Multiple Sclerosis (MS)

Multiple sclerosis (MS) is one of the most frequently encountered neurological diseases in young adults. It represents a chronic disease that causes inflammation in the white and the grey matter of the central nervous system and ultimately destroys myelin and axons. Myelin is like the plastic insulation around an electric cable and is the protective sheathing that insulates and protects the nerve cell fibres in the brain (axons), the optic nerve, and the spinal cord.

Initially, inflammation is transient and remyelination occurs but is not durable. Hence, the early course of the disease is characterised by episodes of neurological dysfunction that usually recover. However, over time the pathological changes become dominated by widespread microglial activation associated with extensive and chronic neurodegeneration, the clinical correlate of which can be a progressive accumulation of disability.

Based on the clinical disease pattern, four types of MS are recognised: relapsing–remitting MS (RRMS),(the most common and about 85%) primary progressive MS (PPMS),(15%) secondary progressive MS (SPMS), and clinically isolating syndrome (CIS)

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Risk Factors

The cause of multiple sclerosis (MS) has been intensively studied. It is conceptualised as a complex disease in which genetic and environmental factors act together to cause disease. It is thought to occur when the body’s immune system attacks itself.

Numerous potential causal factors including infection, immunisations, physical and emotional stressors, climate, diet, and occupational exposures have been studied using various observational study designs. It seems to be a disease of temperate latitudes globally and some geographical clustering has been noted in some studies fuelling the theory of a potential causative infective agent.

Among lifestyle factors, a high rate of smoking and a low mean BMI seem to be the most common risk factors. Recent studies have shown that a low vitamin D may increase susceptibility which may help to explain its absence from equatorial regions of the globe. (Ann Neurol 2007;61:288–299)

Symptoms

Multiple sclerosis (MS) is a chronic nervous system disease that produces various symptoms and signs and may in some cases lead to severe disability.

In addition to physical disability, disease-related symptoms such as bladder dysfunction, sexual problems and fatigue, strongly influence patients’ quality of life. Several studies have shown that MS patients have markedly lower quality of life than the general population, and also lower than patients living with epilepsy, diabetes, and rheumatoid arthritis and bowel diseases.

Symptoms management in multiple sclerosis is an integral part of its care. Accurate assessment and addressing the different symptoms provides increased quality of life among patients with multiple sclerosis. Multiple sclerosis symptoms may be identified as primary, secondary, or tertiary symptoms.

Primary symptoms, such as weakness, sensory loss, and ataxia, are directly related to demyelisation (nerve sheath) and axonal (nerve cell) loss.

Secondary symptoms, such as urinary tract infections as a result of urinary retention, are a result of the primary symptoms.

Tertiary symptoms, such as reactive depression or social isolation, are a result of the social and psychological consequences of the disease.

Common multiple sclerosis symptoms include fatigue and weakness; decreased balance, spasticity and gait problems; depression and cognitive issues; bladder, bowel, and sexual deficits; visual and sensory loss; and neuropathic pain. Less-common symptoms include dysarthria and dysphasia, vertigo, and tremors. Rare symptoms in multiple sclerosis include seizures, hearing loss, and even paralysis.

Detecting Multiple Sclerosis

The diagnosis of multiple sclerosis requires the constellation of clinical findings and various investigations.

Symptoms can initially be vague and can come and go. These have to be recognized early on and investigation and management needs to be individualized. The diagnostic criteria for MS have changed over time to include magnetic resonance imaging (MRI) of the brain. MRI findings are an integral part of the diagnosis and is the gold standard imaging modality. It may also detect other causes of ocular problems which mimic MS.

At Preventicum we routinely scan the whole brain very thoroughly and specifically look for early signs of MS with dedicated technical scan sequences (FLAIR sequences). We have found several clients to have MS over the years often at an early stage; sometimes prior to symptoms occurring and the sooner they can be referred to expert specialist care the better.

Early diagnosis means that early Disease-Modifying Therapies (DMTs) initiation can be accompanied by other appropriate steps to preserve brain tissue and optimize brain health (for example, exercise, smoking cessation and weight loss). This approach maximizes the chances of altering the disease course before further relapses or disability progression occurs. (Giovannoni, 2016)

MS1 (1)

Fig.1 Preventicum Brain MRI showing bilateral callosulcal interface confluent high signal intensity foci.

MS2

 

Fig.2 Preventicum Brain MRI demonstrating marked bilateral supratentorial white matter lesions.

Therapeutics for Multiple Sclerosis

Early intervention is vital. The earlier that MS can be diagnosed; the sooner treatment can be initiated.

Early Disease-Modifying Therapies (DMTs) may improve the long-term course of MS and reduce permanent neurological damage.

Recent studies have shown the efficacy of DMTs for reducing the rate of relapses in patients with relapsing-remitting MS (RRMS) and for slowing the course of MS progression, particularly when treatment is initiated early.

Symptom management includes non pharmacological methods, such as rehabilitation lifestyle modifications and psychosocial support, and an increasing selection of pharmacological methods, ie, medications and surgical procedures.

A great deal of research is currently taking place to try to develop new medicines to stop demyelisation from progressing. Several drugs trials are currently in progress and the sub classification of different types of MS is becoming more sophisticated which may lead to better more targeted bespoke treatments. The key to symptom management are awareness, knowledge, and coordination of care. The goal is to improve quality of life and promote realistic expectations and hope.

MS has historically been a disease to be feared and has in the past robbed many younger people of their true potential, but there is a great deal of research and drug development taking place to try to uncover the cause and eventual treatment of this often cruel disease.

 

This article was written by Sara Alves, one of our Radiographers at Preventicum London

 

 

 

Useful Websites

www.mssociety.org.uk

www.nationalmssociety.org

http://www.ms-uk.org/

References

  1. Frank Dowd, Neil S. Norton, in xPharm: The Comprehensive Pharmacology Reference, 2007
  2. Alberto Ascherio, Kassandra L. Munger, in Annals of Neurology, Environmental risk factors for multiple sclerosis. Part I: The role of infection, Volume 61, Issue 4 April 2007 Pages 288–299
  3. Miller DH, Grossman RI, Reingold SC et-al. The role of magnetic resonance techniques in understanding and managing multiple sclerosis. Brain. 1998;121 ( Pt 1) : 3-24.
  4. Giovannoni, G. Et al, Brain health: time matters in multiple sclerosis, Multiple Sclerosis and Related Disorders 9 (2016) S5–S48
  5. Munger, K. Et al, Serum 25-Hydroxyvitamin D Levels and Risk of Multiple Sclerosis, JAMA. 2006;296(23):2832-2838