So, how do we begin?
How do you know?
You’re reading a chart of a patient,
you’re reading a clinical vignette.
How do you know the patient
has multiple sclerosis?
Things that you will be paying
attention to immediately,
unilateral visual impairment.
Once again, I emphasized unilateral
visual impairment, and this
is due to optic neuritis.
And so whenever you’ve heard
the team optic neuritis,
you should then translate into the
patient having difficulty with vision.
Or retrobulbar neuritis is frequently
the initial manifestation.
Now, we have to understand
in clinical practice,
you could have variants all the time, and
I’ll walk you through a few of those,
but at some point in time,
we have to know as to what is
the most common presentation.
Cranial nerve signs:
you could have
And then at some point in
time, the eyes, both of them,
start moving back and forth, back
and forth, back and forth maybe.
And at that point, you
might be thinking about
lesion to the internuclear
Please pay attention to
It’s a disorder of
conjugate lateral gaze
from interruption of fibers of the
medial longitudinal fasciculus.
INO, internuclear ophthalmoplegia;
MLF, medial longitudinal
Those are some clinical pearls there
that you want to pay attention to.
Spinal cord lesions, spasticity
and urinary incontinence
could also be part
of the syndrome.
But pay attention to, firstly,
what is the initial presentation,
and you’re paying attention to
different behaviors of the eyes, huh?
nystagmus or the conjugate
gaze type of issue,
and that’s your internuclear
Let’s move on.
Other clinical features that
you want to keep in mind.
One is called Lhermitte’s sign.
It’s a shock-like sensation that goes
up and down the spine from the neck,
either due to flexion or extension.
Shock-like sensations that is
moving up and down the spine,
not a very good sensation.
And you have another one
called Uhthoff’s phenomena.
Now, Uhthoff here, you’re looking at
symptoms typically are going to get worse
upon exposure to
So, maybe when taking a
hot bath or hot shower.
These are particular clinical
manifestations of multiple sclerosis.
Well, what may then cause it?
Well, it is kind of difficult to pinpoint
exactly as to what the etiology is.
However, environmental, perhaps, genetics
have been shown to play a possible role.
Immunologic factors as well, all
implicated in pathogenesis.
The peak incidence: Very much pay attention
to young, young, young patients, please.
And that’s unfortunate.
So imagine that this patient has the
most common in clinical course,
which is what again?
The remission and the
relapsing type of course
with steady progression
over a period of time.
And every time that there’s a relapsing
course, what then happens, please?
Yes, unfortunately, the symptoms
here are going to get worse.
And the peak incidence here is only
between 20 to 30 years of age,
So therefore, onset in childhood:
much below, let’s say 20,
if it’s a child at age of 10,
or above the age of 50, extremely
rare to find multiple sclerosis.
However, the peak incidence
is between your 20 and 30.
May become clinically
apparent at any age though.
So, even though you might start young,
it all depends on the
variants of clinical courses.
Risk is 15 times higher when disease
is present in a first-degree relative.
So therefore, there is some
evidence of family history as well.
It is much more common in Caucasian.
And in the Caucasian population,
it will be women that are
affected more so than men.
Let’s talk about the pathology.
What then happens here?
The white matter.
In the brain.
That’s where you begin, please.
White matter undergoes
and you could have primary
and secondary, very unclear,
so we’ll focus on the primary.
Now, with these white matter lesions,
which I’ll show you in a second,
multiple, hence the
name multiple, okay?
It’s the fact that the neurologic
deficit, which is separated in what?
Time along with
separation in space,
which is represented by the white matter
deterioration called these plaques.
Now, these plaques
commonly occur where?
Beside the lateral ventricle.
Picture that for me and I’ll
show you an image in a second.
So around the lateral ventricle is
where you’d expect these plaques.
What do the plaques represent?
Destruction of the white matter.
It may be demonstrated to follow the
course of your paraventricular veins,
and we call this
Don’t worry so much about the name
but understand that this has shown,
interesting enough, where it follows the
course of the paraventricular vein.
So, very close to the lateral ventricles.
Plaques may also be found
in the brain stem,
spinal cord, and of course, the
optic nerve, all representing what?
the white matter.
What’s the initial
presentation most commonly?
Impaired vision, which
is called technically?
So what about the location?
Well, as you can see in the image
here, you got these plaques,
and these plaques
are located where?
Around the ventricles.
It may then follow what kind of pattern?
Around the paraventricular veins,
and we call this Dawson’s Fingers.
Optic nerve could also be found, brain
stem, and then also spinal cord.
Remember, you could, at some point in time,
also have those shock-like
lesions up and down the spine,
and it could also be
sensitive to temperature
in terms of hot shower or hot bath.
Keep those in mind,
Multiple sclerosis only affects
the central nervous system.
That’s important for you to
understand, CNS much more so.