeting this year, in addition to inebilizumab showing positive results, there were reports on satralizumab, a recycling anti-IL-6 receptor monoclonal antibody, decreasing relapses compared with placebo. A retrospective study on rituximab treatment also presented at AAN showed an 89% reduction in ARR over 41 months when compared with the pretreatment ARR. One of the challenges of treating NMOSD has been obtaining insurance approval for off-label use of rituximab. By the time this issue of JNO is published, it is likely that eculizumab will have FDA approval for NMOSD, and it looks like there will be a few other medications approved in the near future, making it easier to effectively treat patients with NMOSD. -Mark L. Moster, MD Adler S, Reichenbach S, Gloor A, Yerly D, Cullmann JL, Villiger PM. Risk of relapse after discontinuation of tocilizumab therapy in giant cell arteritis. Rheumatology (Oxford). [published ahead of print March 26, 2019] doi: 10.1093/rheumatology/ kez091. Objective: It is currently unknown how long giant cell arteritis (GCA) should be treated with tocilizumab. In the first randomized controlled trial, the biologic agent was stopped after 52 weeks. We therefore studied what proportion of patients relapsed, when relapses occurred and whether factors might predict relapse after tocilizumab treatment discontinuation. Methods: All patients in the tocilizumab arm who had received a 52-week treatment were evaluated. In case of lasting remission, MRA was performed, and sera were taken to search for biomarkers associated with subclinical disease activity. Results: Seventeen of 20 patients randomized to the tocilizumab treatment arm were in lasting remission without any comedication at Week 52. Mean follow-up after study end was 28.1 months (range 17-44). Eight patients relapsed Moster and Bhatti: J Neuro-Ophthalmol 2019; 39: 429-436 after a mean of 6.3 months (range 2-14) (6 within the first 5 months, 2 patients at Months 13 and 14, respectively). Relapsing patients were younger and showed more signs of mural enhancement in MRA compared with nonrelapsing patients. MRA documented low-intensity vessel wall signals in all subjects. No morphological changes such as formation of aneurysm of aorta occurred. Biomarkers in sera did not indicate subclinical disease activity: levels of IL-6, MMP3, soluble TNF receptor 2, soluble CD163, soluble intercellular adhesion molecule-1, and pentraxin-3 did not differ from matched healthy controls. Conclusion: The data show that a 52-week treatment with tocilizumab induces a lasting remission that persists in half of the patients after treatment stop. None of the clinical, serological, or MRA findings qualify to predict relapse. Remarkably, MRA revealed a persisting wall enhancement of the descending aorta. COMMENTS Over the past few years, treatment of giant cell arteritis (GCA) has become easier for me with lower doses of prednisone because of the addition of tocilizumab. One of the common discussions I now have with rheumatology occurs after the patient is off prednisone and concerns when to stop the tocilizumab. This study is a follow-up of a Phase 2 double-blind, placebocontrolled randomized controlled trial from a single center in Switzerland which demonstrated that patients on IV infusions of tocilizumab achieved complete remission at 12 weeks 85% of the time compared with 40% with steroids alone, and that at 52 weeks, 85% were relapse free compared with 20% in the steroid group alone. The cumulative prednisolone dose with tocilizumab was only 39% of that required with prednisolone alone. Patients with tocilizumab came off steroids 12 weeks earlier than those on prednisolone alone (1). What we struggle with clinically is how long to keep tocilizumab going. Along with rheumatology, I tend to do the same as with prednisone-follow symptoms, laboratory test results, and eye findings-and go from weekly subcutaneous injections to every other week and then "play it by ear." The current study sheds a little light on the matter. It followed the Swiss patients in the above study looking for relapse rate and whether there were any features that predicted relapse. Relapse was defined as elevation of either erythrocyte sedimentation rate, C-reactive protein, or both and clinical symptoms typical for GCA activity. Of the 17 patients who receive tocilizumab, 9 remained in remission for a mean of 29.3 months. Eight patients relapsed after a mean time of 6.3 months (range 214) after the last tocilizumab infusion. None of the relapsing patients experienced blindness, aneurysm formation, aortic rupture, aortic stenosis, or other vascular complications. Two features predicted relapse. First, relapsing patients were younger than patients without relapse (mean age 64.6 years vs 76.4 years; P = 0.006). Second, the relapsing 433 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Literature Commentary patients showed more areas of vasculitis on initial MRA. No differences were found between relapsing and nonrelapsing patients regarding sex, newly diagnosed GCA, recurrent GCA, cranial symptoms, or positive findings on temporal artery biopsy. Limitations of the study are the small numbers and the fact that the American College of Rheumatology criteria are used for diagnosis. For instance, not all patients received a temporal artery biopsy but were diagnosed with MRA. What I take away from this study is that patients with GCA must be followed carefully after discontinuing tocilizumab in the same manner as we follow them after discontinuing prednisone. In the occasional patient I have seen with relapses, I have restarted the prednisone and considered restarting the tocilizumab. -Mark L. Moster, MD 1. Villiger PM, Adler S, Kuchen S, Wermelinger F, Dan D, Fiege V, Bütikofer L, Seitz M, Reichenbach S. Tocilizumab for induction and maintenance of remission in giant cell arteritis: a phase 2, randomised, double-blind, placebo-controlled trial. Lancet. 