Neurologic University Clinic

Inflammatory brain illnesses include both, acute inflammations caused by agents such as bacteria, viruses or parasites and chronic inflammations classifying as autoimmune diseases such as multiple sclerosis or vascular inflammations (vasculites). The RKU gives inpatient treatment for the entire range of these illnesses. Acute bacterial meningitis constitutes a case of emergency requiring immediate diagnosis and antibiotic treatment often to be given under intensive care conditions. Inpatient diagnostics and therapy are also applied to cases of meningitis and encephalitis caused by viruses and other agents, as well as to acute attacks of multiple sclerosis, vascular inflammations and related diseases. Apart from CSF diagnostics performed by the RKU's CSF laboratory, imaging by NMR tomography is crucial to inflammatory diseases. Patients are later referred to the MS Outpatient Ward of the Neurological Clinic of Ulm University.

Contact:
PD Dr. Tumani
Senior Physician
Phone: 0731 177-1207
hayrettin.tumani@uni-ulm.de

Dr. J. Brettschneider
Phone: 0731/177-0

• Clinical picture, epidemiology and development
• Therapeutic strategies
• A. Stage therapy of episodic MS as recommended by the German consensus conference
• B. Symptomatic therapy
• C. Rehabilitation and aftercare

Multiple sclerosis (MS) is an acquired, chronic, inflammatory illness of the central nervous system (CNS) caused by an autoimmune attack against myelin and/or oligodendrocytes which generates demyelination foci in the brain and spinal cord. Every about thousandth person in Central Europe acquires MS. Most patients develop their symptoms between the ages of 18 and 50 years. Symptoms vary with the location of lesions listed for initial manifestation and decreasing frequency in the course of the illness: Impairment of the visual and oculomotor systems, pareses, paresthesiae, lack of coordination and functional bladder deficits.

MS breaks down into four types distinguished by the course taken by the illness (see figure). In most of the cases (approx. 85%), early stages of MS are characterisied by remittent episodes (episodes of neurological dysfunctions going on for weeks but receding almost entirely). Some of the patients can take a benign course (persistent remission or bland episodes), whereas the majority of patients are incompletely remittent after several episodes, developing a clinical progress independent of episodes (secondary chronic progression).

A minority of MS patients (approx. 15%) experience a slow increase of symptoms without ever having any episodes (primary chronic progression). The latter type of development is particulary probable if first symptoms appear after the 40th year of life. Episodic remittent developments mainly affects women at a ratio of 1.6:1, whereas primary chronic progression is found in slightly more men than women.

It remains unclear whether classical MS is a single illness or whether the different types of development classify as different entities of the illness. Another unclear point is how MS is related to the less frequent inflammatory and demyelinating CNS syndromes such as acute disseminated encephalomyelitis (ADEM), neuromyelitis optica (Devic syndromes), transverse myelitis, Balo's concentric sclerosis or the Marburg variant of acute MS.

Going by clinical and paraclinical criteria, an MS diagnosis classifies as "safe" or "probable" (table to follow). A crucial factor of MS diagnosis is the combination of episodic or slow progression of functional CNS disorders and multiocular symptoms which can be traced back to different cerebral regions. Diagnosis is backed up by supplementary examinations such as magnetic resonance tomography (MRT), evoked potentials (EP) of the visual, acoustic, sensory and motor systems as well as CSF analyses. MRT and EP will safely find multiocular lesions (including clinically silent lesions) in the brain and spinal cord. CSF analysis (identification of oligoclonal IgG bands and/or MRZ reactions) is able to confirm the finding of a chronic inflammatory genesis of these lesions. Differential diagnostics should be applied to exclude illnesses (subacute and chronic infections and autoimmune CNS disorders) showing a similar clinical picture.

The members of the medical advisory boards of the national MS associations in Germany, Austria and Switzerland have agreed on the first comprehensive evaluation of available therapeutic immuno-modulator options of treating MS. Obtain a copy of 'Nervenarzt' 4/1999 to read a comprehensive summary. With regard to a stage therapy of MS, the consensus conference for the European German-speaking region recommend the following empirical expert opinion (see table above to follow):

1. Immuno-prophylactic therapy based on a beta interferon preparation should start as soon as possible after multiple sclerosis of the episodic type has been found by clinically assured diagnosis.
2. Other alternative substances (e.g. copolymer-1, i.v. immunoglobulins, azathioprine) may replace the beta interferon preparation for initial immuno-prophylactic basic therapy, depending on the situation of an individual case.
3. If subcutaneously applied beta interferon produces intolerable side-effects, therapists may choose to apply beta interferons in a different way or to use another preparation of basic therapy instead.
4. If primary therapy based on beta interferon treatment fails, therapists should consider using another highly-dosed beta interferon preparation instead. Patients with very frequent episodes and sub-standard remission or patients where beta interferon-based therapy fails may be more successfully treated using Mitoxantron as a means of escalation therapy. Quickly progressing cases may require an additional escalation therapy based on cyclophosmamide, but not until the above types of therapy have been tried.

Symptomatic MS therapy plays an important role for everyday practice. It aims at removing existing neurological deficits as best as possible. Symptomatic therapy is also crucial to the current quality of life. Not every symptom is susceptible to therapy (e.g. pareses). In cases of spastics, ataxia and dysfunctions of the bladder, pharmaceutical application requires supplementary physiotherapy which will help to reduce the medication dose.

Spastics (most frequent symptom in the overall progress of MS)

• General: treatment of fever, infections, functional bladder/intestinal dysfunction
• Physiotherapy: stretching, active and passive movement, cooling, walking and supporting aids, hydrotherapy, contracture prevention.
• Medication: baclofen, tizanidine, dantrolene, tetrazepam, diazepam, memantine; creeping start and increase of dosage paying respect to side-effects.

Urination problems
At least 90% of patients experience urinary dysfunctions as a particularly obvious MS symptom during the overall progress of their illness. Initial actions consist of detailed anamnesis (liquid intake, frequency of urination, imperative urgency, relative incontinence, difficulties with starting to urinate, autonomous bladder, quality of urine, painful urination) followed by a functional urologic diagnosis (uroflowmetry and measuring of residual urine) as deemed necessary to safely distinguish different causes.

Ataxia and tremor
Permanent training, visual inspection, concentration, ergotherapeutic actcions, attaching weights or cuffs can substantially alleviate these symptoms. Beta blockers may prove useful for treating posture tremor. Intention tremor resists therapy even more than posture tremor.

Increased fatigue
Patients and their environment should be provided with detailed information about the "increased fatigue" symptom and how it is related to the body core temperature. They should be motivated to perform physical activity on a regular basis, start occupational therapy, avoid heavy meals, avoid frustration, and start behavioural therapy. Depressions should be treated (approx. 20% of MS patients).

Pain
Pain causes many patients considerable suffering. Some types of pain are primarily caused by MS (e.g. trigeminal neuralgia, dysesthesia). Secondary pain is a far more frequent effect of disability increasing due to MS (postural problems of the spinal column as caused by spastic contractures and joint stiffening, for example).

Comprehensive rehabilitation and aftercare, otherwise termed comprehensive long-term management, are a fundamental prerequisite of efficient treatment right from the onset through to advanced stages of the illness. Apart from providing patients with information about and drug treatment of the underlying disease, their general physical and psychological state and conditions of life should be assessed. Efficient help to MS patients requires that doctors, physiotherapists, ergotherapists, psychotherapists and, particularly, social workers keep cooperating with persons close to the patient. Patients should not be seen as passive objects of treatment but as active agents who can actively contribute to improving their own possibilities and general situation.