Surveying a waiting room full of patients with multiple sclerosis, and you’ll hear a dozen different stories about their symptoms. Some have blurry vision. Some slur words. One might struggle with numb feet or tingling hands.
But they all share one common experience: the MRI.
Once a year—or more often if the disease is getting worse—patients with multiple sclerosis, or MS, have to take off their jewelry and glasses, don a hospital gown, and lie motionless inside a magnetic resonance imaging machine as it whirs and clangs for an hour or more.
Doctors examine the resulting pictures of the brain and spinal cord, looking for bright white spots—the lesions that cause MS. These are the “many scars” that led to the term “multiple sclerosis,” explains neurologist Daniel Pelletier, the new chief of the neuro-immunology and multiple sclerosis division in the Keck School of Medicine of USC’s Department of Neurology. Those scars indicate spots where the body’s immune system has attacked nerves.
For now, the MRI lights up lesions, but Pelletier believes it can do much more. For longer than a decade, he has focused his research on imaging techniques to better understand the disease and figure out if new drugs are working properly. In the near future, detailed imaging markers may help physicians better diagnose MS and adjust their treatment of the disease. The potential to make more of imaging is part of what drew Pelletier to USC from Yale University in April 2015. With USC’s powerful imaging capabilities and lofty goals for a large-scale MS center, he plans sweeping changes for Keck Medicine of USC’s MS program, including efforts to reach more Angelenos with MS and involve Keck Medicine MS patients as partners in vital research to beat the disease.
“There’s no one who knows more about imaging in MS than Dan Pelletier,” says Leslie Weiner, an MS specialist and Richard Angus Grant Sr. Chair in Neurology at the Keck School of Medicine. “We will be a major center, with more people taking care of MS patients than probably anywhere on the West Coast.”
Researchers need to use imaging and other tools to better understand MS because the disease varies from person to person and scientists don’t know what sets it off. What they do know are the mechanics behind patients’ symptoms: nerves and the immune system.
Nerve cells communicate through long, thin wire-like fibers that are coated with an insulator called myelin. During an episode of MS, the immune system mistakenly attacks myelin as if it’s an infection. Without insulation, the fibers malfunction. The body can repair the damage, but imperfectly, leaving a scar. Thanks to this repair, many people with MS experience long periods without symptoms.
Neurologists can prescribe several medicines that keep the immune system in check, protecting the myelin and slowing the disease. However, eventually the nerves get damaged, and doctors cannot fix that problem — not yet, at least. After that point, the disease only gets worse.
Depending on where nerves are under attack—in the brain, the spinal cord or behind the eyes — MS can hamper thinking, movement and vision, among other things. It can be a challenge to treat and diagnose, but early treatment is key, says Keck Medicine neurologist Lilyana Amezcua. Medications can reduce attacks and delay progression, but they can cause side effects ranging from the unpleasant, such as hair loss, to the serious, including increased risk of brain infection. That’s why she recommends that every MS patient go to a specialized academic center like Keck Medicine, where expert neurologists take a comprehensive approach to the care of MS.
Keck Medicine’s MS team includes specialist nurses, physical therapists, nutritionists, counselors and occupational and speech therapists, in addition to MS-trained neurologists. Those experts were once scattered across USC’s Health Sciences Campus, but Pelletier and colleagues are looking forward to the upcoming opening of a unified MS clinic in its own suite in the new Norris Healthcare Consultation Center. “We’re building a one-stop shop for MS,” Pelletier says. “We’re building a team around the patient, as opposed to a patient going to four or five different places.”
The clinic will be about more than providing top-notch patient care; it will also be a place of science, says Pelletier, vice chair for research for the neurology department. Keck Medicine MS patients can already participate in clinical trials of new medicines, and soon everyone treated at the center will be able to contribute to MS research (unless they choose not to). The clinic will build a research library of patients’ blood samples, DNA, medical images and other information, and scientists will mine the data to better understand the disease. They could look for genes that might raise MS risk, for example, or signs on an MRI that indicate a person’s disease is worsening.
Those thousands of images take a lot of computer space to store, and they’ll have a home at the USC Mark and Mary Stevens Neuroimaging and Informatics Institute. The institute’s new building, opening in spring 2016 on the Health Sciences Campus, will have an MRI machine with the most powerful magnet available. Fewer than a dozen U.S. research centers have a 7-tesla MRI machine, which has a magnet 140,000 times stronger than the Earth’s magnetic field and five times more powerful than that used in common medical MRI units.
With the extra power, Pelletier can peer more closely at what’s happening in the nervous system of someone with MS. For example, he’ll be looking for a little molecule called glutathione, which, if found in low levels, indicates stressed-out nerve cells. He’ll also look for another called glutamate, which in excess damages nerves. And using a different type of imaging called PET, he hopes to see the immune cells that attack myelin.
Pelletier estimates the new clinic will serve 2,500-3,000 people with MS. But he has visions beyond USC’s gates. He wants to open Keck Medicine MS clinics in other locations, including sites in Beverly Hills and Orange County, to treat thousands more. With participating patients as his research partners, he and preventive medicine collaborators at USC hope to investigate the epidemiology of MS: the science of who develops the disease, and why.
He also aims to unite doctors in the U.S. and Canada in a partnership to understand MS risk and how the illness progresses over time. The network would bring together more than 30 clinics across the continent to collect information like genetic profiles and MRIs from as many as 10,000 patients. Patterns in the data may point out risk factors. By comparing MS rates to maps of air pollution, for example, scientists could investigate whether there are links between air quality and the disease.
Scientists admit they still have a lot to learn about MS. While physicians can prescribe drugs to reduce nerve scarring, they can’t reverse the damage. But Keck Medicine’s team is upbeat about the momentum behind MS research. Thanks to the power of imaging, they say, answers are within sight.