Multiple Sclerosis Management

Disease Monitoring and Progression

• Stable lesion burden is associated with better long-term outcomes regarding disability progression, and brain volume loss exceeding -0.4% per year is considered pathological in MS, with patients with low brain volume having a 2.4-fold higher risk of disability progression over 2 years 1
• Cervical spinal cord atrophy is an important marker of disability status and should be monitored alongside lesion stability, as spinal cord involvement is seen in 80-90% of MS patients, with the cervical portion most frequently affected 1, 2
• Despite stable lesions, patients should understand that MS remains a chronic condition requiring ongoing management and monitoring 3

Imaging and Diagnostic Protocols

• Follow-up MRI scans should be conducted at least once yearly in patients with stable MS, using specific protocols including proton density and/or T2 FLAIR sequences, T2-weighted fast or turbo spin echo sequences, and Gadolinium-enhanced T1-weighted sequences (with minimum 5-minute delay after contrast administration) 3, 4
• The following table summarizes the recommended MRI sequences:

• Spinal cord MRI is recommended for patients with spinal symptoms, inconclusive brain MRI findings, or strong clinical suspicion with normal brain MRI, as recommended by the National Institute of Neurological Disorders and Stroke and the American Academy of Neurology 5, 2, 4
• Lesions should have typical MS characteristics, including an ovoid/round shape, at least 3mm along the main axis, and asymmetric distribution, according to the Brain journal guidelines 2

Nutrition and Rehabilitation

• Early detection and treatment of causes of malnutrition by a multidisciplinary team is recommended, with dietary advice provided for prevention and treatment of nutritional problems, and oral nutritional supplements considered for patients unable to meet nutritional needs through diet alone 6
• MS patients are at risk of developing obesity-related complications, which can increase MS risk and worsen outcomes, with a relative risk of 2.25, and commonly experience vitamin D deficiency, which is associated with increased disease activity 6

Symptom Identification and Management

• Symptoms of area postrema syndrome (intractable vomiting and hiccoughs) may indicate neuromyelitis optica spectrum disorders, and multiple sclerosis with cervical spinal cord lesions typically presents with decreased hand dexterity, gait instability, sensory disturbances, and motor dysfunction in the upper and lower extremities 2
• The diagnostic criteria for MS include dissemination in space, dissemination in time, and clinical presentation, as stated by the International Panel on Diagnosis of Multiple Sclerosis, with dissemination in space demonstrated by evidence of multiple focal demyelinating lesions in both cerebral white and grey matter 7, 8, 3
• Symptomatic treatment for MS includes rehabilitation, energy conservation strategies for fatigue and weakness, physical therapy and medications for spasticity and gait problems, with consideration of prophylactic antimicrobials for patients at high risk of infection, and nine classes of disease-modifying therapies are available for relapsing-remitting MS and secondary progressive MS with activity 2, 9, 3

Complications and Comorbidities

• MS patients are at increased risk of infections, neuroinflammatory complications, and autoimmune comorbidities due to both the disease itself and its treatments, with a significantly increased risk of respiratory infections, particularly pneumococcal disease, and are at risk of developing symptoms similar to Myalgic Encephalomyelitis/Chronic Fatigue Syndrome, and dysfunction of the autonomic nervous system 10, 11
• Many MS patients develop hypothalamus-pituitary-adrenal axis dysfunction, leading to abnormal cortisol levels, and are at risk of developing ophthalmological complications, including corneal small nerve fiber loss, retinal abnormalities, and impaired pupillary light responses 11

Follow-up and Monitoring

• Neurology follow-up within 1-2 weeks and repeat MRI in 3-6 months to assess for new lesions and treatment response are recommended, with a moderate level of evidence supporting their use, and regular screening and monitoring are necessary to prevent and manage complications, with a focus on early detection and intervention, as recommended by the National Institute of Neurological Disorders and Stroke 3, 12