Multiple sclerosis: causes, symptoms and treatments

According to WHO (World Health Organization), atherosclerosis is various changes in the inner lining of the arteries (intima). They can manifest themselves as accumulation of lipids, complex carbohydrates, fibrous tissue, blood components, calcification (deposition of calcium salts), which leads to damage to the medial layer of the vessel. In the international classification of diseases ICD-10, the pathology is coded I67 (“Other cerebrovascular diseases”).

Vascular sclerosis occurs as a result of disturbances in lipid and protein metabolism in the body and is accompanied by the deposition of cholesterol, LDL and VLDL (low and very low density lipoproteins) on the walls of blood vessels. In this way, atherosclerotic plaques are formed (they are fibrous and cholesterol), gradually reducing the lumen of the arteries. The smaller their diameter, the less blood flows to organs and tissues, and ischemia occurs. Complete blockage leads to tissue necrosis. Another scenario is possible: an atherosclerotic plaque may break off and travel further in the bloodstream, where it will clog a capillary of a smaller diameter. As a rule, either an infarction occurs in the myocardium of the heart or a stroke in the brain.

The Yusupov Hospital offers complete diagnosis and treatment of cerebrovascular sclerosis using modern equipment. An individual approach to each patient and adherence to current treatment recommendations is the key to the professionalism of our specialists.

Causes of development of vascular sclerosis

The causes of sclerosis depend on risk factors. They can be modifiable, that is, we can influence them - lifestyle and laboratory parameters, or non-modifiable - age, gender and genetic predisposition.

Non-modifiable ones include:

• gender - men suffer more often, this is explained by the fact that in women estrogen has an angioprotective function;
• age - men over 45, women > 50 or with early menopause;
• cases of atherosclerosis in relatives.

Modifiable are:

• smoking;
• drinking excessive amounts of alcohol;
• lack of plant foods in the diet;
• low physical activity;
• stress;
• overweight;
• dyslipidemia;
• diabetes;
• arterial hypertension.

Atherosclerosis of cerebral vessels most often occurs in the following places:

• brachiocephalic trunk;
• carotid artery (common and external carotid);
• cerebral arteries (anterior, posterior and middle);
• vertebral artery and other small vessels.

Expert opinion

Author: Alexey Vladimirovich Vasiliev

Neurologist, Head of the Research Center for Motor Neuron Disease/ALS, Candidate of Medical Sciences

Atherosclerosis of cerebral vessels is an insidious disease that is diagnosed in patients over 45 years of age. The initial stage proceeds almost unnoticed, so patients seek help in an advanced state. People who have relatives with atherosclerosis are susceptible to the disease, so they are recommended to undergo regular diagnostics to detect the disease at an early stage.

The disease occurs due to the accumulation of cholesterol plaques. Most often, BMS sclerosis is diagnosed in people who lead an inactive lifestyle, consume tobacco and alcohol, abuse fried foods and are overweight.

The disease develops in several stages. The initial stage is asymptomatic and very difficult to recognize. However, all stages are accompanied by various symptoms:

• Initial. Headaches and dizziness occur, which are most often attributed to overwork. It is worth considering that after sleep the symptoms disappear.
• Progressive. It is characterized by increased symptoms of the previous stage, the patient experiences emotional instability, and the person becomes depressed.
• Decompensation. It is the most complex form of the disease, in which stroke or paralysis occurs. The patient has memory loss and requires constant care.

The disease is most acutely tolerated by a person, as complications appear that end in complete loss of capacity or, even worse, death of the patient.

Doctor's comment

A commentary on the principles of treatment with drugs that modify the course of multiple sclerosis (DMD) and the goals of therapy is given by a leading specialist in the field of multiple sclerosis, Doctor of Medical Sciences, Professor of the Department of Nervous Diseases and Neurosurgery with the Clinic of the First St. Petersburg State Medical University named after Academician I.P. Pavlova Totolyan Natalia Agafonovna

There are first-line and second-line PEDs. First-line DMTs are prescribed as soon as the diagnosis of multiple sclerosis is confirmed. They slow the progression of the disease and reduce symptoms. Second-line DMTs are used when multiple sclerosis becomes active. But first-line drugs are not effective enough.

