Chapter 6

DEMYELINATIVE DISEASES

Demyelinative diseases of the central nervous system are characterized by loss of myelin with variable loss of axons. In contrast, infarcts, contusions, encephalitis, and other conditions destroy myelin and axons equally. The main demyelinative disease of the CNS is multiple sclerosis (MS) and its variants. Its counterpart in the peripheral nervous system is inflammatory demyelinative polyradiculoneuropathy (Guillain-Barré syndrome-GBS) and its chronic variants. MS and GBS are autoimmune inflammatory diseases. There are also virus-induced demyelinative diseases, such as progressive multifocal leukoencephalopathy. Demyelinative diseases should be distinguished from leukodystrophies, which are inherited metabolic disorders of myelin lipids and proteins.

MULTIPLE SCLEROSIS AND VARIANTS

MS is an autoimmune inflammatory disease of the CNS, which causes demyelination and variable axonal loss. It is characterized by multiple lesions (plaques) involving the brain and spinal cord and has an unpredictable clinical course.

MS affects one in every 500 persons, women twice as frequently as men. It is more common in young adults and causes a variety of neurological deficits (visual loss, paralysis, sensory loss, ataxia, brainstem signs, psychiatric disorders, dementia). Many MS cases evolve over a long period (20-30 years) with remissions and exacerbations. Some cases have an acute, fulminant, even fatal course, and others go into a relentlessly progressive phase after a period of remissions and exacerbations.

PATHOLOGY OF MS

The pathology is characterized by multifocal lesions, the MS plaques. The usual evolution of the MS plaque is s follows: in the acute phase, activated mononuclear cells, including lymphocytes, microglia, and macrophages destroy myelin and to a variable degree, oligodendroctes. Myelin debris are picked up by macrophages and degraded. At an early stage, macrophages contain myelin fragments; later, myelin proteins, and, at the end, lipids from chemical degradation of myelin lipids. This evolution takes a few weeks. With time, gliosis develops, and plaques reach a burned-out stage consisting of demyelinated axons traversing glial scar tissue. Remaining oligodendrocytes attempt to make new myelin. If the inflammatory process is arrested at an early phase, plaques are partially remyelinated. In more advanced lesions, remyelination is ineffective because gliosis creates a barrier between the myelin producing cells and their axonal targets. The pathological process may be arrested at any time, sometimes after partial demyelination.

The pattern described above is variable. In most cases, the inflammatory reaction subsides only to appear at another location or at another time. Some lesions expand at their periphery while activity in their center dies down. In fulminant MS cases, large lesions with diffuse activity develop and expand inexorably. Although myelin is preferentially affected, axonal loss is significant, and necrosis and cavitation may develop, especially in severe, acute lesions.


MS-perivascular lymphocytes

Perivascular lymphocytes in an active MS plaque.


MS plaque-myelin stain

MS plaque. Normal myelin stains deep blue.

In H&E stains, plaques appear pale compared to normal white matter. Active lesions are cellular because they contain inflammatory cells and reactive astrocytes. Biopsy diagnosis of acute MS, especially with stereotactic needle biopsies, may be tricky because cellularity and reactive astrocytes in the lesions may be misinterpreted as a neoplasm. Activity is often confined to the borders of plaques. Myelin stains show complete loss of myelin or pallor of myelin staining. The "normal appearing white matter" around MS plaques is not entirely normal but shows milder pathology.

Immunopathology. The inflamatory cells in MS include primarily CD8 T-lymphocytes, microglia, and macrohages. In addition, components of humoral immunity, including B-lymphocytes, plasma cells, immunoglobulins, and complement have been identified in plaques.

Grossly, MS plaques appear as irregular, sharply demarcated, gray areas in the white matter.


MS-periventricular plaques

MS. Periventricular plaques.


Spinal cord plaques

Demyelination of the spinal cord. The pale lesions are plaques. The deep blue areas are normal myelin.


