What tests can detect multiple sclerosis. How to detect multiple sclerosis? Study of the cerebrospinal fluid

Multiple sclerosis (MS) is the most common inflammatory demyelinating disease of the central nervous system in adolescents and middle-aged adults, but can also occur in the elderly. According to the McDonald criteria, the diagnosis of multiple sclerosis requires objective evidence of white matter lesions, as well as evidence of changes in their number, location, and size over time and space. MRI is an extremely important method for diagnosing this disease, as it allows you to see multiple foci in the brain, including clinically "silent", as well as to identify newly emerging foci in control studies.

WHAT MULTIPLE SCLEROSIS LOOKS ON MRI

MS is characterized by a typical distribution of lesions in the white matter of the brain, which helps to distinguish them from vascular changes. For this disease, lesions of the corpus callosum, arcuate fibers, temporal lobes, brain stem, cerebellum and spinal cord are typical. This distribution of foci is uncharacteristic for. With angiopathy, lesions of the brain stem are possible, but they are usually symmetrical and located centrally, while foci in multiple sclerosis are localized along the periphery.

The most common questions that almost any radiologist asks himself during an MRI scan are:

• Can I suspect multiple sclerosis?
• Are these white matter lesions the result of pathological changes in small vessels, as in patients suffering from hypertension?
• Or is it necessary to think about less typical causes of their occurrence?

To answer these questions, the following points need to be taken into account when examining white matter lesions:

• Many diseases of the nervous system can manifest in the same way as multiple sclerosis, both clinically and on MRI.
• Most incidentally discovered white matter lesions will be found to be vascular in nature.
• The list of possible diagnoses when white matter lesions are found is quite long.

Even if the patient has clinical signs of multiple sclerosis, the most careful examination of white matter changes is necessary to decide whether these changes really suggest a demyelinating process, or if they are incidental findings that are due to age.

The images show typical differences between vascular lesions and multiple sclerosis on brain MRI. On the left, T2 WI shows a typical vascular focus in the brainstem, with damage to the transverse fibers of the pons Varolii. On the right side of the axial T2 WI, a brain stem lesion in a patient with MS is visualized as a hyperintense lesion located on the periphery (often the foci can be located near or directly in the trigeminal trunk tract, or near the edge of the fourth ventricle).

WHAT MRI SHOWS IN MULTIPLE SCLEROSIS AND OTHER WHITE MATTER DISEASES

The location of the foci in the white matter is different, so the diagnosis directly depends on which parts of the white matter the foci are found in. Here, the yellow arrow marks non-specific deep changes in the white matter, which can be observed in many diseases, for example, of a vascular nature. For multiple sclerosis in this case, the following changes are characteristic:

• Temporal lobe involvement (red arrow)
• Juxtacortical lesions in close proximity to the cortex (green arrow)
• Corpus callosum lesion (blue arrow)
• Periventricular lesions (near the ventricles of the brain)

Juxtacortical lesions are specific to MS. They are closely adjacent to the bark. It is not recommended to use the term "subcortical" or "subcortical" to describe their localization, since it is not very specific and is used to describe changes in the white matter up to the ventricles of the brain.

In vascular lesions, the arcuate fibers are not affected, as a result of which a dark “stripe” between the focus and the cortex is visualized on T2 WI and FLAIR (yellow arrow).

Temporal lobe injury also characteristic of multiple sclerosis. In contrast, in hypertensive encephalopathy, the lesions are located in the frontal and parietal lobes; their localization in the occipital lobe is not typical, and they are never found in the temporal lobes. Only in cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is there an early involvement of the temporal lobes.

MRI signs of multiple sclerosis. Multiple lesions adjacent to the ventricles of the brain (red arrow); foci of an oblong (ovoid) shape, oriented across the long axis of the ventricles of the brain (yellow arrow); multiple lesions in the brain stem and cerebellum (right). These lesions are often referred to as "Dawson's fingers" and reflect demyelination of the cerebral white matter along the small cerebral veins, which run perpendicular to the cerebral ventricles.

Dawson's fingers. Dawson's fingers, a characteristic symptom of multiple sclerosis, are believed to result from inflammation of the tissues surrounding the penetrating venules, which are perpendicular to the long axis of the lateral ventricles.

On the presented MRI scans, the following changes are typical for MS:

• Elongated foci oriented perpendicular to the ventricles of the brain (Dawson's fingers)
• Strengthening of the signal from these foci after the introduction of contrast
• Multiple lesions and their location near the ventricles

Contrast-enhanced MRI in multiple sclerosis

Early diagnosis of multiple sclerosis is made by contrast enhancement of these lesions, which persists for a month after their onset, which is another typical sign of MS. The presence at the same time of increasing and not increasing with contrasting foci is explained by their dissemination over time. The edema regresses over time, as a result, only small centrally located areas of a hyperintense signal on T2 WI remain.

On MRI scans (the study was done three months after the clinical debut), typical signs of multiple sclerosis are determined:

• Multiple foci accumulating contrast
• Most of these foci are closely adjacent to the cortex: they should be located in the region of arcuate fibers
• All these foci are recent, since the contrast enhancement of the foci with the introduction of gadolinium preparations is observed only for a month (dissemination in time).

The emergence of new lesions on an MRI scan reflects the process of dissemination over time. The patient underwent MRI three months after the clinical onset of MS. The tomogram on the left shows a single lesion, while the MR tomogram on the right, performed three months later, shows two new lesions.

MRI of the spinal cord in multiple sclerosis

Spinal cord injury in multiple sclerosis: on the sagittal MRI of the spinal cord (left), foci characteristic of MS are determined - relatively small lesions located along the periphery. Most often they are found in the cervical spine, have a length of less than two vertebral segments. In addition, foci in the brain stem are also visualized: their combination with lesions of the spinal cord and cerebellum is a sign that is extremely useful in the early diagnosis of multiple sclerosis.

Damage to the spinal cord is not characteristic of most other diseases of the central nervous system, with the exception of acute disseminated encephalomyelitis, Lyme disease, manifestations of systemic lupus erythematosus, and sarcoidosis. Note that the above images are proton density weighted - this sequence is essential in MS staging. The signal from the spinal cord on proton density-weighted images is uniformly low-intensity (like from cerebrospinal fluid), as a result of which, against this background, MS foci become contrasting with respect to the cerebrospinal fluid and spinal cord, which makes it possible to determine multiple sclerosis by MRI.

Multiple sclerosis under the microscope

The photograph (histological examination) shows signs of perivenular inflammation in multiple sclerosis. The process begins with inflammatory changes in the tissues surrounding the veins. In the first four weeks, areas of inflammation actively accumulate contrast (gadolinium preparations) due to local disruption of the integrity of the blood-brain barrier. At first, the inflammation is diffuse, then - according to the type of "open ring".

HOW TO DIFFERENTIATE MULTIPLE SCLEROSIS AND VASCULAR ENCEPHALOPATHY

Below in the summary table are collected the most characteristic types of foci location in multiple sclerosis and in changes of vascular origin. Differences relate to the location of the foci and contrast characteristics.

SECOND OPINION FOR MULTIPLE SCLEROSIS

It is often difficult to differentiate multiple sclerosis even for an experienced specialist, not to mention young doctors. In such cases, you can get a specialist in demyelinating diseases and other pathological changes in the nervous system. The second opinion of a specialized radiologist helps to avoid medical errors and make the diagnosis more reliable and accurate. In addition, neurologists need a description of MRI in multiple sclerosis, performed according to modern standards. A second opinion can be obtained through the National Teleradiology Network, a diagnostic sharing system that has gained a reputation as a reliable assistant, especially when clinicians are faced with complex or unclear cases.