Main effects of PITRS:

1. slowing down the development of irreversible disorders (disability);
2. reduction in the frequency of exacerbations;
3. reducing the inflammatory response.

Currently developed:

• clear algorithms for treatment with DMT drugs;
• ways to monitor changes in patients' condition;
• recommendations that can significantly reduce the severity of adverse reactions or completely eliminate them.

However, there are cases that may require a change in DMT drugs.

These include:

• severe adverse reactions that cannot be corrected;
• pregnancy (including planned);
• lack of effectiveness of therapy.

In any case, the decision to prescribe or cancel DMTs is made by the attending physician and depends on the patient’s condition.

The international medical community has accepted that DMTs are the first-priority and most effective drugs for the treatment of multiple sclerosis.

Symptoms and signs of cerebral sclerosis

Symptoms and signs depend on the degree of mismatch between the brain's oxygen needs and the body's capabilities, as well as on the duration of this pathological condition. Brain tissue consumes up to 25% of all oxygen entering the body and up to 70% of glucose, since the brain does not have glycogen reserves from which other tissues take it. There is an assumption that if you hold your breath for 10 seconds, the brain is able to use all the oxygen that is currently in its tissues. And with sclerosis of its vessels, oxygen deficiency gradually increases, leading to the appearance of the first symptoms that need to be paid special attention to:

• having trouble sleeping, waking up more tired;
• headaches become more frequent or appear for the first time. Most often as a migraine;
• memory deteriorates, you become absent-minded, it is difficult to concentrate on a task;
• constant lethargy and depressed mood.

General information

Sclerosis is a medical term used to define the process of replacing organ parenchyma with denser connective tissue.
Sclerosis is not an independent disease, but a manifestation of other underlying ailments. The reasons for this phenomenon in the body can be a variety of processes: blood circulation disorders, inflammation, changes that occur in the human body due to age.

Sclerosis can develop in different organs. Thus, with cardiosclerosis, changes occur in the heart, with atherosclerosis - in the walls of blood vessels, with nephrosclerosis - in the kidneys, with pneumosclerosis - in the lungs, etc.

Initial stage of the disease

At the initial stage, all previous “bells” become more pronounced and intensified. In addition to the above, dizziness, ringing in the ears and flickering of “spots” before the eyes occur, and a feeling of heaviness in the head appears.

At this stage, about 90% of patients complain of migraine headaches. They differ from ordinary ones in that they can appear at any time of the day. Their occurrence is provoked by physical or mental work, stress, and being in a stuffy room. In addition to the characteristic pulsating or pressing pain sensations, fear of light and noise is added. Conventional painkillers do not relieve the condition.

Second stage

It is characterized by a combination of complaints similar to the initial stage, but the condition is aggravated by the appearance of neurological microsymptoms:

• reflexes of oral automatism come to life;
• the innervation of facial muscles is disrupted, the tongue deviates in the direction of damage;
• coordination and oculomotor disorders occur;
• the speed of reflexes decreases, there may be convulsions or even paralysis (complete/partial);
• active movements slow down, muscle tone increases;
• Memory lapses increase, negative character traits become sharper, and psychosis is possible.

Diagnosis of cerebral vascular sclerosis

The Yusupov Hospital has all the necessary equipment to carry out a full range of diagnostics. Experienced neurologists pay close attention to each patient, listen to their complaints and collect anamnesis in order to make the correct diagnosis. To clarify this disease, it is necessary to find out the presence of associated factors:

• bad habits - smoking, drinking alcohol and other drugs;
• relatives with the same disease;
• diabetes mellitus, myocardial infarction;
• cerebrovascular accidents, damage to the great vessels of the head;
• transient ischemic attacks in the past.

Laboratory examination methods use a blood test to identify the following indicators:

• dyslipidemia;
• hyperglycemia;
• hypercoagulation;
• increase in atherogenicity coefficient.

During physical examination, a reliable method for determining carotid artery sclerosis is auscultation in the bifurcation area (where the common carotid artery divides into two large branches - the internal and external carotid arteries). If stenosis is present, a systolic murmur will be heard using a phonendoscope.

