多發性硬化症(Multiple Sclerosis, MS)診斷

一、核磁共振(MRI)影像學掃描檢查
神經科醫師最喜歡運用MRI來診斷多發性硬化症,MRI是(核)磁共振的英語縮寫。
MRI是一種無痛的檢查手段,可以將腦部成像,清楚看到腦部的白色斑點(損傷),這些正是多發性硬化症的特點。
造影檢查:這個方法可以發現新的,活動性的感染硬化病灶和陳舊的硬化病灶。在靜脈注射造影劑,如釓,鑒別新、老病灶可以顯得更加容易。
 MRI有著優越的軟組織分辨能力,例如,對腦組織和脊髓的清晰辨別。MRI不使用X-射線,是在一個強大的磁場裏分辨組織。分辨出的影像資料被輸入電腦,然後轉化為影像。這種方法可以觀察到中樞神經系統部位的硬化斑塊,以及顯示硬化斑塊所處的位置和大小。
在疾病的晚期,神經纖維損傷的程度越來越大,此時,腦和脊髓開始萎縮,核磁共振(MRI)也可以觀察到腦萎縮的情況。通過MRI檢查發現,腦萎縮在疾病早期已經發生。
*MRI僅是檢查多發性硬化症的一種手段
MRI是多發性硬化症確切診斷最重要的實驗室檢查手段。同時,MRI提供了神經科醫生早期準確診斷MS的手段,但是,不可能和不可以僅僅依靠MRI就診斷多發性硬化症。
其他疾病在MRI上也可以引起中樞神經系統的改變,而且這些改變和多發性硬化症在MRI上的表現很一致。
*評估多發性硬化症的進展
除了幫助診斷MS,MRI在評估MS的進展上也有極大的價值。MRI中被發現的病灶數量和範圍和疾病的活動性密切相關。除了臨床觀察外,反復的MRI檢查可以長期跟蹤疾病過程,幫助醫生決定最佳和最合適的治療方法。
二、誘發電位(evoked potentials)檢查:其他被用來確切診斷多發性硬化症是一個電生理檢查。
誘發反應(人體會對外界刺激產生反應)可以反應出受損的神經系統在傳導神經資訊過程中所發生的延遲和中斷。髓鞘提供了神經纖維的絕緣功能和神經跳躍式傳導的生理基礎,在多發性硬化症中,髓鞘破壞會導致神經衝動傳導的阻滯。
以下內容列舉了一些典型的誘發反應試驗,這些試驗是在頭部周圍安置線圈製造局部磁場進行檢查。
誘發反應幫助診斷和評估多發性硬化症的進展
誘發反應(誘發電位)不會自主發生,而是在外來刺激下發生。
誘發反應在診斷和評估多發性硬化症的進展上有著重要臨床意義。當疾病的變化還沒有引起顯著的症狀和功能損傷時,誘發電位就可能已經發現了疾病的變化。即使處在緩解期,或者發生在數年以前的症狀,也可以用誘發電位檢查發現神經通路的病理改變。

在皮膚上可以被探測到神經和肌肉細胞所產生的電生理反應(電位)是不一樣的,例如:眼球震顫電描記法,就是腦細胞產生的可以被記錄的電活動的診斷方法。
誘發電位檢查有很多種類,所有這些檢查用來測試身體一個部位或者多個部位的反應。
 誘發電位檢查包括:
A Somatosensory evoked potentials(SSEP)體感覺誘發電位:主要做兩個部分:正中神經(median nerve)和脛神經(tibial nerve)
B Visual evoked potentials(VEP)視覺誘發電位
C Brainstem auditory evoked potentials(BAEP)腦幹聽反射誘發電位
各種誘發電位檢查的區別點如下:

1.視覺誘發電位(VER/VEP)檢測通過視神經通路的神經衝動傳導。電極接頭傳遞每一個針對視覺刺激的腦部反應。健康眼睛在刺激後100-120毫秒即產生反應。如果此反應產生延遲的話,則預示多發性硬化症存在的可能性。

