Multiple Sclerosis

Abdulelah NuqaliIntern

What is Multiple Sclerosis?

• Multiple Sclerosis (MS) is an acquired inflammatory demyelinating disease of the CNS (brain and spinal cord).

MS is a Demyelinating Disease

Myelin – provides insulation to nerve processes (axons)

Blood vessel

Blood vessel

Blood vessel

Inflammation

Inflammation

Inflammation

Myelin – provides insulation to nerve processes (axons)

Blood vessel

Blood vessel

Blood vessel

Blood vessel

Blood vessel

Blood vessel

Inflammation

Inflammation

Inflammation

Inflammation

Inflammation

Inflammation

How Common is MS and Who Gets It?

• 8,000 – 10,000 new cases are diagnosed annually• Affects nearly 500,000 individuals in the U.S.• Occurs most frequently between ages 25 - 35• Affects women 2 to 3 times as often as men• More frequent in populations native to areas further

away from the equator• Prevalence of MS in KSA is 4-8 cases per 100,000

What Causes MS?

• Unknown• Genetics• Environmental factors

Not Everyone with a Genetic Risk Will Develop MS – Why?

• Risk is modified by Environmental factors– Sunlight– Diet (e.g., vitamin D)– Other lifetime experiences (infections?)

Initial Presentation of MS

Incidence (%)

Optic nerve inflammation 14–29

Poor balance (ataxia) 2–18

Dizziness (vertigo) 2–9

Weakness 10–40

Double visions (diplopia) 8–18

Bladder, bowel dysfunction 0–14

Pain 21–40

Sensory loss 13–39

Other Common Symptoms of MS

•Fatigue•Spasticity•Sexual dysfunction•Cognitive impairment

–Generally occurs later in the disease

Multiple Sclerosis Clinical SubtypesMultiple Sclerosis Clinical Subtypes

Lublin FD et al. Neurology. 1996;46:907-911.

Relapsing-remitting

Primary-progressive

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Progressive-relapsing

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How Is MS Diagnosed?

• At least two episodes of symptoms – Occur at different points in time (DIT)– Result from involvement of different areas of

the central nervous system (DIS)

• Absence of other treatable causes for the symptoms

• Results of neurological testing

Examples of MS Onset• Case 1: 26 year old woman

– Decreased vision in the right eye in 9/05– Left leg numbness in 1/06– Right face numbness, right arm and leg weakness in 4/06 – Left leg weakness in 8/06

• Case 2: 45 year old man– Left arm weakness in 2/93– Numbness below the waist in 4/07

How Is MS Diagnosed?

Magnetic resonance imaging (MRI)CSF :• slight mononuclear pleocytosis or elevated in

protein• Increase IgG ( elevated IgG index OR the

presence of oligoclonal IgG bands )Visual evoked potentials

Magnetic Resonance Imaging in MS

Spinal cordOptic nerve

Brain

Spinal cordSpinal cordOptic nerveOptic nerve

BrainBrain

The 2010 McDonald Criteria for Diagnosis of MS

How is MS Treated and Managed?

• Drug therapy– Treat new attacks (exacerbations)– Prevent the occurrence of future attacks– Slow or prevent disease progression– Treat the chronic symptoms of the disease

• Physical therapy• Psychosocial support

Treatment of New MS Exacerbations

• Drug therapy– Corticosteroids– Intravenous immunoglobulin– Plasma exchange

• Physical therapy

Prevention of Future Attacks and Disease Progression

• Immune modulating drugs– Beta-Interferon– Glatiramer acetate– Humanized monoclonal antibodies

• Immunosuppressant drugs– Anti-cancer agents

• Combination therapies

Symptom Management – Examples

Symptom DrugSpasticity Baclofen

Trigeminal neuralgia & Dysethesias

Carbamazepine

Bladder Hyperactivity Anti- Cholinergics ( oxybutynin )

Urinary retention Cholinergics ( Bethanechol )

Fatigue SSRI ( fluoxetine )

Summary• MS is a common inflammatory disease of the CNS

that affects females more frequently than males.• The cause of MS appears to be a combination of

genetic and environmental factors.• The symptoms of MS can be quite variable.• MRI is a sensitive test for making the diagnosis of

MS.• Treatments are available for reducing the number of

MS attacks and for slowing MS disease progression.