MULTIPLE SCLEROSIS OPTIONS

Above, we examined the MRI picture in a typical form of multiple sclerosis. However, there are several atypical forms of the disease that must be kept in mind.

Tumor-like (pseudo-tumorous) form of MS

In this form, multiple sclerosis appears on MRI as a large lesion that usually has a less pronounced volume effect than would be expected with such a size of the lesion.

After administration of gadolinium preparations, some peripheral contrast enhancement may be observed, often in the form of an open ring, which makes it possible to distinguish lesions from glioma or brain abscess, which are enhanced in the form of a "closed ring".

T1 and T2 weighted MR images were obtained from a 39-year-old man with subacute onset hemianopia. In this case, a biopsy was required to differentiate between glioma and a demyelinating process. The red arrow marks the biopsy area.

An intraparenchymal volumetric formation is determined in the right temporal and occipital lobes with a hypointense "rim" along the periphery as an open ring on post-contrast T2 images.

There is perifocal edema, but volume effect is relatively weakly expressed. Biopsy confirmed demyelinating disease. Contrast enhancement in the form of an open ring with a hypointense signal on T2 WI post-contrast tomograms and low blood flow is characteristic of demyelination.

As is clear from the above, the tumor-like form of multiple sclerosis is easily confused with a tumor. One of the common mistakes of inexperienced radiologists is to conclude that there is a tumor when in fact there is pseudotumorous MS. In such cases, it is always important to remember the possibility of repeated consultation of MRI images by experienced radiologists.

Balo's concentric sclerosis

Balo's concentric sclerosis is a rare demyelinating disease characterized by the appearance of alternating foci of demyelination and areas of myelin preservation, which look like curls.

The images show T2 and post-contrast T1 weighted tomograms, which show a large lesion in the left hemisphere with alternating T1 hypointense and isointense "streaks". On T1-weighted tomograms after the administration of gadolinium preparations, alternating contrast enhancement in the form of stripes is observed. On the right there are also similar changes (smaller).

Optocomyelitis Devik

It is very important to consider the possibility of the presence of opticomyelitis (Devic's disease), especially in patients with bilateral optic nerve damage. Optocomyelitis is a disease in which the optic nerves and spinal cord are usually affected, while minor changes are determined in the brain. Devic's disease should be suspected in the presence of widespread lesions of the spinal cord (over more than three segments) with a low signal on T1, in combination with spinal cord thickening due to edema. On axial tomograms, the lesions usually occupy a large part of the spinal cord, which is not typical for MS, in which the lesions are smaller and located at the periphery.

On sagittal T2-weighted images of the spinal cord in a patient with optomyelitis, a longitudinally oriented spinal cord lesion is visualized in combination with its edema.

Acute disseminated (disseminated) encephalomyelitis (ADEM)

ADEM is a disease with which it is necessary to conduct a differential diagnosis in multiple sclerosis. ADEM is a monophasic, immune-mediated demyelinating process that often occurs in children as a result of infection or after vaccination. MRI with ADEM shows diffuse and relatively symmetrical lesions in the white matter, located supra- and infratentorially, which simultaneously increase with contrast. Also, damage to the gray matter of the cerebral cortex and subcortical ganglia, thalamus is almost always observed.

The images show the axialFLAIRandT2 weighted tomograms performed on a teenager with acute disseminated encephalomyelitis. Note the widespread involvement of the cortex and subcortical nuclei, including the thalamus.

Here you can see another case of ADEM. Note the involvement of the basal ganglia.

DIFFERENTIAL DIAGNOSIS OF MULTIPLE SCLEROSIS AND ADEM

Learn more about the differential diagnosis of multiple sclerosis

MULTIPLE SCLEROSIS: MACDONALD CRITERIA

To establish a diagnosis, as well as to minimize MRI errors in multiple sclerosis, it is necessary to demonstrate the dissemination of lesions in time and space.

Dissemination in space:

• Presence of one or more hyperintense T2 lesions in at least two of four areas in the CNS: periventricular, juxtacortical, infratentorial, or in the spinal cord.
• For the conclusion of multiple sclerosis, contrast enhancement of lesions after the administration of gadolinium preparations is not required.

Dissemination in time:

• The appearance of new lesions on T2 or new lesions that accumulate contrast (gadolinium) on the control MRI compared to the original study, regardless of when it was performed.
• Simultaneous occurrence of asymptomatic, aggravated after the administration of gadolinium preparations, and non-aggravated foci.

The text is based on materials from the site http://www.radiologyassistant.nl

Vasily Vishnyakov, radiologist

Clinical, laboratory and instrumental research methods in the diagnosis of multiple sclerosis. MRI in the diagnosis of multiple sclerosis. Diagnostic Criteria for Multiple Sclerosis

Diagnosis of multiple sclerosis

Multiple sclerosis It is quite easily diagnosed in young patients with periodically recurring focal symptoms of white matter lesions in various regions of the central nervous system.

It is much more difficult to diagnose multiple sclerosis at the first attack of the disease and in the primary progressive course of multiple sclerosis (sometimes in such cases, with careful questioning, it is possible to identify signs of a previous exacerbation of multiple sclerosis), as well as in mild disorders (for example, sensory disturbances) in the absence of objective signs of damage CNS.

The first signs of multiple sclerosis may appear several years before the patient first consulted a doctor. In this case, a patient with suspected multiple sclerosis may:

• or forget about these first manifestations of multiple sclerosis (if the symptoms did not cause significant discomfort - for example, transient paresthesias)
• or not linking past symptoms of multiple sclerosis to the present condition (eg, frequent or urge to urinate in the past by the patient has been associated with a suspected urinary tract infection)

Therefore, when taking an anamnesis in a patient with suspected multiple sclerosis, it is necessary to purposefully ask the patient additional questions and talk with his relatives and close people who can provide additional data.

Accurate the diagnosis of multiple sclerosis is made on average 2 to 3 years after the onset of the first symptoms of multiple sclerosis, and almost 50% of patients at the time of establishing the diagnosis of multiple sclerosis, as it turns out in a retrospective analysis, have been sick with multiple sclerosis for at least 5 years.

Diagnosis of multiple sclerosis is traditionally based on clinical manifestations characteristic of multiple sclerosis and anamnesis data indicating previously focal symptoms of CNS white matter damage, "separated in time and different (migrating) in localization."

As with other diseases, the first step to a correct diagnosis of multiple sclerosis is a thorough history taking and analysis. It is very important to find out the time of the first attack of multiple sclerosis and the manifestation of this attack, which in the case of multiple sclerosis is not always easy.

During a clinical examination of a patient with suspected multiple sclerosis, it is necessary to conduct a thorough complete neurological examination in order not to miss such subtle signs of the disease as a slight decrease in vibration sensitivity, a slight violation of color perception, mild nystagmus, prolapse of superficial abdominal reflexes, etc.

Of the instrumental methods for diagnosing multiple sclerosis, it is currently widely used: the study of evoked potentials and magnetic resonance imaging (MRI).

The study of evoked potentials (EP) in multiple sclerosis allows you to determine the slowdown or impaired conduction in the visual, auditory, somatosensory and motor pathways.

