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Multiple sclerosis

Multiple sclerosis is a chronic inflammatory disorder characterised by plaques of demyelination in central nervous system that cause neurological symptoms and disability.

Types of MS

  • Relapsing-remitting (85%): intermittent relapses with subsequent total or partial recovery
  • Primary progressive (15%): sustained, progressive disability from the start
  • Secondary progressive: 65% of people with relapsing-remitting MS will develop secondary progressive MS with sustained, progressive disability

Clinical features

Any part of central nervous system can be affected but common deficits include:

  • Optic nerve: reduced visual acuity, central scotoma
  • Medial longitudinal fasciculus: internuclear ophthalmoplegia (disorder of lateral conjugate gaze)
  • Cerebellum = DANISH
    • Dysdiadochokinesia
    • Ataxia
    • Nystagmus
    • Intention tremor
    • Speech abnormality (slurring/scanning/staccato)
    • Hypotonia
  • Spinal cord: spastic paraparesis, lower limb sensory loss, urinary symptoms

Investigations

Diagnosis requires demonstration of demyelinating lesions ‘disseminated in time and space’

  • MRI brain/spinal cord: shows demyelination
  • Evoked potentials: may reveal delayed visual/auditory/sensory potentials due to demyelination
  • Cerebrospinal fluid analysis: oligoclonal bands

Management

Management requires a multi-disciplinary approach (including neurologist, specialist nurse, physiotherapist, occupational therapist, GP, speech and language therapist)

Acute relapses

  • Methylprednisolone (IV or oral)

Preventing relapses (disease-modifying agents)

Suitable for some patients depending on type of MS:

  • Monoclonal antibodies: alemtuzumab, natalizumab, ocrelizumab
  • Oral therapies: sphingosine 1-phosphate receptor modulators (e.g. fingolimod, siponimod), teriflunomide
  • Platform injection therapies: glatiramer, β-interferon, fumarates (e.g. dimethyl fumarate)

Symptomatic management

  • Neuropathic pain: tricyclic antidepressants, gabapentin
  • Incontinence: intermittent self-catheterisation for overflow, anticholinergics for urge
  • Spasticity: physiotherapy, baclofen, gabapentin
  • Oscillopsia: gabapentin
  • Fatigue: exercise, diet, amantadine

Try some questions

What is oscillopsia?

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Does multiple sclerosis cause upper or lower motor neuron lesions? Why?

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What is Lhermitte’s sign?

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What are the clinical findings of a internuclear ophthalmoplegia due to a right medial longitudinal fasciculus lesion?

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