ms clinical manifestations د.هشام عون

8/3/2019 MS clinical manifestations .

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Clinical manifestations of multiple sclerosis

Dr. Hesham Awn

Taiz 2010


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The clinical syndrome of MS is classicallydescribed as a relapsing remitting disorder that affects multiple white matter within theCNS, with usual onset in young adults.


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The varied clinical features reflect themultifocal areas of CNS destruction ,althoughdiscrepancies occur between the extent ofclinical and pathological findings .The high degree of variability and thedifficulty in predicting the causes and severitymake MS one of the most puzzling ofCNS diseases.


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Cognitive impairment

Cognitive impairment has beenunderreported in MS .neuropsychological test results have shownthat 34% to 65%of patients with MS havecognitive impairment.The most frequent abnormalities are with

recent memory ,attention ,and speed ofinformation processing.


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Affecting disorders:

Cross sectional studies have shown somedegree of affecting disturbance in asignificant number of patients with MS.Depression is the most commonmanifestation and is in part secondary to theburden of having a chronic ,incurable

disease, however , it is more prevalent in MSthan in other chronic diseases, suggesting anorganic component as well.


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Euopharia is infrequent and usuallyassociated with moderate or sever cognitiveimpairment .Patients may manifest a dysphoric state withswing from depression to elation.

Affecting disorders:


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Cranial nerves dysfunction

Impairment of visual pathways:

optic neuritis is the

most frequent type ofinvolvement of visualpathways.


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Although uncommon , homonymous fielddefects caused by involvement of the optic

radiations can be seen in MS.


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Impairment of ocular motor nerves is infrequent inMS , when present , the involved nerves are , indecreasing order of frequency : VI , III and IV .

More frequent findings are those that reflect lesionsof :

vestibulo-ocular connection acquiredpendular nystagmus.

internuclear connection internuclearophthalomplegia.



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Impairment of other cranial nerves: impairment of facial sensation, subjective or objective, isa relatively common finding in MS.Trigeminal Neuralgia in a young adult is frequently an

early sign of MS.Facial myokymia , hemifecial spasm, facial palsy.Vertigo is a reported symptom in 30 to 50 %of patientwith MS.

Malfunction of the lower cranial nerves is usually of UMNtype (pseudobulbar syndrome) and is usually a latefinding in MS.



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Impairment of the sensory pathways:

Sensory manifestations are a frequent initial featureof MS and are present in almost every patient atsome time during the cause of disease.

The sensory features can reflect spinothalamic,posterior column ,or dorsal root entry zone lesions.

the sensory symptoms are commonly described asnumbness ,tingling, pins and needle ,tightness,coldness ,itching or swelling of limb or trunk.


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Impairment of the motor pathways:

Corticospinal tract dysfunction is common inMS.

Paraparesis ,or parapligia ,occurs morefrequently than significant weakness in the

upper extremities.


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Impairment of cerebellar pathways

Cerebellar pathwayimpairment results ingait imbalance andother cerebellar signs.


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Impairment of cerebellar pathways

In sever cases complete astasia ,inability touse the arms because of a violent intention

tremor , and virtually incomprehensiblespeech may occur.


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Impairment of Bladder ,Bowel ,And sexual function

The extent of sphincter and sexualdysfunction often parallels the degree of

motor impairment in the lower extremities.


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Clinical features distinctive of MS

Although no clinical phenomena are entirely unique toMS , some are highly characteristic of the disease :

onset between the ages of 15 and 50 years.involvement of multiple areas of the CNS.optic neuritis.

internuclear ophthalmoplegia.Fatigue.Lhermittes phenomenon. Uhthoffs phenomenon.


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Diagnostic criteria:

The corner stone of the diagnosis of MS

remains the neurological history and physical examination.


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To improve the homogeneity of MS patientgroups being studied , the Schumachercommittee on diagnostic criteria of MS

elaborated six items required to diagnoseclinically definite MS.


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The criteria were modified in 1983 by Poserand colleagues expanding the age at onset to59 years and using data derived from

laboratory studies ,including analysis of theCSF, evoked potentials (EP) andneuroimaging.



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More recently (2005) ,McDonald andcolleagues proposed new criteria that includedetailed guidelines for MRI and timing

intervals to determine possible or definite MS.The outcome of a diagnostic evaluation iseither MS ,possible MS , or not MS.these criteria were designed for use in both

practice and in clinical trial.



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The common thread among all MS diagnosticcriteria has been the requirement forsymptoms and signs that are disseminated in

space and time (more than one episodeinvolving more than one area of the CNS).



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The patient early course who dose not meetdiagnostic criteria remains clinically challenging inthe setting of a monophasic neurological illness thatis clinically consistent with MS and accompanied bymultifocal white matter lesions on MRI consistentwith demyelinating plaques , the diagnosis of MS isalmost certain , this situation is referred to asclinically isolated syndrome.

Such patients would be classed as possible MS bythe latest diagnostic criteria.



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course

Four categories of disease are described: Relapsing remitting (RR) MS:clearly defined relapses with full recovery orwith squelae and residual deficit on recovery.The periods between relapses are characterized by a lack of disease

progression.


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course

Secondary progressive (SP) MS: Initial relapsing remitting disease course

followed by progression with or withoutoccasional relapses , minor remissions ,andplateaus.


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course

Primary progressive (PP) MS: Disease progression from onset with

occasional plateaus and temporary minorimprovement allowed.


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course

Progressive relapsing (PR) MS: Progressive disease from onset ,with clearacute relapses ,with or without full recovery.The periods between relapses are characterized by continuing progression.


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Differential diagnosis

The differential diagnosis of MS is quitelimited in the setting of a young adult withtow or more clinically distinct episodes of

CNS dysfunction with at least partialresolution.Problems arise with atypical presentations,

monophasic episodes , or progressive illness.


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A monophasic illness with symptomsattributable to one site of the CNS creates alarge differential diagnosis that includes

neoplasm , vascular event ,and infectious A appropriate imaging study may help claritythe situation ,depending on the site of

involvement and clinical progression.


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The most trouble arise with progressive CNSdysfunction ,in which great care must betaken to exclude treatable etiologies (vit B12 deficiency ,compression spinal cord lesion , arteriovenous malformation ,cavernous angioma ,Arnold-chiari malformation ) ,

infectious causes , and hereditary disorders.


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A common error to over interpret multiplehyperintense lesions on MRI as equivalent toMS . Clinical symptoms must be consistent

with MS.


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Features that should alert the clinician to the possibility of other disease include:

family history of neurological disease.a well- demarcated spinal level in the absence of disease above the foramen magnum.prominent back pain that persist.Symptoms and signs that can be attributed to one anatomical sites.Patients who are older than age 60 years or younger than 15 years at onset .Progressive disease .


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Non of this features excludes the diagnosis of MS, but these

situations one should seek other etiologies before accepting the diagnosis of MS.


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ms clinical manifestations د.هشام عون

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