The most informative instrumental studies include:

• Doppler ultrasound (duplex scanning) of the vessels of the head. The bottom line is that with the help of ultrasound you can find out the speed of blood flow using the Doppler effect. It is performed in two modes - two-dimensional (B-mode) and transcranial duplex scanning. Their difference is that B-mode allows you to study blood flow in vessels that are not located inside the skull. Transcranial scanning is used additionally when examining brain tissue for the presence of tumors;
• angiography - visualization of blood vessels by introducing a special contrast agent into the bloodstream, which will be visible on x-rays;
• MRI and CT examination. They make it possible to identify cerebral circulatory disorders (ischemia, strokes), vascular malformations (aneurysms, dissections), as well as neoplasms. MRI is preferable because there is no radiation exposure and the method is non-invasive. But with the help of CT, you can detect minimal changes and obtain a three-dimensional image of internal organs, arteries and veins, joints and bones.

MRI anatomy of normal and sclerotic hippocampus

A-T2 coronal section: sclerosis of the right hippocampus, a decrease in its volume is determined, the absence of internal structure compared to the left hippocampus. B – the same section with explanations. The red line outlines the hippocampi (a decrease in the volume of the right hippocampus is visible), and the blue line outlines the subiculum on the left. The yellow line in the center of the hippocampus is drawn along the deep part of the hippocampal sulcus (in Figure A, this sulcus is not identified in the right hippocampus). FG – fusiform gyrus, ITG – inferior temporal gyrus. C – FLAIR coronal section showing decreased volume and hyperintense signal from the right hippocampus.

A fundamental point in understanding the electrophysiology of medial temporal lobe epilepsy is the fact that the scalp EEG itself does not reveal epiactivity in the hippocampus, which has been demonstrated in numerous studies using intracerebral electrodes, i.e. for the appearance of epiactivity on the scalp EEG in the temporal region, its distribution is required from the hippocampus to the adjacent temporal lobe cortex. At the same time, the main clinical manifestations of an attack in medial temporal lobe epilepsy are associated with the spread of epiactivity outside the hippocampus: déjà vu is associated with excitation of the entorhinal cortex, a feeling of fear - with the amygdala, abdominal aura - with the insula, oroalimentary automatisms with the insula and frontal operculum, dystonia in the contralateral arm - with the spread of excitation to the ipsilateral basal ganglia. These anatomical and electrophysiological features may cause the patient to have seizures that are very similar to temporal paroxysms, but actually have an extrahippocampal and extratemporal onset. As experience in the surgical treatment of temporal lobe epilepsy accumulated, it became obvious that removal of the medial structures of the temporal lobe makes it possible to get rid of seizures completely in 50–90% of patients, but in some cases the frequency of seizures does not change at all. Data from studies of electrical activity of the brain using intracerebral electrodes and analysis of unsuccessful surgical outcomes have shown that in some cases the reason for the persistence of seizures after removal of the SG is the presence of a larger epileptogenic zone that extends beyond the hippocampus. Brain regions anatomically and functionally associated with the hippocampus, such as the insula, orbitofrontal cortex, parietal operculum, and the junction of the parietal temporal occipital lobe, can generate seizures similar in clinical and EEG picture to temporal paroxysms. The concept of “temporal lobe epilepsy plus” (preferably temporo-peresylvian (Patrick really doesn’t like plus)) has been proposed to describe situations where hippocampal sclerosis exists along with the extratemporal seizure initiation zone. In this regard, it is important to determine the indications for invasive EEG studies in temporal lobe epilepsy caused by hippocampal sclerosis. Warning symptoms are a taste aura, an aura in the form of vertigo, and noise. Interictal epiactivity is most often localized bilaterally in the temporal regions or in the precentral region. Ictal epiactivity in temporal plus forms is more often observed in the anterior frontal, temporoparietal and precentral areas. Differential diagnosis of temporal lobe epilepsy from temporal lobe epilepsy plus, carried out by a qualified epileptologist, is key in planning surgical intervention and predicting treatment outcome.

Treatment of cerebral vascular sclerosis

Treatment tactics are aimed at eliminating vessel occlusion (if possible), stimulating the development of collateral circulation and preventing the progression of sclerosis with possible complications.

Treatment begins with adjusting the patient’s lifestyle - quitting smoking and drinking alcohol, increasing physical activity, correcting nutrition and monitoring blood pressure, blood sugar and cholesterol levels. Additional, but no less important, treatment methods include physiotherapy: balneotherapy, massage and other procedures prescribed by a doctor.