In this study, repeated stimuli of the same type are applied and, by computer averaging, electrical signals are recorded that occur in response to these stimuli in different parts of the nervous system.

A change in one or more types of evoked potentials is observed in 80 - 90% of patients with multiple sclerosis.

The study of evoked potentials sometimes allows you to determine the localization and prevalence of the pathological process in multiple sclerosis, even if there are no obvious clinical manifestations of multiple sclerosis.

In multiple sclerosis, auditory EPs, somatosensory EPs, and visual EPs are usually examined for reversal of the checkerboard pattern.

The results of this method are especially valuable when, for example, an asymptomatic lesion of other structures is detected in a patient with multiple sclerosis with signs of damage to some CNS structures, or the presence of neurological disorders is confirmed in a patient with complaints, but without objective symptoms during a neurological examination.

The lengthening of the latent periods of evoked potentials is due to a violation of the spasmodic propagation of excitation along unmyelinated fibers.

Prolongation of latent periods of evoked responses is the earliest sign of pathology in multiple sclerosis, and in advanced stages of multiple sclerosis, responses may disappear completely.

The study of visual EPs for the reversal of a checkerboard pattern has a very high sensitivity. In retrobulbar neuritis, MPT detects damage to the optic nerve in about 80% of cases, while visual EPs - in 100%. In general, visual EPs are changed in 75-97% of cases of significant multiple sclerosis, somatosensory EPs - in 96%, and auditory EPs of the brainstem - in 30-67%.

The introduction into clinical practice of neuroimaging research methods - magnetic resonance imaging (MRI) and computed tomography (CT) - is the greatest achievement in the diagnosis of multiple sclerosis in recent years.

The most sensitive method is MRI, which is 10 times more effective than CT for detecting lesions of multiple sclerosis. The sensitivity of MPT in multiple sclerosis is estimated at 95-99% and thus, the absence of changes in MPT of the brain and spinal cord - with a high degree of certainty excludes the diagnosis of multiple sclerosis.

The widespread use of MPT has revolutionized the diagnosis of multiple sclerosis.

Pathological changes according to MRI are observed in more than 95% of patients who meet the diagnostic criteria for multiple sclerosis.

When using the inversion-recovery sequence or on T1-weighted images, there may be no changes, or dark (low intensity) dot foci in the white matter are detected. Multiple sclerosis-specific changes are better seen on T2-weighted images with a spin echo sequence on average-weighted images. At the same time, foci of increased intensity are clearly visible against the background of surrounding brain tissues. Some of them appear to radiate from the ventricular wall and correspond to the periventricular demyelinating lesions characteristic of multiple sclerosis. Lesions are often found in the brainstem, cerebellum, and spinal cord. Unlike most cerebrovascular diseases, in multiple sclerosis, pathological changes are often detected in the corpus callosum.

Foci of demyelination, defined in the T2-mode as hyperintense, are found in 95% of cases of significant multiple sclerosis. If MRT reveals the presence of foci in patients with "probable multiple sclerosis" (in the case of a clinically isolated syndrome), then in 65% of cases they are predictors of the development of significant multiple sclerosis over the next 5 years.

The size of lesions typical of multiple sclerosis is usually 3 mm or more. These foci can be found periventricularly, in the corpus callosum (with a characteristic spread of foci from it into the white matter - “Dawson's fingers”), in the brainstem, cerebellum, spinal cord and in the optic nerves.

Identification of hyperintense foci in several areas of the CNS in the T2 mode reflects the multifocal nature of neurological damage in multiple sclerosis. The most characteristic distribution of foci of multiple sclerosis in the brain with significant multiple sclerosis (according to MPT data) is presented in Table 1.

Table 1. Localization of foci of multiple sclerosis in the brain.

Gadolinium-enhanced MRI may show areas of increased intensity in the white matter as a result of the passage of the contrast agent through the compromised blood-brain barrier. A transient increase in gadolinium T1-weighted intensity usually accompanies or precedes the appearance of new lesions on T2-weighted images. Autopsy data suggest that areas of gadolinium leakage correspond to perivenular foci of inflammation. Lesions that appear on T2-weighted and average-weighted images after administration of gadolinium are not specific for any type of morphological disorders.– they may reflect edema, inflammation, demyelination, gliosis, or axonal death.

Repeated MRI shows that new lesions appear much more frequently than the clinical picture would suggest. This suggests that asymptomatic exacerbations often occur in multiple sclerosis. The volume of the lesion on T2-weighted images correlates weakly with the patient's condition.

In relapsing-remitting multiple sclerosis and secondary progressive multiple sclerosis, the activity of the disease, determined by MRI data, is approximately 10 times higher than the activity of the process by clinical signs, i.e. only 1 in 10 MRI lesions show up clinically. This is probably due to the fact that not all foci are located in clinically manifested areas of brain damage.

A more accurate correspondence between the results of neuroimaging research methods and the real clinical picture can be achieved using modern research methods that make it possible to distinguish between edema, demyelination and death of axons - for example, the magnetization transfer contrast method and proton magnetic resonance spectroscopy - PMRS or +N MRS. PMRS is a modern method of visualization of biochemical processes occurring in the brain.

PMRS method uses the effect of "chemical shift" of the resonant frequencies of hydrogen nuclei (protons) in the composition of various chemical compounds relative to the resonant frequency of the proton in the water molecule. It allows in vivo determination of the content of various metabolites in brain tissues.

The use of high-field PMRS (1.5 - 2.0 T) makes it possible to clearly visualize eight peaks of metabolites in healthy people: myoinositol / inositol (Ins), choline, creatine (Cr) / phosphocreatine, N-acetylaspartate (NAA), glutamine, glutamate, gamma-aminobutyl, and with a certain research mode - acetate. The concentration of these metabolites in the brain tissue is indicated in conventional units for subsequent mathematical processing of the data obtained.

Thus, in multiple sclerosis, PMP spectroscopy makes it possible to identify the degree and extent of axonal damage using the determination of a decrease in the concentration of N-acetylaspartate, a specific axonal and neuronal marker. A decrease in the NAA/Cr index indicates secondary damage to axons and the transition of a phase of reversible inflammation and demyelination into a phase of progressive degeneration. The decrease in the concentration of N-acetylaspartate in the brain tissue in multiple sclerosis reflects a decrease in the number of axons and metabolic disorders in them. In multiple sclerosis, the content of N-acetylaspartate (NAA) decreases not only in the foci (by 80%), but also in the “unchanged white matter” (by 50%), i.e. axonal loss in multiple sclerosis is diffuse and begins before the plaque formation process. This confirms the notion that axonal damage is not only a consequence of gross demyelination, but can occur early in the disease, even before myelin damage.

In "chronic foci" in patients with benign multiple sclerosis, the concentration of N-acetylaspartate is significantly higher than in "chronic foci" of patients with secondary progressive multiple sclerosis, which indicates a greater possibility of repairing damaged axons in patients of the first group. It has been shown that in secondary progressive multiple sclerosis, a decrease in the level of N-acetylaspartate is present not only in the "normal-looking white", but also in the "normal-looking gray" matter - the cerebral cortex, thalamus opticus, and even in the gray matter of the spinal cord. This indicates a significant prevalence of not only axonal, but also neuronal damage during chronicity of the pathological process.

The introduction of the PMRS method into practice made it possible to predict the stage of multiple sclerosis. And the sharing and parallel analysis of the results obtained with PMRS and MRI allows us to characterize the functional and morphological status of multiple sclerosis - table 2.

