Staring Into the Void: Black Holes and MS Prognosis

By Kara Nyberg, PhD
Reviewed by Kevin Hwang, MD, MPH

Physicians commonly measure multiple sclerosis (MS) disease activity based on the appearance of new T2-weighted hyperintense MRI lesions, which arise due to edema, inflammation, gliosis, and axonal loss. Given the nonspecific disease processes leading to these lesions and the often-mediocre correlation between T2 lesions and clinical outcomes, however, the search continues for a more specific tool that lends insight into MS pathophysiology and disease activity.

In recent years, increasing attention has been paid to the possibility of measuring chronic or persistent T1-weighted lesions that appear hypointense relative to normal-appearing white matter—lesions also known as “black holes”—as a means of gauging MS-associated neurodegeneration. This approach is supported by a considerable body of histopathological evidence indicating that chronic T1 black holes reflect irreversible demyelination and axonal loss.¹

“In general, knowledge of the spatial localization and time evolution of T1-weighted lesions may help resolve some mysterious aspects of MS, which remains a largely unresolved pathology,” explained Khader M. Hasan, PhD, an Associate Professor of Radiology at the University of Texas Medical School at Houston, in an interview with MedPage Today.

Some consider the evolution of T1 lesions to be one of the most promising endpoints in phase 2 clinical trials of neuroprotective and reparative MS interventions.² But despite this enthusiasm, a proven link between persistent black holes and clinical outcomes in MS remains elusive. Whereas a handful of studies have pinpointed a correlation between black hole volume and clinical disability as measured by the Expanded Disability Status Scale (EDSS), several others have failed to identify such ties.¹

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