Multiple sclerosis



Multiple sclerosis (MS) is an autoimmune disease of the CNS characterized by:

  1. Chronic inflammation
  2. Demyelination
  3. Gliosis (scarring)
  4. Neuronal loss.


  1. Activated T cells disrupt blood brain barrier (type 4 hypersensitivity)
  2. Some B cells form myelin-specific autoantibodiies, causing demyelination (hallmark of MS).


Site of involvement (demyelination):

The classical 4 locations of MS lesions are :

  1. Periventricular
  2. Juxtacortical
  3. Infratentorial and
  4. Spinal cord.

Classical of MS is dissemination in space & time:

  1. Dissemination in space: Lesions in different locations
  2. Dissemination in time: Lesions at different stages of activity, i.e. (old + new) lesions.


  1. Earliest symptom: Sensory loss → Heat sensitivity (Uhthoff ’s symptom)
    • Uhthoff’s phenomenon is the worsening of neurologic symptoms in multiple sclerosis and other demyelinating conditions when the body gets overheated.
  2. Retrobulbar neuritis:
    • Gradual painful loss of vision
    • Optic disc margin is normal as the inflammation is behind the eyeball
    • Pain on attempted elevation (SR) / adduction (MR).
  3. Spasticity.


According to Harrison 20th, there are 3 types:

  • A. Relapsing MS (RMS)
  • B. Secondary progressive MS (SPMS)
  • C. Primary progressive MS (PPMS).



  • MAGNIMS imaging diagnostic criteria
  • Defined locations characteristic for MS:
    1. Periventricular (minimum 3 lesions)
    2. Cortical
    3. Infratentorial
    4. Spinal cord
    5. Optic neuritis.

B. CSF: Oligoclonal bands on liquid chromatograph: assesses intrathecal production of IgG.


  1. Dawson’s fingers: Areas of demyelination perpendicular to the sagittal surface of ventricle
  2. Open ring sign: It is a relatively specific sign for demyelination.

Severity grading: Expanded Disability Status Scale (EDSS)


  1. DOC of acute attack: Methylprednisolone
  2. Diesase modifying agents:
    1. Interferon β
    2. Glatiramer Acetate
    3. Fingolimod (sphingosine-1-phosphate [S1P] inhibitor)
    4. Natalizumab (Highly Effective): Humanized monoclonal antibody directed against the α4 subunit of α4β1 integrin, a cellular adhesion molecule expressed on the surface of lymphocytes. The major concern with long-term treatment is risk of PML, which increases in subsequent years of treatment.
    5. Ocrelizumab (humanized monoclonal antibody directed against the CD20 molecule present on the surface of mature B cells)
    6. Teriflunomide (inhibits the mitochondrial enzyme dihydro-orotate dehydrogenase, which is a key part of the pathway for de novo pyrimidine biosynthesis; thus limiting the proliferation of rapidly dividing T and B cells)
    7. Alemtuzumab (humanized monoclonal antibody directed against the CD52 antigen that is expressed on both monocytes and lymphocytes)
    8. Mitoxantrone (risk of cardiotoxicity & acute leukemia, rarely used now).


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