Table 2. Functional and morphological diagnostics of stages of multiple sclerosis

* inositol - a structural component of myelin, released during its decay

** choline is a structural component of myelin released during its breakdown

*** creatine is a marker of energy metabolism and is used to assess basal metabolic activity

Recently, a new domestic method of studying the brain with the help of superposition electromagnetic scanner(SPEMS), developed by acad. N.P. Metkin (patent for invention 2290869). The components of the scanner are a personal computer, digital recording and calibration units, a 120-channel sensor that allows you to simultaneously apply to the surface of the head and remove frequency, time and amplitude calibration signals and indicators of electrodynamic activity in a wide range, and an output device. By determining the functional activity of brain tissues method comparable to positron emission tomography(PET) and allows you to obtain data on the spectrum of activity of enzymes, neurotransmitters, the density of ion channels, and in multiple sclerosis, and on the level and nature of the process of total and focal demyelination.

As a result of a survey using SPEMS of 60 patients with secondary progressive multiple sclerosis in the phase of unstable remission with EDSS from 2.0 to 5.5 points, data were obtained indicating profound metabolic changes, consisting in lactic acidosis, tissue hypoxia, due to impaired function of the respiratory cascade ubiquinone and cytochrome enzymes, an increase in peroxidation with the appearance of hydroperoxides, and a decrease in the functional activity of neurotransmitters.

Because the damage to small vessels of the white matter of the brain in T2 mode looks the same as foci of multiple sclerosis, and occurs much more frequently, the diagnosis of multiple sclerosis cannot be made based solely on the presence of lesions on T2 MRI.

Diagnostic criteria are used to confirm the diagnosis of multiple sclerosis by MPT.

Various diagnostic criteria for multiple sclerosis based on MPT data have been proposed.

For patients under 50:

The diagnosis of multiple sclerosis is considered highly probable when a patient has four or more lesions or three lesions on average or T2-weighted images, at least one of which is located periventricular (lesion diameter is at least 3 mm).

For patients over 50 years of age:

two of the following additional criteria are also required:

• the diameter of the foci is not less than 3 mm;
• one or more lesions in the posterior cranial fossa.

Diagnostic MPT criteria for multiple sclerosis according to F.H. Fazekas

• the presence of at least 3 foci, 2 of which must be located periventricularly and their size must be more than 6 mm, or 1 lesion may be localized subtentorially.

For the purpose of even more accurate neuroimaging diagnosis of multiple sclerosis, F. Barkhof et al. proposed criteria according to which foci must meet 3 of 4 conditions:

1. one lesion accumulating contrast or 9 hyperintense foci in T2 mode
2. must have at least 1 subtentorial lesion
3. at least 1 lesion must be located near the cerebral cortex
4. must have at least 3 periventricular lesions

In this case, 1 spinal focus can replace 1 cerebral. Lesions must be greater than 3 mm in diameter. Spinal lesions should not cause thickening of the spinal cord, spread over more than 3 segments and occupy the entire diameter of the spinal cord.

MRI of the spinal cord is recommended for all patients with multiple sclerosis. In it, unlike the brain, in the absence of clinical signs of circulatory disorders, nonspecific vascular foci are not detected, which makes it possible to clarify the diagnosis in elderly patients.

The effectiveness of the treatment of multiple sclerosis is usually measured by reducing the frequency of exacerbations and slowing the increase in disability. But exacerbations in multiple sclerosis are in many cases not too frequent (therefore, long-term follow-up is necessary), and in primary progressive multiple sclerosis they are not at all. In addition, both in determining the exacerbations of multiple sclerosis, and in assessing the degree of disability of the patient, there is a lot of subjectivity. That's why it is very important to conduct repeated MPT studies in dynamics, which allow to objectify the results of treatment. For this, it is sufficient to estimate only two parameters:

• the number of new foci accumulating contrast in the Tl mode, and
• total area of ​​foci in T2 mode

In the CSF are found:

• lymphocytosis
• oligoclonal antibodies
• increased concentration of immunoglobulins

Usually the number of cells in the CSF does not exceed 20 µl -1 , but at the beginning of multiple sclerosis it can reach 50 µl -1 and more. Lymphocytosis above 75 µl -1 or the appearance of neutrophils in the CSF is not characteristic of multiple sclerosis.

Cytosis is more common in young patients with a relapsing course than in older patients with a progressive course.

The protein concentration is usually normal, and only sometimes slightly increased.

The most convincing confirmation of the presence of multiple sclerosis is the determination of oligoclonal antibodies (OAT) to myelin proteins and an increase in the concentration of immunoglobulin G in the cerebrospinal fluid (CSF) compared to its content in the blood serum.

In 80% of cases, there is an increased concentration of IgG against the background of a normal protein concentration as a result of selective IgG synthesis in the CNS. The increase in the concentration of IgG in the CNS in multiple sclerosis reflects the process of increasing the titer of specific autoimmune IgG autoantibodies.

A number of indicators have been proposed to distinguish such formation of IgG in the CNS from their passive penetration through the damaged blood-brain barrier. One of them is the CSF IgG index (the ratio of the concentrations of IgG and albumin in the CSF, divided by the ratio of the same concentrations in serum).

OAT are determined in patients in 90 - 95% of cases. They may not be present at the onset of the disease, but having appeared once, OATs always remain, although they do not correlate with disease activity. In order to exclude other causes of the appearance of oligoclonal antibodies, it is necessary to examine paired sera.

The use of corticosteroids leads to a decrease in the concentration of immunoglobulin G, but does not affect the content of OAT.

However, changes in the composition of CSF are not specific for multiple sclerosis.

OATs are also determined in this way in other inflammatory and immunological diseases, many of which must be differentiated from multiple sclerosis (Table 2).

Table 3 Diseases in which oligoclonal antibodies to CNS myelin proteins are found in the CSF

Autoimmune diseases:

• multiple sclerosis;
• systemic lupus erythematosus;
• Sjögren's syndrome;
• Behcet's disease;
• nodular periarteritis;
• acute disseminated encephalomyelitis;
• Guillain-Barré syndrome

Infectious diseases:

• viral encephalitis;
• neuroborreliosis;
• chronic fungal meningitis;
• neurosyphilis;
• subacute sclerosing panencephalitis

Sarcoidosis

Cerebrovascular diseases

markers of inflammatory activity in progressive multiple sclerosis in the peripheral blood and in the cerebrospinal fluid, circulating adhesion molecules (sE-selectin, sICAM-1 and sVCAM), as well as soluble receptors (sTNF-R) serve. There is a correlation between the titers of circulating markers of inflammatory activity and the degree of activity of multiple sclerosis, the degree of disability, and visible foci of CNS lesions determined using magnetic resonance imaging. This is equally true for both primary progressive and secondary progressive types of multiple sclerosis.

Due to the variety of manifestations, multiple sclerosis has to be differentiated from very many other diseases.

For multiple sclerosis, there are no pathognomonic symptoms, laboratory or instrumental data that unequivocally indicate the diagnosis of multiple sclerosis. However, there are manifestations not characteristic of multiple sclerosis that cast doubt on the diagnosis, such as aphasia, parkinsonism, chorea, isolated dementia, amyotrophy with fasciculations, neuropathy, epileptic seizures, and coma. In doubtful cases, it is better not to rush to the diagnosis of multiple sclerosis, but first to exclude other diseases.

