Multiple sclerosis

• Multiple sclerosis (MS) is an important cause

of longterm disability in adults
• The lifetime risk of developing MS is about 1 in
400.
• The incidence of MS is higher in temperate
climates and in Northern Europeans, and the
disease is about twice as common in women
as men.
 Pathophysiology
• Genetic factors
• Enviromental factors
An attack of CNS inflammation in MS starts with the
entry of activated T lymphocytes across the blood–brain
barrier.

These recognise myelin-derived antigens on the surface of the

nervous system’s antigen-presenting cells, the microglia, and
undergo clonal proliferation.

The resulting inflammatory cascade releases cytokines

and initiates destruction of the oligodendrocyte–myelin
unit by macrophages.
• Histologically, the characteristic lesion is a
plaque of inflammatory demyelination
occurring most commonly in the
periventricular regions of the brain, the optic
nerves and the subpial regions of the spinal
cord
 Photomicrograph from
demyelinating plaque showing perivascular cuffing of blood vessel by
lymphocytes
 Brain MRI in multiple sclerosis. Multiple high-signal
lesions (arrows) seen particularly in the paraventricular region on T2
image.
 In T1 image with gadolinium enhancement recent lesions
(A arrows) show enhancement, suggesting active inflammation
 Clinical features
• A diagnosis of MS requires the demonstration
of lesions for which there is no other
explanation in more than one anatomical site
at more than one time.

• Around 80% of patients have a relapsing and

remitting clinical course of episodic
dysfunction of the CNS with variable recovery.
The peak age of onset is in the fourth decade
and onset before puberty or after the age of 60
years is rare.

There are a number of clinical symptoms and

syndromes suggestive of MS, some of which
may occur at presentation while others may
develop during the course of the illness
 Clinical features of multiple sclerosis

• Optic neuritis
• Relapsing and remitting sensory symptoms
• Subacute painless spinal cord lesion
• Acute brain-stem syndrome
• Subacute loss of function of upper limb (dorsal
column deficit)
• 6th cranial nerve palsy
 Clinical features of multiple sclerosis
Afferent pupillary defect and optic atrophy (previous optic
neuritis)
• Lhermitte’s symptom (tingling in spine or limbs on neck
flexion)
• Progressive non-compressive paraparesis
• Partial Brown–Séquard syndrome
• Internuclear ophthalmoplegia with ataxia
• Postural (‘rubral’, ‘Holmes’) tremor
• Trigeminal neuralgia under the age of 50
• Recurrent facial palsy
 Prognosis
About 15% of patients have a single attack of demyelination
and do not suffer further events, whilst those with relapsing
and remitting MS have, on average, 1–2 events every 2 years.

Approximately 5% of patients die within 5 years

of onset, whilst others have a benign outcome.

About one-third of patients are disabled to the point of

needing help with walking after 10 years, and this rises to
about 50% after 15 years.
 Investigations

• There is no specific test for MS, and the results

of investigation need to be considered in
conjunction with the clinical picture to make a
diagnosis of varying probability
 Investigations in a patient suspected
of having multiple sclerosis
MRI:Exclude other structural disease and
identify plaques of demyelination

VEP

CSF: IgG Index and Oligoclonal bands

 Management
The management of MS involves
Treatment of the acute episode
Prevention of future relapses
Treatment of complications
Management of the patient’s disability.
 The acute episode

• In a function-threatening exacerbation of MS,

pulses of high-dose methylprednisolone,
either intravenously (1 g daily for 3-5 days).
 Prevention of relapse
In relapsing and remitting MS, subcutaneous
or intramuscular interferon beta reduces the
number of relapses by some 30%, with a small
effect on long-term disability .

Glatiramer acetate has similar effects.

 Other treatment
Natalizumab,
Mitoxantrone
Cyclophosphamide.

Special diets, including a gluten-free diet or

linoleic acid supplements, and hyperbaric
oxygen therapy are popular with patients but
are of no proven benefit.
 Treatment of complications and disability
• Complication Treatment

Spasticity Physiotherapy
Baclofen 15–100 mg* (oral)
Dantrolene 25–100 mg*
Tizanidine 18–32 mg*
Intrathecal baclofen

Local (i.m.) injection of botulinum toxin

Chemical neuronectomy
Ataxia Isoniazid 600–1200 mg*
Clonazepam 2–8 mg*

Dysaesthesia
Carbamazepine 200–1800 mg*
Gabapentin 900–2400 mg*
Phenytoin 200–400 mg
Amitriptyline 10–100 mg
• Fatigue
Amantadine 100–300 mg*
Modafinil 100–400 mg*
Amitriptyline 10–50 mg

• Impotence
Sildenafil 50–100 mg/24 hours
Thank You