Spinal cord plaques

Spinal cord plaques. Same patient as figure 6-4 at a different cord level

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They are usually multiple. Long-standing plaques are firm (sclerosis) because of gliosis. Plaques are randomly distributed. They have a predilection for the periventricular white matter, optic nerves, and spinal cord but spare no part of the CNS. They may involve gray matter such as cerebral cortex, deep nuclei, and brainstem. In these locations, they involve myelinated axons while sparing the neuronal bodies.

Because of the predilection of plaques for the optic nerves, most MS patients present with visual loss (optic neuritis). Spinal lesions cause paralysis and sensory loss (transverse myelitis). Usually, these patients have plaques elsewhere in the brain or develop them later. These other plaques may be clinically silent, whereas the optic and spinal lesions always cause symptoms.


Schilder's disease

CT. Diffuse demyelination in Schilder's disease. Reproduced with the permission of the Department of Radiology of Akron Children's Hospital.


Concentric sclerosis of Balo

Concentric sclerosis of Balo. Concentric rings of demyelination and preservation of myelin

Clinical and radiological variants of MS include tumefactive MS (characterized by a large, acute, tumor like lesion with cerebral edema and mass effect), Marburg type MS ( a form of tumefactive MS), and concentric sclerosis of Balo (another severe form of MS, with an unusual pattern of concentric rings of demyelination and partial preservation of myelin, which can be detected by MRI). The pathogenesis of this pattern is unclear. Schilder's disease is an acute relentlessly progressive form of MS seen most commonly in children and young adults. It causes extensive confluent demyelination instead of multiple focal lesions. This MS variant has been confused in the past with X-linked adrenoleukodystrophy. Neuromyelitis optica-NMO (Devic's disease) is a special monophasic or relapsing inflammatory demyelinative disease that causes transverse myelitis and optic neuritis. Formerly classified as a variant of MS, NMO is now recognized as an autoimmune encephalitis caused by antibodies directed against neuronal-glial surface antigens, specifically antibodies to the water channel protein Aquaporin-4 (AQP4), which is present in astrocytic processes along the BBB. A commercially available test, which detects NMO IgG in serum, distinguishes NMO from other inflammatory demyelinative diseases. NMO has diverse clinical manifestations besides optic neuritis and transverse myelitis, including intractable vomiting and pain.

IMAGING STUDIES

The best test for diagnosis of MS is MRI. Old plaques are hyperintense on T2-weighted and FLAIR studies. Active plaques are also show gadolinium enhancement. The latter correlates with inflammation and increased vascular permeability, and disappears after treatment (or with time), when the integrity of the blood brain barrier is restored. Mass effect, mimicking a malignant brain tumor, may also be present in acute MS (tumefactive MS). Schilder's disease tends to cause bilateral lesions that join across the corpus callosum, a feature seen also in some glioblastomas. MRI reveals “silent” plaques-usually around the lateral ventricles- in most cases. Advanced MS causes brain atrophy. Extensive periventricular plaques cause dilatation of the lateral ventricles.

CSF FINDINGS IN MS

CSF protein is moderately elevated, and there is mild mononuclear pleocytosis. The latter is a measure of the activity of the disease. Total protein exceeding 110 mg/dl and cell counts higher than 50/cubic mm make the diagnosis of MS unlikely. The IgG fraction is elevated above 11% of total CSF protein, especially in chronic MS. The IgG/albumin index in CSF is elevated in 90 percent of MS patients, including some who have normal total protein. Elevation of IgG/albumin index in CSF but not in serum means that IgG is produced inside the blood-brain barrier. Oligoclonal IgG bands are detected on agarose electrophoresis in 90% of patients. This pattern may be present even when the total amount of IgG is normal. Oligoclonal bands indicate that IgG represents antibodies to specific antigens. About 70% of MS patients and only 5% of controls have antibodies to measles. A smaller number have antibodies to rubella, mumps, and herpes simplex. Similar CSF changes are seen in some chronic CNS infections such as chronic measles encephalitis and syphilis. Myelin proteins such as myelin basic protein leak from plaques into the CSF and can be detected by radioimmunoassay.