The diagnosis of multiple sclerosis should be doubted and a thorough differential diagnosis should be made if:

• with complaints of increased fatigue and muscle weakness, no objective neurological symptoms are detected
• one lesion is determined (especially when it is localized in the posterior cranial fossa: tumors and vascular malformations of this localization are the most common cause of misdiagnosis of multiple sclerosis)
• spinal symptoms progress from the onset of the disease in a patient younger than 35 years without pelvic dysfunction
• there is a normal composition of CSF or, conversely, a very significant increase in the number of cells
• the leading symptom is pain (although various pain syndromes are not uncommon in multiple sclerosis, they are not the main symptom of the disease)
• there is a decrease or loss of tendon reflexes (reflexes fall out only in the later stages of multiple sclerosis due to a sharp increase in muscle tone)

The diagnosis of multiple sclerosis remains uncertain, if 5 years after the onset of symptoms suggestive of multiple sclerosis:

• no oculomotor disorders;
• no sensory or pelvic disorders;
• no remissions in patients younger than 40 years;
• no "multifocal" symptoms

In the vast majority of patients with multiple sclerosis, neurological examination reveals objective symptoms. Often there are much more of them than one might assume on the basis of complaints - for example, a patient complaining of dysfunction of one leg has neurological disorders on both. This makes it possible to exclude diseases caused by a single lesion in the central nervous system. Sometimes, on the contrary, objective symptoms are not detected, and complaints are mistakenly regarded as a manifestation of a conversion disorder - forgetting that good reasons are needed to make this diagnosis.

Sometimes systemic lupus erythematosus (SLE) is accompanied by recurrent or progressive CNS damage similar to multiple sclerosis. However, other signs of SLE are also observed: symptoms of a systemic disease, increased ESR, the presence of autoantibodies, etc.

Behcet's disease may be accompanied by optic neuritis and myelitis or, more commonly, acute or subacute multifocal CNS involvement. Distinctive signs of this disease are iridocyclitis, aphthous stomatitis, ulcers of the genital organs, and an increase in ESR.

Neurological disorders occurring with exacerbations and remissions occur in Sjögren's syndrome.

With sarcoidosis, damage to the cranial nerves (especially the facial one), progressive atrophy of the optic nerve, and myelitis are possible. Sarcoidosis can be distinguished by an increase in lymph nodes, damage to the lungs and liver, an increase in ACE levels and hypercalcemia.

Lyme disease may involve damage to the optic nerve, brainstem, or spinal cord without the characteristic rash, fever, and meningoradiculopathy.

Differential diagnosis is also carried out with other chronic infectious diseases, in particular, with meningovascular syphilis, HIV infection, etc.

Tropical spastic paraparesis is characterized by back pain, progressive spasticity (primarily in the legs), and bladder dysfunction. Diagnosis is based on the detection of antibodies to human T-lymphotropic virus type 1 in serum and CSF and isolation of the virus itself.

Human T-lymphotropic virus type 2 can cause a similar progressive myelopathy.

With the sudden development of focal symptoms, multiple sclerosis sometimes has to be differentiated from stroke and migraine.

Progressive focal neurological symptoms are characteristic of volumetric education. So, in primary CNS lymphoma, single or multiple foci appear that accumulate contrast during MPT and look like fresh plaques of multiple sclerosis. However, in rare cases of multiple sclerosis, inflammation and swelling lead to a large lesion resembling a tumor.

Arteriovenous malformations in the posterior cranial fossa can cause progressive or recurrent stem disorders.

In contrast to multiple sclerosis, pons glioma develops progressive symptoms, indicating damage to neighboring parts of the central nervous system.

Osteochondrosis of the cervical spine, tumors and arteriovenous malformations of the spinal cord can lead to progressive myelopathy.

With funicular myelosis and hereditary diseases close to it - homocystinuria of the cbl G type and insufficiency of plasma R-proteins - the same neurological disorders can occur as in multiple sclerosis. At the same time, megaloblastic anemia may be absent, and it is far from always possible to judge clinically significant B12 avitaminosis by the serum concentration of vitamin B12. In such cases, serum concentrations of methylmalonic acid and total homocysteine ​​are determined.

In order to exclude mitochondrial diseases (Lie's disease, MELAS syndrome, Leber's syndrome), lactate levels in the blood and CSF are determined, muscle biopsy or gene diagnostics are performed.

Multiple sclerosis must be differentiated from hereditary ataxias, which are accompanied by progressive symmetrical lesions of the posterior cords, corticospinal and spinocerebellar tracts and, sometimes, lesions of the peripheral nervous system.

Differential diagnosis of multiple sclerosis is also carried out with other monogenic diseases: metachromatic leukodystrophy, Krabbe disease, Fabry disease and adrenoleukodystrophy. The latter is accompanied by pronounced inflammatory changes in the CSF.

With optomyelitis (Devic's disease), a few days or weeks after acute bilateral optic neuritis, transverse myelitis develops. Sometimes neuritis is unilateral or occurs after the first attack of myelitis. The severe form may be accompanied by necrosis. Most often, Asians are sick, whites - rarely. In the CSF, cytosis is found with a predominance of neutrophils, an increase in protein concentration. Optocomyelitis often resolves on its own. However, it may be the first attack of multiple sclerosis, as well as a manifestation of SLE or Behçet's disease.

In every case of suspected multiple sclerosis, a careful differential diagnosis is necessary to rule out some other, often curable disease. This is especially important at the onset of the disease, since there are no formalized diagnostic criteria that allow one to settle with 100% certainty on the diagnosis of multiple sclerosis during the 1st attack of the disease.

Thus, the diagnosis of multiple sclerosis should be based on a comprehensive analysis of the clinical picture, data from MRI, EP, reflecting the nature and "dispersion of the process in time and space", and, if necessary, the study of the CSF.

Currently, many useful clinical and laboratory diagnostic criteria for multiple sclerosis have been proposed to verify the diagnosis of multiple sclerosis - tables 3 and 4.

1. Objective symptoms on neurological examination
2. Damage to the pathways, especially:
   1. corticospinal;
   2. spinocerebellar;
   3. medial longitudinal bundle;
   4. optic nerve;
   5. posterior cords
3. Damage to two or more parts of the central nervous system according to anamnesis or examination
   1. the presence of a second lesion can be confirmed by MPT . About multifocal lesions based on MPT alone can be judged if:
      • 4 lesions in white matter
      • or 3 lesions, one of which is located periventricular (lesion diameter ≥ 3 mm).
      • For patients older than 50 years, two of the following are also required. additional criteria:
        • lesion diameter ≥ 3 mm.
        • one or more foci adjacent to the wall of the lateral ventricle;
        • one or more lesions in the posterior cranial fossa
   2. If the neurological examination revealed only one focus, then the presence of the second can be confirmed using the study of evoked potentials
4. The course of multiple sclerosis:
   1. two or more separate exacerbations of neurological disorders, reflecting damage to different parts of the CNS, each lasting ≥24 hours, with an interval between them ≥1 month, or
   2. gradual or stepwise increase in neurological symptoms for ≥6 months, accompanied by signs of increased synthesis of IgG in the CNS or the appearance of ≥2 oligoclonal antibodies
5. Start at age 15-60
6. Neurological disorders cannot be caused by another disease. To exclude such a disease, it is recommended to use the following studies and indicators (depending on the situation):
   1. CSF study;
   2. MPT of the head and spine;
   3. serum concentration of vitamin B 12 ;
   4. antibody titer to human T-lymphotropic virus type 1;
   5. rheumatoid factor, antinuclear antibodies, anti-DNA antibodies (SLE)
   6. precipitation reaction of inactivated serum with cardiolipin antigen;
   7. ACE (sarcoidosis);
   8. serological tests for Borrelia burgdorferi (Lyme disease);
   9. very long chain fatty acids (adrenoleukodystrophy);
   10. serum and CSF lactate, muscle biopsy, mitochondrial DNA analysis (multochondrial diseases)

