multiple%20sclerosis
MULTIPLE SCLEROSIS
Multiple sclerosis is an acquired chronic immune-mediated inflammatory disease of the brain and the spinal cord characterized by presence of multiple discrete areas of myelin loss within the CNS and subsequent axonal degeneration.
Affects more women than man; however, men are more likely to have a malignant clinical course.
A multiple sclerosis attack is usually characterized by any neurological disturbance with minimum 24 hours duration, in the absence of fever or infection.

Diagnosis

  • Consider sending patient to a neurologist who is experienced in diagnosing multiple sclerosis
  • There is no single test diagnostic for multiple sclerosis
  • Multiple sclerosis is defined clinically by:
    • Evidence from history and examination
    • Neurological investigations show lesions within the central nervous system that are disseminated in time and space

McDonald Criteria for Diagnosis of Multiple Sclerosis 2010

  • Should only be applied to patients presenting with a typical clinically isolated syndrome suggestive of multiple sclerosis or patients presenting with symptoms consistent with central nervous system's inflammatory demyelinating disease

Presentation

  • ≥2 attacks and ≥2 lesions or 1 lesion with evidence of a prior attack implicating a different site
  • ≥2 attacks, 1 lesion and dissemination in space demonstrated by:
    • Magnetic resonance imaging based on McDonald Criteria or
    • Further clinical attack implicating a different site
  • 1 attack, ≥2 lesions and dissemination in time demonstrated by:
    • Magnetic resonance imaging based on McDonald Criteria or
    • Second clinical attack
  • 1 attack, 1 lesion and with dissemination in space and time
    • Dissemination in space demonstrated by:
      • Magnetic resonance imaging based on McDonald Criteria or
      • Second clinical attack
    • Dissemination in time demonstrated by:
      • Magnetic resonance imaging based on McDonald Criteria or
      • Second clinical attack

McDonald Criteria for Diagnosis of Primary-Progressive Multiple Sclerosis (PPMS) 2010

  • 1 year of disease progression plus
  • 2 of 3 from the following brain imaging criteria:
    • Evidence of dissemination in space (DIS) in the brain: ≥1 T2 lesions in at least 1 area characteristic for multiple sclerosis (periventricular, juxtacortical or infratentorial)
    • Evidence of dissemination in space (DIS) in the spinal cord based on ≥2 T2 lesions in the spinal cord
    • Positive cerebrospinal fluid: evidence of oligoclonal bands and/or increased IgG index

Evoked Potential Studies

  • May also confirm dissemination in space in multiple sclerosis
  • Visual evoked potential (VEP) is the initial and most useful method; may identify patients with clinically definite multiple sclerosis
  • Considered positive if visual evoked potential is delayed but with well-preserved wave form

Lumbar Puncture

  • Usually needed to establish diagnosis
  • Considered positive for multiple sclerosis if evidence of ≥2 oligoclonal bands is present or an increased IgG index in the cerebrospinal fluid (CSF)
  • Positive findings can provide supportive evidence that the underlying disorder is inflammatory demyelinating 

 

Classification

Clinical Types of Multiple Sclerosis

Relapsing-Remitting Multiple Sclerosis (RRMS)

  • Patient experiences cycles of relapse and remission
    • Relapses are characterized by acute worsening of neurologic function
    • Relapses are followed by periods of remission within no disease progression
  • Patient may suffer residual deficit from relapse

Secondary-Progressive Multiple Sclerosis (SPMS)

  • At onset of multiple sclerosis, patient experiences relapsing-remitting multiple sclerosis
  • This is followed by progression with or without sporadic relapses, plateaus and minor remissions
  • Most patients who start with relapsing-remitting multiple sclerosis  will eventually convert to progressive disease

Primary-Progressive Multiple Sclerosis (PPMS)

  • Patients present with continuous worsening of disease
  • Disease does not have distinct episodes of relapses
  • Patient may have temporary minor improvements or plateaus

Progressive-Relapsing Multiple Sclerosis (PRMS)

  • Progressive disease occurs from course onset
  • Clear, acute relapses which may or may not resolve with full recovery
  • Periods in-between relapses have continuing disease progression

History

History and Physical Exam

  • Identify multiple sclerosis-related events
  • Evaluate mental, emotional, language functions, balance, vision, hearing, sense of smell, sense of touch, sense of taste

Imaging

Magnetic Resonance Imaging (MRI)

  • Preferred imaging of brain to detect the presence of lesions, plaques or scars caused by multiple sclerosis
  • More sensitive and specific for predicting evolution to clinically definite multiple sclerosis than other studies (eg Computed tomography scan, evoked potential studies, cerebrospinal fluid analysis)
  • Confirms dissemination in space and time typically found in multiple sclerosis
  • Dissemination in space is demonstrated by the following McDonald criteria1
    • ≥1 T2 lesion in ≥2 of 4 central nervous system areas: periventricular, juxtacortical, infratentorial, spinal cord
    • Gadolinium enhancement is not required
    • Lesions within the symptomatic region should be excluded in patients with brainstem or spinal cord syndromes
  • Dissemination in time is demonstrated by the following criteria1
    • A new T2 and/or gadolinium-enhancing lesion(s) on follow-up Magnetic resonance imaging, compared to a reference or a baseline Magnetic resonance imaging, irrespective of the timing of the baseline scan
    • Simultaneous presence of asymptomatic gadolinium-enhancing and nonenhancing lesions at any time

Evoked Potential Studies

  • May also confirm dissemination in space in multiple sclerosis
  • Visual evoked potential (VEP) is the initial and most useful method; may identify patients with clinically definite multiple sclerosis
  • Considered positive if visual evoked potential is delayed but with well-preserved wave form

Lumbar Puncture

  • Usually needed to establish diagnosis
  • Considered positive for multiple sclerosis if evidence of ≥2 oligoclonal bands is present or an increased IgG index in the cerebrospinal fluid (CSF)
  • Positive findings can provide supportive evidence that the underlying disorder is inflammatory demyelinating

Computed Tomography

  • Used only to exclude alternative diagnosis
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