1. Multiple Sclerosis Abdulelah Nuqali Intern

3. DemyelinationCNSAquired Multiple Sclerosis Optic neuritis Acute Disseminated Encephalomyelitis Hereditary (Dysmyelinating) Periphral Nervous System

4. What is Multiple Sclerosis? Multiple Sclerosis (MS) is an acquired inflammatory demyelinating disease of the CNS (brain and spinal cord).

6. How Common is MS and Who Gets It? 8,000 – 10,000 new cases are diagnosed annually Affects nearly 500,000 individuals in the U.S. Occurs most frequently between ages 25 - 35 Affects women 2 to 3 times as often as men More frequent in populations native to areas further away from the equator Prevalence of MS in KSA is 4-8 cases per 100,000

7. What Causes MS? Unknown Genetics Environmental factors

8. Not Everyone with a Genetic Risk Will Develop MS – Why? Risk is modified by Environmental factors – Sunlight – Diet (e.g., vitamin D) – Other lifetime experiences (infections?)

9. Initial Presentation of MS Incidence (%) Optic nerve inflammation 14–29 Poor balance (ataxia)2–18 Dizziness (vertigo)2–9 Weakness10–40 Double visions (diplopia)8–18 Bladder, bowel dysfunction 0–14 Pain21–40 Sensory loss13–39

10. Other Common Symptoms of MS Fatigue Spasticity Sexual dysfunction Cognitive impairment –Generally occurs later in the disease

11. Multiple Sclerosis Clinical Subtypes Lublin FD et al. Neurology. 1996;46:907-911. Relapsing-remitting Primary-progressive Disability Time Disability Secondary-progressive Progressive-relapsing Time Disability

12. How Is MS Diagnosed? At least two episodes of symptoms – Occur at different points in time (DIT) – Result from involvement of different areas of the central nervous system (DIS) Absence of other treatable causes for the symptoms Results of neurological testing

13. Examples of MS Onset Case 1: 26 year old woman – Decreased vision in the right eye in 9/05 – Left leg numbness in 1/06 – Right face numbness, right arm and leg weakness in 4/06 – Left leg weakness in 8/06 Case 2: 45 year old man – Left arm weakness in 2/93 – Numbness below the waist in 4/07

14. How Is MS Diagnosed? Magnetic resonance imaging (MRI) CSF : slight mononuclear pleocytosis or elevated in protein Increase IgG ( elevated IgG index OR the presence of oligoclonal IgG bands ) Visual evoked potentials

16. The 2010 McDonald Criteria for Diagnosis of MS

17. How is MS Treated and Managed? Drug therapy – Treat new attacks (exacerbations) – Prevent the occurrence of future attacks – Slow or prevent disease progression – Treat the chronic symptoms of the disease Physical therapy Psychosocial support

18. Treatment of New MS Exacerbations Drug therapy – Corticosteroids – Intravenous immunoglobulin – Plasma exchange Physical therapy

19. Prevention of Future Attacks and Disease Progression Immune modulating drugs – Beta-Interferon – Glatiramer acetate – Humanized monoclonal antibodies Immunosuppressant drugs – Anti-cancer agents Combination therapies

20. Symptom Management – Examples SymptomDrug SpasticityBaclofen Trigeminal neuralgia & Dysethesias Carbamazepine Bladder HyperactivityAnti- Cholinergics ( oxybutynin ) Urinary retentionCholinergics ( Bethanechol ) FatigueSSRI ( fluoxetine )

21. Summary MS is a common inflammatory disease of the CNS that affects females more frequently than males. The cause of MS appears to be a combination of genetic and environmental factors. The symptoms of MS can be quite variable. MRI is a sensitive test for making the diagnosis of MS. Treatments are available for reducing the number of MS attacks and for slowing MS disease progression.