1. The diagnosis of multiple sclerosis is reliable: meeting all 6 criteria
2. The diagnosis of multiple sclerosis is likely: meeting all 6 criteria, but:
   1. neurological examination revealed only one focus, although 2 exacerbations were observed, or
   2. only one exacerbation was observed, although ≥ 2 lesions were detected
3. The diagnosis of multiple sclerosis is possible: full compliance with all 6 criteria, but only one exacerbation was observed and only one focus was detected

Table 5 Criteria for the diagnosis of multiple sclerosis (W.I McDonald, 2005)

1 However, if additional investigations (MRI, CSF) are done and no changes characteristic of MS are detected, other possible diagnoses should be considered.

Registration for a consultation:

Literature

1. Bisaga G.N., Pozdnyakov A.V. Magnetic resonance spectroscopy // Multiple sclerosis / ed. I.A. Zavalishin, V.I. Golovkin. M., 2000. S. 244-249.
2. Internal diseases according to Tinsley R. Harrison. Ed. E. Fauci, J. Braunwald, K. Isselbacher, J. Wilson, J. Martin, D. Kasper, S. Hauser and D. Longo. In two volumes. Per. from English. - M., Practice - McGraw - Hill (joint edition), 2002.
3. New technologies for predicting the treatment of multiple sclerosis / Golovkin V.I., Pozdnyakov A.V., Kamynin Yu.F., Martens // Bulletin of Siberian Medicine. - 2010, No. 4. - S. - 138 - 144.
4. Pozdnyakov A.V. Proton magnetic resonance spectroscopy of the brain in the diagnosis of remission and exacerbation of the disease // Immune-mediated relapsing-remitting multiple sclerosis / ed. IN AND. Golovkin, N.M. Kalinin. St. Petersburg: "Rose of the World", 2003. S. 35-50.
5. Pozdnyakov A.V. The role of proton magnetic resonance spectroscopy in the diagnosis of brain diseases: Ph.D. dis. … Dr. med. Sciences. SPb., 2001. 32 p.
6. Multiple sclerosis: a guide for doctors / T.E. Schmidt, N.N. Yakhno. -2nd ed. - M.: MEDpress-inform, 2010. - 272 p.
7. Adhesion molecules in multiple sclerosis / Elovaara I., Ukkonen M., Leppakynnas M. et al. Arch. Neurol. - 2000. - v.57. – P.546-551
8. Assessment of MRI criteria for a diagnosis of MS./ Offenbacher H, Fazekas F, Schmidt R, et al. // Neurology. - 1993 May;43(5):905-9.
9. Belair M, Girard M. Diagnostic criteria in clinical evaluation of multiple sclerosis: role of magnetic resonance imaging. // Can. Assoc. Radiol. J. - 2004. - v.55, No. 1. – P.29-33.
10. Comparison of MRI criteria at first presentation to predict conversion to clinically definite multiple sclerosis. / Barkhof F., Filippi M., Miller D.H., et al. // brain. - 1997 - v.120. - P. 2059 - 2069.
11. Criteria for an increased specificity of MRI interpretation in elderly subjects with suspected multiple sclerosis. / Fazekas F, Offenbacher H, Fuchs S, et al. // Neurology. - 1988 Dec;38(12):1822-5.
12. Droogan, A. G., McMillain, S. A., Dougkas, J. R, Hawkins, S. A.: Serum and cerebrospinal fluid levels of soluble adhesion molecules in multiple sclerosis: predominant intrathecal release of vascular cell adhesion molecule-1 J. Neuroimmunol. - 1996, 64: 185-191
13. Fatigue, depression and progression in multiple sclerosis / Koch M., Uyttenboogaart M. et al. // Mult. Scler. - 2008. - v.14, No. 6. – P. 815 – 822
14. Magnetic resonance imaging in multiple sclerosis. / Haller S, Pereira VM, Lalive PH, et al. // top. Magn. Reson. Imaging. - 2009. - v.20, No. 6. - P. 313-323.
15. Magnetic resonance spectroscopy of multiple sclerosis: in vivo detection of myelin breakdown products / Koopmans R.A., Li D., Zhu GT. et al. // Lancet. 1993. V. 341. P. 631-632.
16. Recommended diagnostic criteria for multiple sclerosis: guidelines from the International Panel on the diagnosis of multiple sclerosis. / McDonald W.I., Compston A., Edan G., et al. // Ann. Neurol. - 2001. - v.50. – P. 121 – 127.
17. Recommended standard of cerebrospinal fluid analysis in the diagnosis of multiple sclerosis: a consensus statement. / Freedman M.S., Thompson E.J., Deisenhammer F., et al. // Arch. Neurol. - 2005. - v.62, No. 6. - P.865-870.

Multiple sclerosis refers to degenerative immune-mediated diseases of the nervous system that have a chronic course. It is accompanied by inflammation, demyelination and degeneration of axons with the formation of scattered foci of sclerosis in the white matter of the brain - plaques. It affects young people and in most cases leads to disability.

The diagnosis is made on the basis of an analysis of the symptoms of the disease, the number and severity of exacerbations, and a competent interpretation of the results of the studies. In the neurology clinic of the Yusupov hospital, the following methods of diagnosing this pathology are used:

• Magnetic resonance imaging;
• electroencephalography;
• electromyography;
• duplex examination;
• electroneuromyography.

Patients of the Yusupov hospital are treated individually and only with original drugs. Research is carried out on modern equipment. The treatment takes a holistic approach.

How to identify multiple sclerosis

Neurologists at the Yusupov Hospital make a diagnosis on the basis of objective data and the results of magnetic resonance imaging, during which dissemination of foci is detected. Evidence of the presence of a pathological process is the identification of two or more foci on MRI, as well as the progression of symptoms over time (subsequent attacks, new foci, or excessive accumulation of injected contrast). The clinic also examines the cerebrospinal fluid to identify oligoclonal bands of immunoglobulins.

Ophthalmologists determine the visual fields, check the contrast sensitivity of the eye, the thickness of the retina, and examine the fundus. An important diagnostic method used by neurologists at the Yusupov Hospital is the study of somatosensory, auditory and visual evoked potentials of the brain.

Multiple sclerosis. Blood diagnostics

In order to exclude or confirm the diagnosis of multiple sclerosis, it is necessary to take a blood test, according to which neurologists will analyze the following indicators:

• the level of anti-inflammatory cytokinins in peripheral blood;
• blanctransformation reaction of lymphocytes upon contact with myelin basic protein;
• myelin antibody level.

If the patient has already been diagnosed with multiple sclerosis, a blood test will show the dynamics of the pathological process.

Neurologists at the Yusupov Hospital approach the diagnosis and treatment of multiple sclerosis individually. The selection of drugs and doses is carried out taking into account the clinical signs of the disease and its course. After the therapy, the quality of life of patients improves. In order to make an appointment with a neurologist specializing in the treatment of multiple sclerosis, you need to call by phone.