Physical activity should be appropriate for age and level of physical fitness, be regular and strictly dosed. It increases the supply of oxygen and blood circulation throughout the body. Physical exercise will help reduce cholesterol levels and weight if it is overweight.

Sensory impairment

A unique aspect of the symptoms of multiple sclerosis is the extremely common temperature sensitivity of patients whose neurological symptoms are temporarily aggravated by an increase (or decrease) in body temperature.

Heat sensitivity, or Uthoff's phenomenon, occurs in 60–80% of patients with this disease. An increase in body temperature may cause temporary deterioration, usually associated with exposure to a warm environment or exercise, and lasts until core temperature returns to baseline. However, a decrease in body temperature as a result of taking cold baths or exposure to low ambient temperatures can also provoke a worsening of the clinical picture of the pathology.

Episodes of temperature sensitivity among patients with sclerosis are also known as pseudoexacerbations or pseudorelapses. Although the increase in symptoms may be similar in nature to those that occur during an exacerbation, the worsening of the condition is not associated with the active progression of the disease and is temporary. Moreover, the symptoms return to normal when the internal temperature is restored. Therefore, the patient experiences significant difficulties in maintaining an appropriate level of physical activity

Drug therapy

The following groups of drugs are prescribed. Our specialists at the Yusupov Hospital will select the most suitable combination based on your medical history and examination.

• statins;
• antiplatelet agents;
• nootropics to improve cerebral circulation;
• antihypertensive drugs and drugs that lower blood sugar (if there is a concomitant pathology).

Statins are drugs that reduce certain fractions of lipids (in particular low- and very low-density lipoproteins), which are deposited on the walls of blood vessels. Antiplatelet agents increase blood clotting to prevent the accumulation of red blood cells on the atherosclerotic plaque. Thus, these two groups of drugs protect against recurrent sclerosis and the risk of stroke.

Nootropic drugs, in turn, have a stimulating effect on the integrative function of the brain. By regulating energy processes in cells, they fight hypoxia and also improve blood supply to the central nervous system. Taking nootropics improves the trophism of nervous tissue, which leads to increased brain activity, activation of operational and long-term memory and restoration of hemodynamics after a stroke or brain injury.

Antihypertensive therapy aims to lower blood pressure below 140/90 to prevent complications.

List of sources

• Schmidt T.E., Yakhno N.N. Multiple sclerosis. M.: MEDpress-inform; 2010;
• Korkina, M.V. Mental disorders in multiple sclerosis / M.V. Korkina, Yu.S. Martynov. G. F. Malkov. - M.: Publishing house UDN, 1986;
• Multiple sclerosis and other demyelinating diseases. Ed. E.I. Guseva, I.A. Zavalishina, A.N. Boyko. M.: Miklos. 2004;
• Gusev E.I., Boyko A.N. Multiple sclerosis: from studying immunopathogenesis to new treatment methods. M. 2001;
• Yakhno N.N., Shtulman D.R. Diseases of the nervous system: a guide for doctors in 2 volumes. M.: Medicine, 2001.

Diet for cerebral sclerosis

Diet No. 10C is prescribed, which consists of reducing the intake of animal fat, easily digestible carbohydrates and cholesterol, as well as salt to 5–7 grams per day. It is recommended to eat plant foods and seafood. The diet should include ingredients that contain B vitamins and vitamin C, dietary fiber, potassium, magnesium (vegetable oils, vegetables and fruits, seafood, cottage cheese). Ready meals should be fresh. Boiled food is preferred, sometimes baking is allowed. The food temperature is normal. Approximate composition of KBZHU: 2200-2600 kcal, proteins - 90-100 g (50% animal), fats - 70-80 g (40% vegetable), carbohydrates - 300-350 g (50 g sugar). Low numbers are recommended for comorbid obesity. Consume up to 1.2 liters of water per day, table salt - up to 7 g.

It is prohibited to consume any types of fatty, salty and spicy foods: fatty meats, fish, poultry, canned food, sausage, caviar, smoked and salted fish, butter and puff pastry, fatty dairy products, rice, semolina, pasta, various salty and spicy foods. snacks and sauces.

