MULTIPLE SCLEROSIS (MS)
Multiple sclerosis is a chronic autoimmune demyelinating disease of the central nervous system (CNS),
in which the immune system attacks myelin sheaths around nerve fibers, leading to impaired nerve
conduction and neurological deficits.
Etiology / Risk Factors
Autoimmune mechanism: T-cells attack myelin and oligodendrocytes in CNS.
Genetic predisposition: Family history increases risk.
Environmental factors:
- Low vitamin D levels
- Viral infections (e.g., Epstein-Barr virus)
Gender & age: More common in women, onset usually 20–40 years.
Geography: Higher prevalence in temperate regions.
Pathophysiology
Genetic & environmental trigger
Immune system activation
CNS inflammation
Demyelination
Axonal injury
Plaque formation
Disrupted nerve conduction
Clinical symptoms
Types of MS
1. Relapsing-Remitting MS (RRMS)
₋ Most common (≈85%)
₋ Acute relapses followed by partial or complete recovery
2. Secondary Progressive MS (SPMS)
₋ Follows RRMS in some patients
₋ Gradual worsening without clear relapses
3. Primary Progressive MS (PPMS)
₋ Progressive neurological decline from onset
₋ No relapses
4. Progressive-Relapsing MS (PRMS)
₋ Rare, progressive decline with occasional relapses
Clinical Manifestations
Motor symptoms: Weakness, spasticity, tremors, gait disturbances
Sensory symptoms: Numbness, tingling, pain, Lhermitte’s sign (electric-shock sensation down
spine with neck flexion)
Visual symptoms: Optic neuritis (blurred vision, eye pain), diplopia
Cerebellar symptoms: Ataxia, dysmetria, intention tremor
Autonomic dysfunction: Bladder/bowel disturbances, sexual dysfunction
Fatigue: Very common and disabling
Cognitive/psychological: Memory issues, depression, emotional lability
Diagnosis
1. Clinical Evaluation
History: Look for relapsing-remitting neurological symptoms:
₋ Visual disturbances (optic neuritis)
₋ Weakness or numbness in limbs
₋ Gait imbalance, spasticity
₋ Bladder/bowel dysfunction
₋ Fatigue, cognitive changes
Neurological exam: Detects objective signs of CNS involvement:
₋ Weakness, hyperreflexia
₋ Sensory deficits
₋ Lhermitte’s sign (electric-shock sensation on neck flexion)
₋ Gait abnormalities, cerebellar signs
2. MRI
MRI is the most sensitive paraclinical test for MS:
Brain MRI: T2 hyperintense lesions in characteristic locations:
- Periventricular
- Juxtacortical
- Infratentorial (brainstem, cerebellum)
Spinal cord MRI: Focal T2 lesions in cervical or thoracic cord
Contrast enhancement (Gadolinium): Active lesions enhance, showing DIT
Typical MRI criteria (McDonald 2017):
Dissemination in space: ≥1 T2 lesion in ≥2 typical CNS regions
Dissemination in time:
- New T2 or gadolinium-enhancing lesion on follow-up MRI
- Or simultaneous presence of enhancing and non-enhancing lesions on the same
MRI
3. Cerebrospinal Fluid (CSF) Analysis
Oligoclonal bands (OCBs): IgG bands present in CSF but absent in serum
Mild lymphocytic pleocytosis
Slightly elevated IgG index
CSF supports diagnosis, especially in atypical cases, but is not strictly required if MRI criteria are
met.
4. Evoked Potentials
Visual evoked potentials (VEP): Delayed P100 latency indicates prior optic nerve
demyelination
Can detect subclinical lesions
DIAGNOSTIC CRITERIA
Feature Requirement for Diagnosis
Clinical evidence of ≥2 attacks MS can be diagnosed if DIS is evident
Clinical evidence of 1 attack MRI or CSF evidence needed for DIS and DIT
Exclusion of mimics like neuromyelitis optica, sarcoidosis, B12
No better explanation
deficiency, etc.
EXCLUSION OF OTHER CONDITIONS
Vitamin B12 deficiency
Neuromyelitis optica spectrum disorder (NMO/NMOSD) – test AQP4 antibodies
Acute disseminated encephalomyelitis (ADEM)
CNS infections or vascular lesions
Complications
Permanent neurological deficits (motor, sensory, visual)
Spasticity and contractures
Falls and mobility issues
Bladder and bowel dysfunction
Cognitive impairment and depression
Management
1. Disease-modifying therapies (DMTs)
Aim: Reduce relapse rate and slow progression
Examples: Interferon-beta, glatiramer acetate, fingolimod, ocrelizumab
2. Symptom management
Spasticity → Baclofen, physiotherapy
Fatigue → Amantadine, energy conservation techniques
Pain → Gabapentin, pregabalin
Bladder issues → Anticholinergics, catheterization
Mobility → Physical and occupational therapy
3. Acute relapse management
High-dose corticosteroids (e.g., methylprednisolone)
4. Nursing care
Monitor neurological status
Assist with mobility and ADLs
Promote safety to prevent falls
Educate patient and family about disease course, treatment, and lifestyle modifications