Bibliography

• ICD-10 (International Classification of Diseases)
• Yusupov hospital
• "Diagnostics". - Brief Medical Encyclopedia. - M.: Soviet Encyclopedia, 1989.
• "Clinical evaluation of the results of laboratory studies" / / G. I. Nazarenko, A. A. Kishkun. Moscow, 2005
• Clinical laboratory analytics. Fundamentals of clinical laboratory analysis V.V. Menshikov, 2002.

Our specialists

Prices for the diagnosis of multiple sclerosis

*The information on the site is for informational purposes only. All materials and prices posted on the site are not a public offer, determined by the provisions of Art. 437 of the Civil Code of the Russian Federation. For exact information, please contact the clinic staff or visit our clinic. The list of paid services provided is indicated in the price list of the Yusupov hospital.

Multiple sclerosis is represented by the following methods:

• blood analysis– venous blood sampling for testing according to various parameters;
• MRI- magnetic resonance imaging, allows you to identify foci of inflammation and damage to brain tissues and blood vessels using magnetic waves and fields;
• superposition electromagnetic scanner– designed for early detection of MS by the activity of the nervous tissue;
• potential measurement(neurological method) - checking sensory states, sensitivity and brain activity;
• spinal puncture (lumbar)– analysis of the substance of the spinal cord;
• proton magnetic resonance spectroscopy– study of the chemical composition of the nervous tissue.

It is sad that this disease does not spare either young or children.

Types of studies of biological fluids

It is important when taking tests to comply with all prescribed measures regarding:

1. physical activity;
2. smoking;
3. psychoemotional state.

Consider what types of analyzes are taken and what their results show.

Study of the cerebrospinal fluid

Examination of the cerebrospinal fluid (CSF) to determine the degree of damage to this part. A needle is punctured at the level of the lower back, the analysis is carried out immediately (no later than half an hour) in four stages:

• biochemical research– study of the qualitative and quantitative composition of cerebrospinal fluid for the diagnosis of tumors;
• microscopic- counting elements at the cellular level;
• macroscopic- by color (normally transparent), red indicates the presence of red blood cells (inflammation), green or yellow indicates the presence of meningitis, subarachnoid hemorrhage, fibrinous film (normally absent);
• bacterioscopic and bacteriological- allows you to determine the presence of bacteria (tuberculosis bacilli, meningococci, strepto- and staphylococci), determine immune reactions (Kahn, Wasserman, RIBT, Wright, etc.).

Oligoclonal IgG linkages

In multiple sclerosis, oligoclonal immunoglobulin G is found in the cerebrospinal fluid, which indicates the influence of the immune system on the brain (infection). Cerebrospinal fluid and venous blood (serum and cerebrospinal fluid) are taken for analysis.

IMPORTANT! Results are obtained within half an hour after sampling and the answer is positive in the presence of IgG.

Quantitative IgG

It is done when taking venous blood to check for infections, rubella or its transfer in the past, to count the number of antibodies (oligoclonal immunoglobulin G indicates the presence of MS at any of its stages), the deadline is about ten days.

IgG value:

1. Reference values is a polyclonal type of IgG synthesis.
2. Positive result– MS, pathologies and damage to the nervous system, vascular inflammation.
3. Negative result- the norm.

myelin basic protein

Serum is taken for analysis from venous blood (peripheral vein) or cerebrospinal fluid, the analysis takes nine days.

Its increased concentration indicates the presence of destruction and inflammation. Used to predict and control the development of MS.

The results of the study - negative (normal), positive (RS)

Albumin index

Sampling of venous blood and CSF to assess the nutritional status, protein-synthetic function of the liver. It is done immediately after sampling under the calculation of the index - the amount of albumin in the blood plasma is divided by the amount of albumin in the life expectancy. Its low indicator indicates the presence of pathologies and diseases.

total liquor protein

REFERENCE! CSF is used immediately after sampling for the evaluation and diagnosis of infectious and inflammatory diseases, oncological changes, and diseases of the central nervous system.

The results of the analysis with an increase indicate the disease:

• bacterial (0.4-4.4 g/l);
• cryptococcal (0.3-3.1 g/l);
• tuberculous (0.2-1.5 g/l) meningitis and neuroborreliosis.

Gamma globulin

A venous blood test is performed to evaluate the amount of immunoglobin antibodies or immune gamma globulin. A certain amount shows the presence of various infections and inflammations.

• The norm is IgA (0.4–2.5 g/l), IgG (7–16 g/l).
• IgM in women older than 10 years (0.7–2.8 g/l).
• In men older than 10 years (0.6–2.5 g/l), IgD (0.008 g/l or less), IgE (20–100 kU/l).

IgG concentration in CSF

Comparison of the concentration of gamma globulin in the blood and CSF helps to assess the stage of development of MS, as well as the nature of its manifestation, the deadline is 11 working days.

The norm for a healthy person is from 7 to 16 g / l. An increase in the norm indicates the presence of diseases (MS, infections).

IgG ratio

Normally, IgG in the blood serum is 70-80 / about all immunoglobulins. The content of the main part of the antibodies indicates the resistance to a number of viruses and bacteria. Oligoclonal accumulations in the CSF are found in 98% of patients with MS. The ratio has a CD4+/CD8+ ratio of 2:1.

lgG velocity in CSF

The analysis is taken with the help of a puncture in the lower back and is done within half an hour, the spinal cord cerebrospinal fluid is analyzed. The rate of IgG synthesis in MS is increased, it is equal to > 3.3 mg/day.

PCR

Polymerase chain reaction based on venous blood or CSF, which is treated with special enzymes, the result is received within a day.

ATTENTION! After the introduction of the enzyme, RNA and DNA of disease-causing cells are divided. Their calculation gives results on the presence of various diseases.

peripheral blood

Venous blood is taken for analysis from the peripheral zone. When determining multiple sclerosis, lymphocytes are counted (more than 62%).

Prices

Multiple sclerosis is a dangerous, severe, currently incurable disease of the nervous system, which can not be detected immediately. With it, the nervous tissue is gradually destroyed, which is replaced by connective tissue. As a result, pathological foci do not fully participate in the functioning of the nervous system, which outwardly manifests itself in the form of symptoms characteristic of the disease. According to statistics, sclerosis can be detected in middle age in about 20 out of 100,000 people. Diagnosis of multiple atherosclerosis at an early stage is of great importance, since the earlier the diagnosis is determined, the more favorable the prognosis for health and life.

Clinical symptoms

MS more often manifests at a young age

The disease occurs more often in women under the age of 45 living in places with a cool climate. After 55 years, pathology is less likely to be diagnosed. If you pay attention to race, then sclerosis affects more Europeans.

It is impossible to determine the disease at the beginning without conducting an additional examination. This is due to the absence of symptoms at an early stage. In three out of 9 patients, the disease has a benign course. Less commonly, an illness in the next five years leads to disability.

Why is sclerosis not recognized at the very beginning? This is due to the fact that healthy tissue of the nervous system replenishes the lost function of the replaced areas with connective tissue. The presence of the first signs indicates the defeat of approximately 40-50% of the nerve fibers. How to recognize multiple sclerosis by clinical symptoms?