資料來源:virtualmedicalcentre

資料來源:utah
2.聽覺或者聽誘發電位(AER/AEP)幫助神經科醫師發現聽覺或者聽神經上的感覺通路的紊亂,以及小腦和向心路徑的紊亂。
一個滴答聲通過耳機傳達到被測者的耳朵裏,在相應的枕部區域就可以測量電位。這個方法對於先前臨床上已經判斷沒有大腦功能紊亂的患者來說特別的重要。

資料來源:dizziness-and-balance.
A. I、II 波是由外耳到聽神經所產生的
B. II 到III 波是反映上橄欖核(superior olive)附近的區域
C. IV、V 波所反映的解剖位置並不一定,但可以知道是在上橄欖核之後,主要是外側蹄系(lateral lemniscus),有時候下丘(inferior colliculus)也在其中

資料來源:lsu
3.體感誘發電位(SSER/SSEP)通過對身體的特定部位,大多情況下是手和腳的觸覺進行檢測,包括這些觸覺衝動傳導到腦部情況的檢測。經常會用輕微的電衝動刺激脛神經通路上的腳踝處或者正中神經或者尺神經通路上的腕關節內側,以檢查相對應的腦部區域。
磁誘發電位 區別於先前討論幾種誘發電位檢查方法。
淺表的電極用來評估上臂和下肢肌肉反應,腦部不同部位對應手臂和下肢的肌肉功能。腦細胞受到的刺激和肌肉產生反應之間的有一個時間差,這個時間差可以被測得。刺激也可以在頸髓或者腰椎所在區域進行以區別衝動是通過大腦還是脊髓傳導。


資料來源:wikimedia
三、電腦斷層掃描(CT)
電腦斷層掃描(CT)是腦部專門的X-射線掃描檢查。圖像一旦被電腦技術處理,腦部正常組織和腦部任何變化都可以被觀察到。放射性和其他X-射線檢查如胸部X檢查幾乎一致。對於醫生來說,電腦斷層掃描(CT)對排除其他不是MS的疾病以及症狀和MS相似,但不是MS的疾病非常有用。
誘發電位
四、腰椎穿刺(Lumbar puncture)
為了獲得腦脊液,醫生往往進行腰椎穿刺。
雖然穿刺技術已經非常先進了,但是,腰椎穿刺經常使人感到恐懼,實際上,這個想法是有失偏頗的。
在局部麻醉下,在髂骨棘高度,用空心針在脊柱椎體突起部分之間(通過椎間隙)進針,進入椎管中央。進針至少6-10釐米,這樣可以避免對脊髓的傷害。
如果腦部和脊髓受到感染的話,腦脊液就會發生生化改變。在實驗室檢測腦脊液的成分並比對標準值。幫助醫生判斷中樞神經系統是否發生了免疫反應的紊亂。多發性硬化症患者的腦脊液感染細胞數目會增加。
(一) 第一管:送革蘭氏染色,細菌培養及抗生素敏感試驗。
(二) 第二管:送檢蛋白質,葡萄糖。
(三) 第三管:送檢細胞計數及分類。
(四) 第四管:送檢細菌抗原 ID test。
(五) 第五管:病毒培養,結核菌培養或黴菌培養,視情況而定。
資料來源:國防大學國防醫學院首頁
五、血液檢查
常規血液檢查,例如血細胞計數,肝,腎功能檢測對於多發性硬化症的診斷意義不大。多發性硬化症患者的檢測值往往在正常範圍內。但是,免疫系統特異性的血液檢查卻是有價值的。這些檢查被用來鑒別症狀和多發性硬化症的症狀相類似的其他疾病,例如感染性疾病或者免疫系統紊亂的疾病。其中,一個檢測白細胞的人類白細胞抗原的方法有時可以提供多發性硬化症診斷的根據。
資料來源:國立臺灣大學
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