1. DR. SADIK AL-GHAZAWI
CONSULTANT NEUROLOGIST
MRCP, FRCP UK

2. numerous scars better known as
 The name multiple sclerosis refers to the
numerous scars better known as
( plaques or lesions) that develop on the
white & gray of the brain and spinal cord over time.
T & B cells disease.

3. Multiple sclerosis (MS) is a
1- Demyelinating in which the insulating covers of nerve
cells in the brain and spinal cord
are damaged.
2-This damage disrupts the ability of parts of the
nervous system to communicate, resulting in a range of signs  and symptoms.

4. 1- physical, mental and sometimes psychiatric
including,
1- physical,  mental and sometimes psychiatric
problems.
2-Specific symptoms can include-
double vision, INO, optic neuritis blindness in one eye,

5. muscle weakness,
trouble with sensation,
&troubles with coordination,
partial transverse myelitis,
or clinically isolated syndrome (CIS)
which 60 percent develop MS in 10 years. ,

6. Signs and symptoms (cont)
1-loss of sensitivity or changes in
sensation such as tingling, pins and
needles or numbness.
2-muscle weakness

7. 3- very pronounced reflexes.
4-muscle spasms, or difficulty in moving.
5- difficulties with coordination and balance (ataxia).

8. 6-problems with speech or swallowing.
7- visual problems (nystagmus ,optic neuritis  or double vision.
8-feeling tired, acute  or chronic pain, and
9-bladder and bowel difficulties,

9. such as depression or unstable mood are also common.
1110-difficulties thinking and emotional problems
such as depression  or unstable mood are also common.

10. 11-Uhthoff phenomenon, a worsening of
symptoms due to exposure to higher than usual temperatures,
12-Lhermitte,sign, an electrical sensation that
runs down the back when bending the neck, are particularly characteristic of MS.[

12. Rotatory nystagmus

13. Horizontal nystagmus

14. Ataxic gait

15. Intention tremor

16. 3-The disease usually begins between the
ages of 20 and 50 .
4- MS is twice as common in women as in man.  

17. CLINICAL COURSE
1-relapsing-remitting MS (RRMS).
secondary progressive MS (SPMS).
primary progressive MS (PPMS).

18. The relapsing-remitting subtype.
present.
--female predominant.
1- characterized by unpredictable rapid onset relapses
followed by period of months or years of partial or
complete recovery.

19. 1-Attack is a symptoms or objectively observed signs
suggestive demyelination process with duration of at
least 24 hours, in the absence of fever or infection.
2-For paroxysmal symptoms (such as paroxysmal
dysarthria, tonic spasms, or paroxysmal sensory
symptoms) to be considered an attack, must be recurrent over at least 24 hours.

20. 3-Once MS has been established ,we must
evaluate for evidence of dissemination in
space DIS (multiple areas) , and for
dissemination in time DIT(ongoing disease
activity over time).

21. 2- Deficits that occur during attacks may either
A-Resolve or leave problems  in about 40% of
attacks.
B-being more common the longer a person has had the disease.

22. 3- When deficits always resolve between attacks, this is
sometimes referred to as benign MS, although people
will still build up some degree of disability in the long term.

23. The primary progressive subtype=-
1- occurs in approximately 10–20% of individuals,
with no remission after the initial symptoms.
2- It is characterized by progression of disability
from onset, with no, or only occasional and
minor, remissions and improvements.

24. 1- 10% to 15%.
2-insidious onset of symptoms followed by gradual deterioration over time.
3-Clinical disease in these patients typically presents
as a progressive myelopathy, and less frequently as
a brainstem or cerebellar syndrome.

25. Older.
no clear gender predominance
MRI lesions :
fewer in number
less likely to enhance with gadolinium
compared to relapsing-remitting MS.

26. 3- The usual age of onset for the primary
progressive subtype is later than of the
relapsing-remitting subtype.
4- It is similar to the age that secondary
progressive usually begins in relapsing-
remitting MS, around 40 years of age.

27. Secondary Progressive Multiple Sclerosis

28. 1-25% to 40% of patients with relapsing remitting MS go on to
a secondary progressive course after an average of about 20 years.
2-diagnosed when, after an initial relapsing-remitting course,
a patient demonstrates disease progression independent of
relapses for at least 6 months.

29. 3-deterioration with respect to gait, balance,
spasticity, and bladder function ,Many
patients experience cognitive decline.