2016;387:1921-1927. I agree, this study adds to our understanding of how to use tocilizumab for GCA and what we can expect. The conclusion made by the authors "that a 52-week treatment with tocilizumab induces a lasting remission that persists in half of the patients," in my opinion is not something all that impressive. In fact I would suggest it is weak. There is still much that we need to learn about tocilizumab. A few questions that I have that hopefully will be answered soon are: Should all patients be started on tocilizumab in addition to corticosteroids from the onset of symptoms? Or should tocilizumab be initiated, similar to what has been done for methotrexate or some of the other immunosuppressive medications, when the dose of corticosteroids cannot be tapered down to a "safe dose" or the corticosteroids need to be stopped because of severe complications? How long should patients stay on tocilizumab to lower their risk of a relapse? As I see it maybe 1 year is not long enough. -M. Tariq Bhatti, MD Weber D, Sarva H, Weaver J, Wang F, Chou J, Cornes S, Nickels K, Safdieh JE, Poncelet A, Stern BJ. Current state of educational compensation in academic neurology: Results of a US national survey. Neurology. 2019;93:30-34. Abstract: In the current medical climate, medical education is at risk of being de-emphasized, leading to less financial support and compensation for faculty. A rise in compensa- 434 tion plans that reward clinical or research productivity fails to incentivize and threatens to erode the educational missions of our academic institutions. Aligning compensation with the all-encompassing mission of academic centers can lead to increased faculty well-being, clinical productivity, and scholarship. An anonymous survey developed by members of the A.B. Baker Section on Neurologic Education was sent to the 133 chairs of neurology to assess the type of compensation faculty receive for teaching efforts. Seventy responses were received, with 59 being from chairs. Key results include the following: 36% of departments offered direct compensation; 36% did not; residency program directors received the most salary support at 36.5% full-time equivalent; and administrative roles had greatest weight in determining academic compensation. We believe a more effective, transparent system of recording and rewarding faculty for their educational efforts would encourage faculty to teach, streamline promotions for clinical educators, and strengthen undergraduate and graduate education in neurology. COMMENTS One of the challenges of our subspecialty is recruiting new fellows into the field of neuro-ophthalmology. Although numerous causes have been identified, one of them particularly for ophthalmologists is the relatively lower compensation than other subspecialties. Neuroophthalmologists are traditionally excellent educators and have often been compensated for teaching, as residency directors for example, It is with the above background that I chose to review this article which is a survey of 113 neurology department chairs from the Association of University Professors of Neurology on the mechanism of compensation for teaching used in their departments. Seventy responses were received with 59 from department chairs. Back in 1998, the Association of the American Medical Colleges developed a blueprint for a relative value unit (RVU) for education, an educational value unit (EVU) similar to a RVU for clinical activities. This was based on direct teaching, scholarship, creation of an educational product, or educational administration. As it turns out from the current survey, this formal process has rarely occurred. Only 13 departments had an EVU system, with 5 being present for #3 years, and in 1 department, there was an EVU maximum of $10.000. Thirty-six percent of departments offered direct compensation for teaching, and 36% did not. However, 64% required teaching, and 34% answered that teaching was expected but not required. Twenty-five percent checked off "no designated reimbursement-expected function of academic neurologist." Compensation typically was available only for physicians with administrative titles. Residency director was associated with 10%-60% full-time equivalent (median 36.5%) and clerkship director with 5%-50% (median 20%). The Moster and Bhatti: J Neuro-Ophthalmol 2019; 39: 429-436 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Literature Commentary associate residency director and associate clerkship director positions were supported with lower median compensations (10% each). No compensation was given to 7% of associate residency director