Multiple Sclerosis
Expertise in the management of multiple sclerosis (MS), the most common demyelinating disorder of the central nervous system, requires mastery of four distinct disease stages. A clinically isolated syndrome suggestive of MS is often challenging, as there
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linically Isolated Syndromes (CIS) Suggestive C of Multiple Sclerosis CIS is the most common initial presentation of MS. It is usually due to a single lesion or multiple simultaneous lesions of the central nervous system, though a thorough history may reveal prior events that suggest MS. Examples of CIS include:
Visual Loss Optic neuritis is one of the most common presentations of MS (see also Chap. 5). Typically, this condition is characterized by unilateral visual loss and a tugging retrobulbar pain which develops over several days. Eye movements and bright lights may exacerbate the eye pain. Visual acuity may be decreased to any degree, and color vision is often affected out of proportion to other vision modalities. A relative afferent pupillary defect is present in the affected eye. Ophthalmoscopic examination is usually normal at presentation, as most patients have retrobulbar optic neuritis.
Myelopathy Transverse myelitis is an inflammatory disorder of the white matter of the spinal cord that produces acute or subacute weakness, sensory loss, gait impairment, and urinary incontinence. The transverse myelitis most typical of MS is usually a partial myelopathy rather than a dense paraplegia (Chap. 17). A thoracic banding sensation, in which the patient describes tightness around the thoracic region, may occur. A sharp sensory level is not typical.
© Springer Nature Switzerland AG 2021 A. Tarulli, Neurology, https://doi.org/10.1007/978-3-030-55598-6_22
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Sensory Syndromes A variety of sensory syndromes may herald the onset of MS. Typical symptoms include numbness and a perception of abnormal vibration, or of pins and needles. Sharp, burning pains are a less common presenting symptom. Common locations of sensory system involvement include a single limb, both legs simultaneously, a band around the thorax, and in the distribution of the trigeminal nerve. Trigeminal neuralgia in a young person, especially when associated with trigeminal sensory loss, suggests MS. Lhermitte’s symptom occurs when forward flexion of the neck leads to an abnormal electrical sensation shooting down the back. It is secondary to cervical spinal cord lesions, especially MS, but is not pathognomonic for the disease.
Motor Syndromes Focal weakness is another common initial MS presentation. A lesion in the subcortical white matter or brainstem may produce weakness of the contralateral face, arm, or leg. Pontine lesions may lead to ipsilateral facial weakness which mimics Bell’s palsy. Patchy spinal cord lesions may result in ipsilateral monoparesis. Transverse myelitis, as noted above, may cause bilateral leg weakness.
Diplopia The classical pattern of diplopia in MS is internuclear ophthalmoplegia (INO) in which a lesion of the medial longitudinal fasciculus disconnects the contralateral abducens nucleus in the pons from the ipsilateral oculomotor nucleus in the midbrain (Chap. 6). Abduction of the contralateral eye is normal, while adduction of the ipsilateral eye is impaired. When INO occu
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