Multiple Sclerosis and other Neurological Conditions
Morgan Howells-Resendez, MD
Resident Physician
East Carolina University Health Medical Center
Greenville, North Carolina, United States
Ehime Abhulimen, BS
MS2
East Carolina University Brody School of Medcine
Apex, North Carolina, United States
Lindsay M. Ellson, DO
Resident Physician
ECU
Greenville, North Carolina, United States
Morgan Howells-Resendez, MD
East Carolina University Health Medical Center
Greenville, North Carolina, United States
Hemorrhagic Stroke in Multiple Sclerosis (MS) Patient
Case Description:
64-year-old female with bipolar disorder, depression, and MS presented with acute left-sided hemiparesis and hypertensive emergency, found to have right frontal intracranial hemorrhage with intraventricular extension. Neurosurgery recommended non-operative management and she was admitted to Inpatient Rehabilitation. Thorough review of imaging with neuro-radiologist noted probable chronic ischemic infarcts that had not been previously diagnosed. Given the lack of diagnosis of ischemic infarct prior to admission, her risk factors (tobacco use, hypertension) had not been aggressively managed.
Discussions:
MS is a chronic autoimmune-mediated disease that causes demyelination of the central nervous system (CNS) and takes many different forms (clinically isolated, relapsing remitting MS, primary progressive MS, and secondary progressive MS). Due to disruptions in the normal sensory, motor, and cognitive systems with significant neuroinflammation, these patients are at increased risk for multiple CNS diseases, including stroke. Several studies evaluating the incidence of strokes in MS have noted inconsistency due to diagnostic challenges on imaging. Patients are having missed stroke diagnoses as lesions on imaging are being mis-attributed to MS lesions, due to difficulty differentiating between similarly appearing ischemic infarcts and MS lesions on MRI. This also does not account for the likely variation in risk amongst different subtypes of MS.
Conclusions:
This case highlights a clear opening for improved collaboration amongst radiologists and care teams for closer reviews of imaging with associated thorough history to hopefully decrease the incidence of mis-labeled infarcts, and this enable teams to further evaluate stroke risk factors in patients with MS. Given the complexity of the disease process, further research is needed to truly evaluate the extent of increased risk for stroke in MS patients. Regardless of imaging findings, this case shows the value of regular cardiovascular risk evaluations and education in patients with MS as a type of preventive care.