and 12% of associate clerkship directors. One-third of departments spent less than 5% of departmental funds on education. With compensation being tied to income from clinical revenue and research grant revenue, education is bound to suffer if neurologists are not compensated. Although directors of residency and clinical clerkships have designated salary support, most educators do not have these titles and remain uncompensated. The survey also noted that those without titles have a harder time in academic promotion based on their educational activities. I agree with the authors that aligning compensation with the allencompassing mission of academic centers, which includes education, can lead to increased faculty well-being, clinical productivity, and scholarship. Although this study was in neurology departments, the problem is likely even worse in ophthalmology departments where the difference between clinical revenue and educational budget is even greater. AT NANOS we have a "Demonstration NeuroOphthalmology Value Committee" whose purpose is to demonstrate the value of neuro-ophthalmology to the broader medical community by writing and publishing peer-reviewed articles that document the quality and efficiency of neuro-ophthalmic care. We also ought to join our colleagues in neurology and ophthalmology in documenting the quality and importance of our teaching activities. -Mark L. Moster, MD I could not agree with you more. As someone who is and has been employed in an ophthalmology department, I agree with you Mark that it is worse in ophthalmology compared with neurology. In all my years working in an academic environment one my primary responsibilities has been training PGY-2 (first year ophthalmology) trainees. I have loved doing it, and being young and naive, I did not think it was necessary to let administrators know what I did and the value it brought to the Department. But as I have moved on in my career, I found that justifying my value as a neuroophthalmologist solely based on clinical production (i.e., RVU) has been difficult. As I think about this subject matter, there are many examples I can give but here is just one. Similar to you Mark, I have written many articles with trainees, and I think you would agree that such an endeavor requires a lot of work and frankly often a complete rewrite of the article during nonwork hours. To date, I have not been acknowledged for such work or been given any type of compensation or "credit." I have tried to share what my mentors taught me with all my trainees, but in this current climate with all the rules, regulations, and expectations in medicine, it has been challenging to say the least. The current model needs to change if we want to continue to educate the Moster and Bhatti: J Neuro-Ophthalmol 2019; 39: 429-436 next generation of physicians at a high level. As with so many things in life, I guess it boils down to money, but for me, just a simple acknowledgment translated to some meaningful nonmonetary credit would be a nice beginning. -M. Tariq Bhatti, MD Calabrese M, Gasperini C, Tortorella C, Schiavi G, Frisullo G, Ragonese P, Fantozzi R, Prosperini L, Annovazzi P, Cordioli C, Di Filippo M, Ferraro D, Gajofatto A, Malucchi S, Lo Fermo S, De Luca G, Stromillo ML, Cocco E, Gallo A, Paolicelli D, LanzilloR, Tomassini V, Pesci I, Rodegher ME, Solaro C; RIREMS group (Rising Italian Researchers in Multiple Sclerosis). "Better explanations" in multiple sclerosis diagnostic workup: A 3-year longitudinal study. Neurology. 2019;92:e2527- e2537. Background: The exclusion of other diseases that can mimic multiple sclerosis (MS) is the cornerstone of current diagnostic criteria. However, data on the frequency of MS mimics in real life are incomplete. Methods: A total of 695 patients presenting with symptoms suggestive of MS in any of the 22 RIREMS centers underwent a detailed diagnostic workup, including a brain and spinal cord MRI scan, CSF and blood examinations, and a 3-year clinical and radiologic follow-up. Findings: A total of 667 patients completed the study. Alternative diagnoses were formulated in 163 (24.4%) cases, the most frequent being nonspecific neurologic symptoms in association with atypical MRI lesions of suspected vascular origin (40 patients), migraine with atypical lesions (24 patients), and neuromyelitis optica (14 patients). MS was diagnosed in 401 (60.1%) patients according to the 2017 diagnostic criteria. The multivariate analysis revealed that the absence of CSF oligoclonal immunoglobulin G bands (IgG-OB) (odds ratio [OR] 18.113), the presence of atypical MRI lesions (OR 10.977), the absence of dissemination in space (DIS) of the lesions (OR 5.164), and normal visualevoked potentials (VEPs) (OR 3.550) were all independent predictors of an alternative diagnosis. Interpretation: This observational, unsponsored, real-life study, based on clinical practice, showed that diseases that mimicked MS were many, but more than 45% were represented by nonspecific neurologic symptoms with atypical MRI lesions of suspected vascular origin, migraine, and neuromyelitis optica. The absence of IgG-OB and DIS, the presence of atypical MRI lesions, and normal VEPs should be considered suggestive of an alternative disease and red flags for the misdiagnosis of MS. COMMENTS