October 7 Hamas Terrorist Attack Exacerbated MS Severity

MRI activity significantly increased among patients with multiple sclerosis (MS) during the first 3 months following Hamas’ attack on Israel on Oct. 7, 2023, compared with the corresponding period in the preceding year, according to an observational retrospective case–control study in the Annals of Clinical and Translational Neurology.1

“Healthcare providers should be aware of the potential for increased disease activity in [patients with MS] during extreme stress and may consider more frequent monitoring, including MRI scans, or treatment adjustments during such periods,” the authors wrote.

Hamas' assault on Israel on October 7, 2023, was the deadliest attack on Jewish people this century | image credit: CYBERUSS - stock.adobe.com

There existed a discrepancy between MRI activity and clinical relapses; there were 23 patients with active MRIs during wartime, 2 of which experienced clinical relapses, highlighting the sensitivity of imaging to detect subclinical disease activity.

MRI results were as follows between Oct. 7, 2023 to Jan. 7, 2024 compared with Oct. 7, 2022 to Jan. 7, 2023: 11/93 vs. 23/93. (P = .0139). Analysis revealed an OR of 4.0 (95% CI: 1.29–16.442).

Patients with MS with an expanded disability status scale (EDSS) score of 4 or higher showed a significant increase in MRI activity (P = .045). No significant increase was observed in patients with an EDSS score of 3.5 or less (P = .23). These results imply that individuals with significant disability are more vulnerable to the effects of increased stress, the authors wrote. Typically, older patients with MS and those with longer durations of disease have MRIs with less inflammatory lesion activity.

The study evaluated 93 patients with MS who were 18 or older at the start of the war, who had routine annual MRI scans from 3 3-month periods spanning 2021-2024. The third period was Oct. 7, 2023 to Jan. 7, 2024. Data were collected from medical records and MRI scans at Hadassah Medical Center in Jerusalem. MRI scans were classified as active if new or enlarging T2 lesionsor enhancing T1 lesions were present, or both.

The authors speculated that stress significantly impacts disease activity, as demonstrated by MRI results that were observed across all ages.

Of the cohort, 86% had relapsing–remitting MS (RRMS) and 14% had progressive MS. The group included 74 females and 19 males, aged nearly 45 years on average, with average EDSS scores just over 3, and average disease durations of 11 years at the time of the war. Most patients, or 84%, had not experienced a clinical relapse in the 12 months before the war.

"The psychological impact of war-related stress is well documented, with anxiety, depression, and PTSD occurring even in those indirectly exposed through media, as seen after the events of September 11th," the authors noted.

Additionally, a recent meta-analysis of 3 studies investigating stress disorders and MS risk showed a nearly 2-fold increased risk of MS for individuals with stress disorders, underscoring the severe implications of stress on individual wellbeing.2

The underlying pathology that connects MS activity and psychological stress remains misunderstood; however, the authors added, current hypotheses propose that the impact stress has on immune functioning, inflammatory processes, and therefore the blood-brain barrier, may contribute to these outcomes.

“Our findings are crucial for understanding the full spectrum of MS activity and highlight the importance of routine MRI monitoring in MS management, particularly during periods of high stress,” the authors concluded.

References

1. Zveik O, Friedman-Korn T, Rechtman A, et al. Subclinical imaging activity in multiple sclerosis patients during war-related psychological stress. Ann Clin Transl Neurol. 2024. doi:10.1002/acn3.52241.

2. von Drathen S, Heesen C, Gold SM, et al. Stress and multiple sclerosis – systematic review and meta-analysis of the association with disease onset, relapse risk and disability progression. Brain Behav Immun. 2024; 120: 620-629. doi:10.1016/j.bbi.2024.06.004