1. Early signs are causeless pain in the eyeballs, doubling of objects, a noticeable visual impairment.
2. Simultaneously with the above symptoms, hypoesthesia occurs, that is, a violation (or rather) a decrease in skin sensitivity. In particular, the person may experience numbness in the fingers (or slight tingling).
3. Another characteristic symptom is weakness in the muscles, and with it a change in gait, which is associated with impaired coordination.

Clinical symptoms may occur simultaneously, or they may appear alternately. An increase in the temperature of the external environment (hot shower, insolation, stuffy room, etc.) worsens the patient's condition. It is these signs that help the specialist to differentiate the disease.

How was the disease previously diagnosed?

Timely diagnosis will provide the patient with many years of active life.

How was multiple sclerosis diagnosed in the past and what has changed by now?

During the absence of additional diagnostic methods that reliably confirm the diagnosis, the doctor focused on the presence in the anamnesis of typical symptoms of "dispersion", which either arose or disappeared - thus, an undulating course of the disease manifested itself. Only in the 80s of the last century, the study of brain potentials was added to clinical signs, confirming damage to parts of the nervous system. In the late 1980s, MRI was used for the first time in diagnostics. During the procedure, a contrast agent was injected. In patients, foci of the affected nervous tissue with the absence of myelin substance were detected. However, at the beginning of the introduction of this method, there were repeated errors in the diagnosis. It became possible to detect the disease using MRI diagnostics after the improvement of the method in 2005.

The order of medical actions in the process of detecting a disease

In the process of identifying multiple sclerosis, early diagnosis includes the following criteria:

1. Mandatory differential diagnosis, followed by the exclusion of other pathologies associated with damage to the central and / or peripheral parts of the nervous system.
2. Carrying out not only instrumental research methods, special tests, but also testing.

In the process of detailed differential diagnosis, the specialist draws attention to the deterioration in vision. As a rule, one eye sees worse. This is due to damage to the optic nerve. Hands often become numb, and there is a feeling of crawling. Legs or hands become like cotton. It is not possible to make an active movement with them. Often there is a feeling of nausea, the gait becomes shaky. Differential diagnosis is carried out with the following diseases: cerebellar damage, osteochondrosis, sciatica, etc.

MRI allows visualization of pathological foci in the CNS

The next step in clarifying the diagnosis is MRI, with which you can check the affected areas of the nervous tissue.

In 2010, the criteria table was amended, based on which it is possible to make a diagnosis using additional research methods.

• A history of several attacks characteristic of the disease, as well as the presence of two foci.
• A history of more than 2 attacks, confirmation of one or more pathological foci in the central nervous system.
• The presence in the anamnesis of an attack, more than 2 foci, the expectation of a recurrence of the disease according to the results of MRI.
• Confirmation in the anamnesis of the attack, as well as the spread of the pathological focus with the involvement of areas of the central nervous system that were not previously affected by the disease.

Before making a diagnosis of "progressive type of sclerosis", the specialist draws attention to the presence of the following components: identification of characteristic symptoms that are more clearly manifested; the spread of the pathological process in the tissues beyond the boundaries of the first detected focus using MRI; when taking cerebrospinal fluid (liquid circulating in the spinal canal and ventricles of the brain) for oligoclonal IgG, positive results are found.

Symptoms of the disease manifest themselves in different ways. One symptom may accompany the disease for several months with periods of remission.

Magnetic resonance imaging in the diagnosis of pathology

How is multiple sclerosis diagnosed based on MRI results? A modern device must have a power of at least 1.5 T. If the indicator is lower, then it will not be possible to determine the pathological foci, as well as the structures of the nervous system. With a disease, lesions are located in the following parts of the brain:

1. Temporal lobes.
2. Cerebellum.
3. Lateral sections of the ventricles.
4. Calloused body.
5. Brain stem.
6. White matter of the brain.

MRI can show not only the shape, but also the size of pathological foci (in mm or cm). In the gray matter, they are usually few - only 10%. When the spinal cord is affected, the foci are located along. They can be distinguished by an oblong shape up to 2 cm in size. Large diameter areas predispose to the emergence of new ones. Over time, the number of foci increases - extensive zones up to 8 cm are formed. Sometimes this indicator has to be differentiated from benign or malignant formations. To identify at what stage of the disease helps MRI of the brain. With the help of this method, the examination of the spinal cord is an optional procedure, but it is desirable, and is an absolute indication in the presence of pathological areas in it.

Study of cerebrospinal fluid

CSF analysis in multiple sclerosis

Using this immunological method, the following indicators can be determined:

• Increasing the level of class G immunoglobulins.
• Detect the content of oligoclonal immunoglobulins class G.
• Determine the increase in myelin levels during periods of exacerbation.

The study of cerebrospinal fluid is the most accurate analysis that allows you to determine the duration of the disease and helps to make a diagnosis, screening out the alleged pathologies.

Determination of the disease using the technique of evoked potentials

This technique (abbreviated as EP of the brain) is carried out using a special device that records the response of the brain to any stimuli (for example, visual, auditory), in addition, peripheral nerves are irritated. Irritation of individual zones is shown in specific cases, for example, the visual zone is irritated when diagnosing complex variants of the course of the disease, when only one area of ​​the central nervous system is affected.

Diagnosis of the disease by the results of a blood test

Among the existing tests for multiple sclerosis, a blood test is taken into account. Diagnostic criteria in biochemical analysis are markers of inflammatory activity - circulating adhesion molecules. There is a certain relationship between the number of markers that independently circulate in the blood and cerebrospinal fluid and are responsible for the degree of pathological progress of inflammation. This pattern is true for all types (primary and secondary progressive) course of the disease. Thus, the diagnosis of multiple sclerosis by blood is taken into account.

In MS, oligoclonal IgG can be detected in the blood serum.

Differential diagnosis of the disease

Due to the great similarity with other diseases, and at first poor symptoms, the doctor conducts a differential diagnosis. For sclerosis, there is no specific diagnostic criterion that would absolutely accurately allow a specialist to exclude other ailments. At the same time, with sclerosis, there may be such rare symptoms that are not characteristic of the disease (lack of speech, hand trembling, coma, parkinsonism, etc.). The doctor may question the diagnosis if:

1. The patient complains of increased fatigue, but no neurological changes are detected.
2. Only one lesion is identified. Very often, the focus is confused with a tumor or altered blood vessels.
3. The patient is dominated by spinal symptoms, but there are no disorders of the pelvic organs.
4. There are no significant abnormalities in the cerebrospinal fluid, as well as peripheral blood, which were described above.
5. Pain is the leading symptom of the disease. (Pain is not the main symptom in multiple sclerosis.)
6. The patient has mild tendon reflexes (with the disease, they fall out only in the later stages).

The diagnosis remains in doubt if, 5-7 years after the disease was suspected, the patient has no oculomotor changes, no pelvic organ disorders, and no other characteristic symptoms.

MS has to be differentiated from many other diseases due to the variety of symptoms

Some diseases that have similar symptoms:

• Systemic lupus erythematosus affects the nervous and immune systems. With it, the ESR rises, antibodies are determined in the blood.
• Behcet's disease - accompanied by damage to the nervous system. Distinguishes the disease from sclerosis - ulcerative lesions of the genital organs, accelerated ESR, aphthous stomatitis.
• Sarcoidosis is accompanied by damage to the cranial nerves, atrophy of the optic nerve is possible, there is an increase in lymph nodes, etc.

Thus, in the diagnosis of the disease, the specialist focuses on the data obtained during the examination, as well as using instrumental, laboratory research methods.