As the authors point out, the 2017 McDonald diagnostic criteria revision simplified the multiple sclerosis (MS) diagnostic process, allowing for a more rapid diagnosis of MS. The McDonald criteria are intended to make a 435 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Literature Commentary diagnosis in patients presenting with a clinically isolated syndrome but are not focused on eliminating other entities in the differential diagnosis. However, the increasing focus on an earlier diagnosis of MS to allow for initiation of disease modifying therapies may also increase the risk of misdiagnosis. In real life, MS centers receive consultations in patients who may not have typical MS symptoms. The current study had 3 aims: finding the main diseases that mimic MS at presentation, the most relevant features suggesting an alternative diagnosis, and the best diagnostic workup to exclude the mimickers. It looked at 695 consecutive patients in 20 Italian MS centers presenting over a 7month period. At the end of the initial diagnostic workup, an alternative diagnosis was formulated in 94 patients (13.5%); among these, nonspecific neurologic symptoms associated with atypical magnetic resonance imaging (MRI) lesions of suspected ischemic origin (4.3% of the total diagnoses and 31.9% of the alternative diagnoses) were the most frequent alternative diagnosis. Migraine associated with atypical MRI lesions (3.2% of the total diagnoses and 23.4% of the alternative diagnoses) and neuromyelitis optica spectrum disorder (NMOSD) (1.6% of the total diagnoses and 11.7% of the alternative diagnoses) were the other most frequent diagnoses. According to the 2010 revision of McDonald diagnostic criteria, an MS diagnosis was possible in 286 (41.2%) patients while a conclusive diagnosis was not reached in 315 (45.3%) patients. Using the 2017 revision of MS diagnostic criteria, among the 695 patients included in the study, 388 (55.8%) patients were diagnosed with MS while a conclusive diagnosis was missing in only 213 (30.6%) patients. At the end of the 3-year follow-up, an alternative diagnosis was made in an additional 69 patients. Among the 667 patients who completed the 3 year study, an alternative diagnosis was formulated in 163 (24.4%) patients. Nonspecific neurologic symptoms associated with atypical MRI lesions of suspected ischemic origin (24.5% of the alternative diagnoses) and migraine associated with atypical MRI lesions (14.7% of the alternative diagnoses) were still the main alternative diagnoses. After 3 years, 15% of participants still were without a definitive diagnosis. The best predictor of an alternative diagnosis was MRI not meeting the McDonald criteria for DIS or being atypical for MS. Other predictors were the absence of oligoclonal bands in the cerebrospinal fluid and normal visually evoked 436 potentials. Laboratory work was not helpful except in the few patients who had NMOSD and the presence of antiaquaporin-4 antibodies. A total of 24 different alternative diagnoses were made, but most were in very few patients. Interesting to me was that after initial workup, 1 patient had Susac syndrome, and at the 3-year follow-up, 4 patients had been diagnosed with Susac syndrome. In addition, 7 patients were ultimately diagnosed as "recurrent optic neuritis" without further detail. However, anti-myelin oligodendrocyte glycoprotein antibody testing was not performed and may have explained some of these. There is clearly much subjectivity in the diagnoses made by these clinicians. This is exemplified by the fact that very few patients were ultimately diagnosed with functional disorders or fibromyalgia, which was a common diagnosis in previous studies of mistaken diagnosis of MS. The main thing I gained from this study is that using the McDonald criteria to diagnose MS is only valid when the clinical presentation is characteristic of MS. When patients present with atypical history or examination, it is very important to consider alternative diagnoses. Previous studies have shown that misdiagnosed patients have been treated with disease modifying therapies that were not indicated and that are potentially harmful. -Mark L. Moster, MD Confirmation bias, anchoring, and other cognitive biases are a major hurdle all of us face on a day-to-day basis when evaluating patients. There are many good books that explore these issues, but my particular favorite is "How Doctors Think" by Jerome Groopman (1). In terms of neuro-ophthalmology, a few nice articles come to mind when addressing the issue of incorrect diagnoses (2-4). -M. Tariq Bhatti, MD 1. Groopman J How Doctors Think. Boston, MA: Houghton Mifflin, 2007. 2. Stunkel L, Kung NH, Wilson B, McClelland CM, Van Stavern GP. Incidence and causes of overdiagnosis of optic neuritis. JAMA Ophthalmol. 2018;136:76-81. 3. Fisayo A, Bruce BB, Newman NJ, Biousse V. Overdiagnosis of idiopathic intracranial hypertension. Neurology. 2016;86:341- 350. 4. Kahraman-Koytak P, Bruce BB, Peragallo JH, Newman NJ, Biousse V. Diagnostic errors in initial misdiagnosis of optic nerve sheath meningiomas. JAMA Neurol. [published ahead of print December 17, 2018] doi: 10.1001/jamaneurol.2018.3989. Moster and Bhatti: J Neuro-Ophthalmol 2019; 39: 429-436 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.