Saudi Consensus Recommendations on the Management of Multiple Sclerosis: Diagnosis and Radiology/Imaging
, Nuha M. AlKhawajah 8,9, Majed M. Al-Luqmani 10,11, Abdulrahman O. AlMalki 12, Hajer Y. Al-Mudaiheem 7, Hind A. AlNajashi 13, Rayan A. AlShareef 14, Amani A. AlShehri 15, Faisal Y. AlThekair 16,17, Nabila S. Ben Slimane 18, Edward J. Cupler 19, Mamdouh H. Kalakatawi 20, Hanaa M. Kedah 21, Eslam Shosha 24 and Mohammed A. Al Jumah 25,*add
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Round 1
Reviewer 1 Report
The submitted manuscript aims to outline practice guidelines for the diagnosis of and imaging of multiple sclerosis (MS) in Saudi Arabia, where like in most countries around the world, its prevalence is rising. The specific strengths of the paper include its concise nature and references. The specific weaknesses include its broad topic, grammatical style, and Figure/Table formatting. Although the paper is one of many review articles on MS, it should be accepted as it contributes to the literature via specific recommendations for practicing physicians in Saudi Arabia.
Author Response
Thank you for your comment. Additions and modifications have been made to the revised manuscript. If you would like to suggest any specific recommendations regarding the weaknesses you have pointed out, we would be more than happy to act upon them.
Reviewer 2 Report
Overall, this is a well written paper. There are a few suggestions:
- Would recommend a discussion of the MAGNIMS criteria even if you do not use it for completeness sake.
- There should be discussion about separation of classic MS lesions in the cord as white matter and short segment (< 3 vertebral body segments long, < 2/3rds cord diameter) as opposed to transverse myelitis which is long segments, more often grey matter involvement seen with NMO/ MOG, etc. It may also be useful to discuss central "H" sign in NMO spine involvement and heterogenous shaggy enhancement in 30% and the bright spotty sign in NMO. Also, long segment pencil thin peripheral enhancement in MOG.
- Use of 3T whenever available to increase conspicuity of small lesions, enhancement, etc
- Central vein sign in MS, restricted diffusion also
- Tumefactive MS should be discussed. Did you have any cases of this?
- NMO specific paragraph is needed. Laboratory differences with NMO (CSF neutrophils/ increased protein w/o oligoclonal band and elevated IgG. IgG4 sero-positivity of 99% sensitive and 90% specific with different tx. Also pathophysiology of NMO aquaporin channels with associated different brain regions (around 3rd/ 4th vents). This matters to ensure that they are not including in their dx of MS. Also poorer prognosis due to more neurological cord destruction and less brain lesions. Different locations of optic nerve involvement - posterior ON/ chiasm.
- Also need a separate paragraph to discuss MOG- different therapy, and pathology, younger age of presentation, but patients can have both. Again different optic nerve involvement pattern (ON head) and nerve sheath edema. Also high Pons predilection
- Brain imaging use of double inversion recovery to see cortical lesions for dx.
- Need associated references for all the above. This is a short number of references for such a broad topic. Need at least double.
- You really can't appropriately discuss radiology without at least a few images. Do you have a neuro-radiologist involved in this publication??? Maybe of some of the differentiating factors from NMO/MOG since need to differentiate since different tx (steroids, plasma exchange etc).
Author Response
Thank you for your comments. Please see the attachment.
Author Response File: 
Author Response.docx
