Diagnosis and treatment of multiple sclerosis

The article is written by Specialist Doctor II Pham Thi Son - Neurologist, Department of Examination & Internal Medicine - Vinmec Hai Phong International General Hospital

Multiple sclerosis (MS) is an autoimmune inflammatory disease of the central nervous system that is a leading cause of disability in young adults.

Histopathology is due to demyelinated white matter patches. These acute lesions are associated with inflammatory infiltrates that, in remission, leave plaques of astrocytes and glial cells.
Despite great progress in the clinical assessment of MS due to the widespread availability of brain and spine MRI, our understanding of the underlying etiology of the disease remains limited. Complete control of the disease and repair of damaged myelin are important goals for current and future treating physicians.

Clinically isolated syndrome, representing the first attack of MS
relapsing-remitting MS - Remission
primary progressive MS

Is the first episode of an MS-compatible disease that exhibits features of an autoimmune inflammatory process but does not yet meet the diagnostic criteria for MS.

The typical patient presents as an adolescent with one or more clinically distinct episodes of CNS dysfunction (eg, optic neuritis, diplopia, brainstem syndrome). or cerebellum , or partial transverse myelitis ). The clinical symptoms are characterized by the following features:

Acute development, with a duration of at least 24 hours, with or without recovery Occurs in the absence of fever or infection. Unilateral optic neuritis, manifested by loss of vision in one eye, pain in the eye. Diplopia is due to demyelinating damage of the medial longitudinal bundle of the brain stem, or more rarely, sixth nerve palsy. Cerebellar or cerebellar syndromes, such as diplopia described above, ataxia with nystagmus, vertigo, facial numbness, or episodes of arrhythmia or paroxysmal vertigo. Partial transverse myelitis, often with predominantly sensory symptoms, including partial Brown-Sequard syndrome, or Lhermitte's sign; Other manifestations may include sphincter symptoms, with bladder involvement (eg, urinary incontinence) more common than bowel, and erectile dysfunction. Symptoms usually develop over a period of hours to days and then gradually subside over the following weeks to months, although remission may not be complete. Manifestation of symptoms and signs may be monofocal (consistent with one lesion) or multifocal (consistent with more than one lesion). CIS is considered a precursor to MS in most patients.

Characterized by well-defined relapses with complete recovery or mild sequelae. The diagnosis of relapsing-remitting MS depends on showing evidence of dysfunction in various parts of the central nervous system at two separate points in time. Relapsing MS accounts for about 85 to 90 percent of onset cases. Exacerbations are similar to clinically isolated syndromes (CIS). Magnetic resonance imaging (MRI) of the patient revealed the simultaneous presence of old and new lesions of the central nervous system. Symptoms and signs associated with relapse usually peak within days to weeks, followed by remission in which symptoms and signs are relieved to varying degrees. The minimum time to relapse has been arbitrarily established to be 24 hours, although most are much longer. Severe relapses leading to permanent disability are uncommon. One study followed 1078 patients who experienced a total of 2587 relapses. Only seven patients had a relapse that required them to use a cane, crutches or brace to walk 100 meters with or without rest.

Characterized by a relatively early progression of disease from onset and leading to disability, with little or no improvement in symptoms and progressive worsening. This type accounts for about 10% of adult cases at onset.

Magnetic resonance brain - spinal cord with injection of magnetic contrast: Over 90% of lesions are small or round in the periventricular white matter, corpus callosum, brain stem, and spinal cord. Best seen on T2. Acute lesions are enhanced in the presence of magnetic contrast. Cerebrospinal fluid: CSF pressure is normal, Lymph is slightly increased (5-40 white blood cells/mm3), glucose is normal, IgG is increased. However, CSF is not specific for MS. evoked potentials: Often used to find supporting evidence of myelin degeneration when magnetic resonance imaging and CSF are undiagnosed. Visual evoked potentials are commonly used.

The goal of treatment is to shorten the neurological recovery time after exacerbations. However, acute treatment has no clear benefit to improve the recovery of later sequelae and prolong the time to relapse.

MS exacerbations are usually treated with glucocorticoids:
Dose of methylprednisolone: ​​1g/day intravenously for 3 days or methylprednisolone 500 mg/day for 5 days, intravenous infusion Prednisolone oral dose, reduce dose to 60 -80 mg/day for 03 weeks

A purified form of bovine or porcine adrenocorticotropic hormone (ACTH), available in the United States (as HP Acthar Gel) and some other countries for self-administration intramuscular (IM) or subcutaneously (SQ). It can be used for patients with exacerbations of MS who cannot tolerate high doses of glucocorticoids or have poor venous access or prefer self-injection.
Usually start with corticotropin at 80 units per day for one week, then tapered over the second week (eg, total dose: 80 units for seven days, 40 units for four days, and 20 units for in three days). The use of corticotropin IM and SQ appears to be bioequivalent. However, corticotropin injection gels are much more expensive than equivalent doses of methylprednisolone or prednisone.
Before initiating therapy with glucocorticoids or ACTH, acute infection (particularly of the urinary tract) should be ruled out, as glucocorticoids have immunosuppressive effects and may exacerbate infection.

For patients with acute, severe neurological deficit due to MS who have responded poorly to treatment with high-dose glucocorticoids, immunoglobulin should be treated at a dose of: 0.4 mg/kg/day for 5 days.

Recommended when disease recurrence more than 2 times in 2 years is the main cause of disability for the patient:
Interferon - beta 1a: dose 30 micrograms IM once a week Interferon- beta 1b: dose 250 micrograms injected below skin used every other day

Methotrexate; Cyclophospha- mid; mitoxantron; Azathioprine

Antidepressants, muscle relaxants, antipsychotics
V. Summary
The progression of disability due to MS is highly variable. The impact of MS varies by several measures, including severity of signs and symptoms, frequency of relapses, rate of deterioration, and residual disability. In most patients, deterioration is slow. Secondary progressive MS usually occurs 10 to 20 years after disease onset.
Multiple sclerosis is an autoimmune disease that is paralyzing, disabling, and difficult to treat. Vinmec is the first hospital in Vietnam that has successfully performed autologous hematopoietic stem cell transplantation - a new method that can completely treat this disease.
>>> Details see here:
First time in Vietnam successful stem cell transplant to treat multiple sclerosis
When hematopoietic stem cell transplant, the patient's old immune system is removed, the patient's old immune system is removed. new immune system to prevent the creation of autoantibodies that damage the nervous system.