ETIOLOGY-PATHOGENESIS OF MS

MS is thought to be an autoimmune disorder which is probably triggered by a viral infection. Genetic susceptibility and environmental factors play important roles in its pathogenesis.
Genetic factors:
The risk of MS in relatives of patients is 7 times higher than in the general population. Monozygotic twins are 25.9% concordant for MS; dizygotic twins are only 2.3% concordant. Genetic susceptibility is probably conferred by MHC molecules that modulate the immune response (particularly autoimmunity) and cell-cell interactions. MS patients express with high frequency certain class I and II HLA antigens, particularly DW2 and DR.

Environmental factors:The incidence of MS is higher in high latitude zones. Prevalence in the northern US is 4-6 times higher than in the South. Individuals who grow up in high prevalence areas retain the high risk even if they subsequently migrate to low-risk regions. These findings suggest that an unknown predisposing factor is acquired by prolonged exposure to some environments. Viruses, particularly measles and HTLV-1, have been suspected (but not proven) to be involved in the pathogenesis of MS.

There are several immunological abnormalities apparent in MS, including perivascular T- and B-lymphocytes, activation of T-lymphocytes, intrathecal immunoglobulin production, and the presence of immunoglobulins, complement, and cytokines in the plaques. Pregnancy, which causes a diffuse immunosuppression, suppresses MS activity. The disease flares up postpartum. Interferon (INF) gamma, which enhances the immune response, provokes MS attacks. Infections such as URIs stimulate secretion of INF gamma by immune cells and exacerbate MS. On the other hand, INF beta, which suppresses the immune response, decreases the frequency of attacks.

The first event in the pathogenesis of MS may be a viral infection in childhood. Activated T- lymphocytes generated during such an infection cross the blood- brain barrier and become sensitized to myelin antigens. Alternatively, lymphocytes are sensitized to viral proteins that may have some similarity to myelin proteins. How, after remaining latent for years, these lymphocytes re-enter the CNS and initiate an immune reaction against myelin is a subject of speculation. B-lymphocytes entering acute plaques become sensitized and produce antibodies to myelin antigens. Myelin, oligodendroglial cells, and axons are damaged by inflammatory cytokines, glutamate, NO, and other toxic substances produced by microglia/macrophages. While the agents of CNS damage are the same, the immune reactions that initiate and propagate the process may vary among different forms of MS.

PATHOPHYSIOLOGY OF MS

The neurologic deficits, in MS, are due to loss of myelin and axons. Demyelination causes loss of saltatory conduction. Linear conduction along demyelinated axons is slow because the internodal axon membrane has few ion channels. In addition, lack of insulation of axons allows impulses to disperse laterally to adjacent demyelinated axons. The abnormal physiology of demyelinated axons results in inefficient conduction or conduction block. This is reflected by abnormal evoked response potentials, an electrodiagnostic test that measures conduction velocity in the CNS. Loss of axons, which occurs during the acute inflammatory phase of the disease, explains the permanent disability.

While loss of function is easy to explain, clinical recovery is not. Remyelination is limited and does not fully explain the remissions. The neurological deficit from an acute MS plaque is caused not only by the loss of myelin and axons, but also by inflammation and edema that involve a wide area around the lesion. Even without remyelination, neurological function returns to some extent when the inflammatory reaction subsides and homeostasis is restored. In tracts that are partially involved by MS lesions, remaining axons may carry out the function. New ion channels may develop on axonal membrane, helping demyelinated axons conduct more efficiently. Conductivity in demyelinated areas is also influenced by electrolyte concentration and other changes in the extracellular fluid and by physical factors such as body temperature. These factors explain why the severity of neurological deficits fluctuates. Recovery probably depends on structural and functional reserves and on a potential for CNS repair and regeneration that we do not fully appreciate. Anatomical observations alone do not explain adequately the recovery seen in some MS patients. The autopsy is like a snapshot and is not ideally suited to follow the changes of an evolving disease. MRI imaging is better for this purpose.


Further Reading

Updated: July, 2014

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