Multiple sclerosis

Posted On May 10, 2020

Multiple sclerosis (MS) is the most common demyelinating disease of the central nervous system. Symptoms are highly variable. A very brief summary is is follow.

Types

  • Clinically isolated syndrome
  • Relapsing remitting MS
  • Secondary progressive MS
  • Primary progressive MS

Features suggestive of MS

  • Relapses and remissions
  • Onset age 15-50 years old
  • More typical presentations:
    • Optic neuritis
    • Lhermitte sign – electric shock like sensation down the back on neck flexion
    • Internuclear ophthalmoplegia
    • Fatigue
    • Heat sensitivity

Common signs and symptoms

  • Sensory symptoms in limbs 31%
  • Visual loss 16%
  • Subacute motor weakness 9%
  • Diplopia 7%
  • Gait disturbance 5%
  • Acute weakness 4%
  • Balance problem 3%
  • Facial paresthesia 3%

Clinically isolated syndrome

  • Unilateral optic neuritis
  • Painless diplopia
  • Brainstem or cerebellar syndrome
  • Partial transverse myelitis

EDSS form

Diagnosis

  • 2 or more clinical attacks
  • Objective evidence of 2 or more lesions
  • No other cause to explain the above

Tests

  • MRI head, spinal cord wo and w contrast
    • Typical findings
      • White matter lesions: Periventricula and juxtcortical regions, corpus callosum, pons, cerebellum, spinal cord
      • Periventricular lesions at right angle to corpus callosum
    • Enhancing lesion usually disappears after a few weeks., median 2 weeks
      • Persistence of the enhancing lesion may suggest other causes
  • CSF
    • WBC rarely > 50, mostly lymphocutes
    • Oligoclonal bands: up to 95% of patient clinically definite MS
    • Increased IgG index
  • Evoked potential
  • AQP4: if positive, suggest NMOSD

Differential diagnosis

  • Acute disseminated encephalomyelitis (ADEM)
  • Neurosarcoidosis: meningeal, nerve root enhancement
  • Vasculitis
  • Progressive multifocal encephalopathy (PML)
  • Neuromyelitis optica spectrum disorder (NMOSD)
  • Microvascular disease
  • Migraine
  • SLE, Sjogren syndrome, polyarteritis nodosa
  • Syphilis, HiV