31. CLINICALLY ISOLATED SYNDROM (CIS)
1-the condition begins in 85% of cases
as clinically isolated syndrome (CIS) .
2--45% having motor or sensory problems.
3--20% having optic neuritis, and

32. 4--10% having symptoms related
brain stem dysfunction,
5-while the remaining 25% have
more than one of the previous
difficulties

33. ETIOLOGY of MS
The real cause of MS is unknown; however,
it is believed to occur as a result of some
combination of genetic and environmental
factors such as=-
1-infectious agents.

34. Similarly, viral infections such as the
common cold,  influenza
or gastroenteritis increase their risk.
2- Stress may also trigger an attack  

35. 2-Geography
1-MS is more common in regions with
northern European populations.
2-the geographic variation may simply
reflect the global distribution of these high-risk populations.

36. 1-the probability of developing the disease is
3-Genetics
1-the probability of developing the disease is
higher in relatives of an affected person,
with a greater risk among those more closely related. 

37. EXAMPLE identical twins both are affected about 30% of the time, while around 5% for non-identical twins and

38. 3-if both parents are affected the risk in their
children is 10 times that of the general population.
4- MS is also more common in some ethnic groups than others.

39. Pathology
Lesions
1-The name multiple sclerosis refers to the scars,
better known as plaques or lesions that form in the nervous system.

40. 2-These lesions most commonly affect
the white matter in the optic nerve, brain stem,
basal ganglia and spinal cord, or
white matter tracts close to the lateral ventricles.

41. Periventricular
Juxtacortical
Infratentorial
Spinal cord

44. 3- The function of white matter cells is to
carry signals between grey matter areas,
where the processing is done.
4-The peripheral nervous system is rarely involved.

45. DIAGNOSIS of MS
1-Multiple sclerosis is typically diagnosed based on
the presenting signs and symptoms, in combination
with supporting medical imaging and laboratory testing.

46. 2-It can be difficult to confirm, especially early
on, since the signs and symptoms may be
similar to those of other medical problems.

47. 3- The McDonald criteria, which focus on
Clinical ,laboratory, and radiologic evidence of
lesions at different times and in different areas,
is the most commonly used method of diagnosis .

48. bands of IgG \\on electrophoresis, which are
4-The cerebrospinal fluid is tested for oligoclonal
bands of IgG \\on electrophoresis, which are
inflammation markers found in 75–85% of people with MS. 

49. 5-The nervous system in MS may respond less
actively to stimulation of the optic
nerve and sensory nerves due to demyelination of such pathways.
These brain responses can be examined
using visual and sensory- evoked potentials.

50. TREATMENT.
Acute attacks
1-During symptomatic attacks,
administration of high doses
mg of intravenous corticosteroids such
as methylprednisolone, is the usual therapy for 3-5d,

51. 1-Optimal treatment response :complete return to the pre-relapse level of functioning.
2-lack of complete recovery warrant consideration of expeditious use of a second-line relapse therapy. 1

52. 3-Plasma exchange (every other day for at least 5 exchanges ),
cyclophosphamide,
intravenous immunoglobulin (IVIg),

53. Disease-modifying treatment.
Relapsing remitting multiple sclerosis
disease-modifying treatments have been approved by
regulatory agencies for relapsing-remitting multiple
sclerosis (RRMS) including: ,beta and 1a interferon
Mitoxantrone , fingolimid.   

54. low-dose interferon beta-1a (IM weekly).
High dose interferon beta-1a (subcutaneous 3 times a week).
Interferon beta-1b (subcutaneous every other day).

55. ORAL AGENTS Fingolimod

56. 1-sphingosine-1- phosphate receptor (S1P1) modulator and has immunoregulatory features.
2-inhibits the migration of T cells from lymphoid
tissue into the peripheral circulation and target
organs, including the CNS.
0.5 mg/day .

57. Side effects.
1-first-dose bradycardia, the possible risk of herpes
virus dissemination, macular edema, long-term
consequences of elevated blood pressure.
6-hour first-dose observation (FDO) includes hourly
vital signs as well as an ECG before treatment and at
the end of the 6-hour observation period.

58. 2-Treatment of clinically isolated syndrome (CIS)
with interferon decreases the chance of
progressing to clinical MS.

59. Associated symptoms treatment
1-Both medications and neuro-rehabiltation have
been shown to improve some symptoms, though
neither changes the course of the disease.

60. 2-Some symptoms have a good response to medication, such as an unstable bladder and spasticity, while others are little changed.