Rapid Improvement of Symptoms after Fibrinolysis in a Patient with Multiple Sclerosis Exacerbation (P3.405)

Objective: To describe a unique case of rapid improvement in multiple sclerosis (MS) exacerbation following fibrinolytic therapy. Background: Most demyelinating lesions in MS emerge around deep cerebral venules and are associated with fibrin deposition. Fibrin depletion ameliorates clinical symptoms in a mouse model for MS. We and others reported acute demyelinating lesions with restricted diffusion (ADLRD) seen on brain and spinal cord MRI in selected MS patients during clinical relapse. The pathogenesis of restricted diffusion is not clear but an ischemic process is possible. Design/Methods: The patient is a 38-year-old woman with relapsing-remitting MS treated with fingolimod. Her baseline neurological exam was significant for mild right hemisensory deficit and right hemiparesis. The patient developed acute onset of flaccid right-sided weakness and hypoesthesia involving the face, arm and leg. Due to rapid and fulminant onset of neurological deficit, she was suspected to have a stroke and received intravenous recombinant tissue plasminogen activator (rtPA, 0.9 mg/kg) at 227 minutes after symptom onset. The patient was followed with serial neurological exams and MRI. Results: Prior to rtPA treatment, her NIH Stroke Scale score was 9. The patient’s deficit rapidly improved in 5.4 hours after intravenous rtPA administration (NIH Stroke Scale score was 1, right upper limb drift). Brain MRI at 20 hours after symptom onset revealed a large (2.8×2.4 cm) symptomatic, contrast-enhancing ADLRD in the left centrum semiovale. However, the patient’s deficits deteriorated again by 21 hours from initial symptom onset with flaccid hemiplegia of the right side and NIH Stroke Scale score of 12. After a 5-day course of IV methylprednisolone followed by 5 sessions of plasmapheresis, she partially regained motor strength. NIH Stroke scale score on day 15 was 7. Conclusions: Rapid transient clinical improvement after a single infusion of rtPA during acute MS relapse suggests that fibrin is a potential therapeutic target in acute MS exacerbation. Study Supported by: N/A Disclosure: Dr. Balashov has received personal compensation for consulting, serving on a scientific advisory board, speaking, or other activities with TEVA, Genzyme. Dr. Balashov has received research support from Biogen. Dr. Dhib-Jalbut has received personal compensation for consulting, serving on a scientific advisory board, speaking, or other activities with TEVA, Genzyme. Dr. Dhib-Jalbut has received research support from TEVA, Biogen. Dr. Rybinnik has nothing to disclose.