Plasma Exchange for Steroid-Refractory Relapses in Multiple Sclerosis: An Observational, MRI Pilot Study

Abstract

BackgroundNumerous studies have shown that plasma exchange (PE) is effective as second-line treatment of severe exacerbations of multiple sclerosis (MS) or other idiopathic inflammatory demyelinating diseases of the central nervous system that are nonresponsive to steroid therapy. ObjectiveThe goal of this study was to analyze the effect of PE on clinically active radiologic lesions in steroid-refractory relapses of MS and idiopathic inflammatory demyelinating diseases of the central nervous system. MethodsThis was a prospective, observational pilot study in which the primary end point was the degree of radiologic resolution of active lesions after PE. ResultsA total of 15 patients were included (median age, 36.9 years [age range, 21–67 years]; 60% women). Five (33.3%) of the 15 patients had relapsing-remitting MS, 2 (13.3%) had clinically isolated syndrome that presented with transverse myelitis, 2 (13.3%) had recurrent myelitis, 1 (6.7%) had transverse myelitis, 1 (6.7%) had longitudinally extensive transverse myelitis, 1 (6.7%) had acute disseminated encephalomyelitis, 1 (6.7%) had Baló's concentric sclerosis, and 2 (13.3%) had neuromyelitis optica. Mean increase on the expanded disability status scale scores due to relapses was 4.8 (2.53). After PE, 93.3% showed a marked to moderate clinical improvement, and 46.7% recovered their baseline expanded disability status scale score 3 months post-PE. On the post-PE MRI, 60% showed radiologic resolution (80% mass-effect lesions, 83.3% new-onset disease, and 100% neuromyelitis optica), 20% had partial resolution, and 20% no resolution. A significant relationship was not obtained between degree of resolution of radiologic lesions and the variables: clinical response to PE, new-onset disease, mass-effect lesions, number of PE sessions, and early initiation of PE. ConclusionA marked to moderate clinical improvement post-PE accompanied by a lack of radiologic resolution of the active lesion is not indicative of poor prognosis.