A sample menu for one day would look like this:

First breakfast: low-fat cottage cheese with a small handful of nuts and dried apricots, a protein omelet, weak tea.

Second breakfast: fresh apple.

Lunch: fresh cabbage soup, steamed meat balls (chicken), vegetable sauté, compote.

Snack: rose hip decoction, apple or pear.

Dinner: tomato and seaweed salad, baked fish and boiled potatoes, tea with lemon.

At night: a glass of 1% kefir.

Surgical intervention

Surgical treatment of carotid artery stenosis is recommended for patients with stenosis greater than 60% (NASCET). For this pathology, two types of surgical interventions are possible: carotid endarterectomy and carotid angioplasty. Surgical treatment is determined by the attending physician based on medical history, examination data and possible risks.

Carotid endarterectomy (CEA) is an open surgical procedure aimed at removing the inner wall of the carotid artery affected by atherosclerotic plaque. Technique of the operation: under anesthesia, an incision is made in the neck in the projection of the carotid artery. It is released and opened at the site of narrowing. A temporary shunt is placed to ensure blood flow to the brain. Then the inner part of the vessel wall with the atherosclerotic plaque is removed. Afterwards, plastic surgery of the artery is performed and the wound is sutured layer by layer.

Carotid angioplasty with stenting (CAS) is a minimally invasive X-ray surgery that involves installing a stent at the site of the narrowing. A stent is a tube made of a special metal mesh. The first stages of stenting are the same as for angiography: preparation, local anesthesia, puncture of the artery, insertion of a catheter and injection of a contrast agent. After installing a guiding catheter, a special metal filter is inserted into the affected carotid artery. Its essence is to delay possible microemboli that can break away from the plaque and enter the brain vessels. Then a stent is inserted along the guide, it is inflated by a balloon catheter, and it restores the normal diameter of the artery, serving as its frame. Thanks to this, proper blood supply to the brain is restored. The entire manipulation is carried out under X-ray control - everything is visible on the monitor. At the end of the operation, the filter and catheter are removed, leaving a stent inside. Over time, it epithelializes and becomes one with the wall.

After surgery, it is recommended to avoid intense exercise for six weeks. You should stop driving for three weeks.

Prevention of cerebral vascular sclerosis

Prevention consists of leading a healthy lifestyle, namely giving up bad habits, maintaining a work-rest schedule and a balanced diet. If you have diseases that can lead to sclerosis (diabetes mellitus, arterial hypertension), you should follow the instructions of your doctor.

All patients who have undergone surgery for carotid artery stenosis should be periodically observed by a neurologist and a vascular surgeon, and at least once a year undergo an outpatient examination with mandatory Doppler ultrasound of the vessels of the neck and head.

You can undergo examination and treatment for cerebral vascular sclerosis in Moscow at the Yusupov Hospital. The clinic’s doctors use the latest equipment to detect the disease at the initial stages. An individual approach to each patient consists of developing a personal treatment plan. Therapy is carried out in accordance with the latest European recommendations for the treatment of atherosclerosis. You can sign up for a consultation and ask all your questions by phone.

Disorders in the functioning of the pelvic organs

Sixty-eight percent of people with MS experience one or more types of pelvic floor abnormalities. Symptoms include loss or absence of bladder or bowel control: urinary incontinence, urinary frequency and urgency, bowel incontinence, sexual dysfunction, pelvic organ prolapse, and pelvic pain associated with a “spastic” pelvic floor.

The most common diagnosis among MS patients is a spastic (overactive) bladder. The organ is unable to hold a normal amount of urine in the bladder, which does not empty properly.

A spastic bladder is characterized by:

• private urination;
• hesitancy to start urinating;
• frequent night urination;
• urinary incontinence;
• inability to completely empty the bladder.

Healthy bladder function is important for long-term kidney health, infection prevention, personal independence, self-confidence and improved quality of life. Untreated bladder problems can cause:

• increasing weakness;
• Bladder and urinary tract infections (UTIs) or kidney stones, which cause serious pain and compromise your overall health;
• problems with work, home and social activities;
• loss of independence, self-esteem and self-confidence.

Early medical evaluation is important to determine the cause of bladder dysfunction and select appropriate treatments. More serious urinary problems can lead to blood and skin infections.