Polly: Can you have a clear MRI scan but still have MS?
Professor Gavin Giovannoni: Yes, you can. The reason I’m saying that is because, I assume the MRI’s referring to the brain…
Professor Gavin Giovannoni: …because sometimes you can have lesions in the spinal cord not picked up on a brain scan. Occasionally we have a small number of people where the brain and the spinal cord MRI is normal. The reason for that is lesions can cause symptoms that are microscopic, in other words, not picked up by the MRI of the brain, so the average lesion that’s picked up with the new scanners is about 4mm or larger. So some people could have tiny lesions causing symptoms or attacks that haven’t shown up on the MRI of the brain. I personally would feel uncomfortable making that diagnosis without other evidence, like a lumbar puncture with spinal fluid analysis, or electrical tests as well to support the diagnosis. Because you don’t really want to rush into a diagnosis in somebody and might get it wrong, because once you’ve got a label of MS, it affects your life forever and you can’t get insurance policies, it affects employment prospects, it changes your whole standing in the world. So my personal opinion is if somebody’s got normal MRI imaging, okay, and they had a high risk of getting MS, I’d rather say to them let’s just wait six or 12 months and if you have got MS it will almost certainly declare itself, another attack or something like that. So the MRI, you can have a normal MRI, it’s unusual, it’s less than two and a half per cent of patients. So it’s less than one in 40 people will have, at the beginning of the disease, a normal MRI.
Polly: Why do relapses sometimes takes months and months to show any sign of remission and why do people often never recover that much from them?
Professor Gavin Giovannoni: Well, what causes a relapse, first of all. So what causes a relapse is an inflammatory lesion, an MS lesion in a particular neuronal pathway. So, let’s say it’s in the pathway that controls the motor symptoms, walking, for example. So those inflammatory lesions actually damage the nerve fibres, they cut them and some of them die. So the recovery mechanism then is quite complicated. What happens is the damaged nerve fibres have to recover or repair themselves or existing nerve fibres have to put out what we call sprouting, they have to grow out another root, for example, to take over that function. That can take months, even up to years to occur. So the mechanisms of recovery take ages, so up to two years, so this is why I always tell people that they shouldn’t necessarily expect to recover from a relapse very quickly, it could take months or years, and also if the damage is severe there may not be full recovery, that’s why some people are left behind with some disability, because the recovery’s incomplete.
Polly: Okay. And if people take steroids to get over relapses, would it make a difference how quickly into the relapse they took the steroids as to how quickly they’d possibly recover?
Professor Gavin Giovannoni: Well, they do recover quicker, but the final outcome is the same, whether or not you have steroids or not makes no difference to the final outcome. What it does do, it speeds up the time to recovery. And we think the reason for that is around an acute, or a new MS lesion there’s lots of swelling, because there’s inflammation, and the steroids reduce the swelling, which allow some of the nerve fibres to start functioning earlier. So I think people with MS need to be aware that steroids doesn’t affect the final outcome, it just means you get to the final outcome a few weeks, literally two to three weeks earlier. Which is why I try not to use steroids.
Polly: Oh really?
Professor Gavin Giovannoni: Well, the reason is there are complications attached to steroids and some of those complications can be severe and irreversible. Now, one of the complications is a condition called AVN – avascular necrosis – where the blood vessel supplying the hip joint gets blocked and the hip joint dies. And the only treatment for that is to have a hip replacement, so that’s a serious complication of steroids, and I’ve had a few of my patients with that. And because of that I would rather them not have that complication so I try and avoid steroids. But obviously if the relapse is very severe and disabling or associated with a lot of pain, the risk benefit switches and you’ll offer steroids.
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Professor Gavin Giovannoni has an MBBCh, PhD, FCP (Neurol., SA), FRCP, FRCPath amongst his qualifications. He is the Chair of Neurology at Barts and The London School of Medicine. His research interests have focused around multiple sclerosis and inflammatory disorders of the central nervous system. His teaching focuses on clinical neurology and neuroimmunology.