An Illustrated Pocketbook of Multiple Sclerosis

An Illustrated Pocketbook of Multiple
Sclerosis
An Illustrated
Pocketbook of Multiple
Sclerosis
Charles M.Poser, MD, FRCP, DMS
Department of Neurology,
Harvard Medical School and Beth Israel
Deaconess Medical Center, Boston,MA,
USA
The Parthenon Publishing Group

International Publishers in Medicine, Science &
Technology
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Library of Congress Cataloging-in-Publication Data
Data available on application
British Library Cataloguing in Publication Data
Poser, Charles M.
An illustrated pocketbook of multiple sclerosis
1. Multiple sclerosisDiagnosis 2. Multiple sclerosis
Treatment
I. Title
618.929
ISBN 0-203-48749-4 Master e-book ISBN
ISBN 0-203-59620-X (Adobe eReader Format)

ISBN 1-84214-141-4 (Print Edition)
Copyright 2003 The Parthenon Publishing Group
No part of this book may be reproduced in any form without
permission from the publishers except for the quotation of brief
passages for the purposes of review
Composition by The Parthenon Publishing Group
Contents
Introduction
Epidemiology and genetics
Etiology
Pathogenesis
Pathology
19
Physiology
33
Clinical aspects
34
Clinical course
35
Diagnosis
38
Diagnostic criteria
38
The newMSdiagnostic criteriaof McDonald
39
Optic fundus and visual fields
39
Confirmatory laboratory procedures
39
Examination of cerebrospinal fluid
41
Evoked potential studies
47
Neuroimaging
49
Magnetic resonance imaging
53
Imaging differential diagnoses
59
Single photon emissioncomputed tomography
62
Positron emission tomography
63
Treatment
83
Conclusion
84
Bibliography
85
Index
90
Introduction
Multiple sclerosis (MS) has fascinated physicians ever since it was

first described. Its extraordinary clinical variability and its
unpredictability, when added to the complexities of the immune
system alterations believed to play an important role in its
development, may explain why it has attracted such great
interest. Its importance is underlined by the fact that it affects two
million people world-wide. The disease has been known for over
160 years but, despite enormous expenditures of time and money
on research, many aspects of its pathogenesis are still unknown.
There is, as yet, no clear understanding of the etiology and risk
factors, and of the meaning of much epidemiological data. Most
importantly, fully effective modes of prevention and treatment
remain elusive. Because it affects men and women in their most
productive time of life, and may cause the end of a promising
career or a happy marriage, it is often viewed as a devastating
illness that can rarely be helped with treatment. Most acute bouts
can be rapidly and effectively terminated and there are many
symptomatic measures available that can significantly improve
the comfort and quality of life of patients with MS. Long-term
treatment has now become available, but, while these drugs
reduce the number of relapses, it is not yet clear if they have a
significant effect on the progress of the disease. Fortunately, only
a minority of patients are rendered severely disabled by the
disease. There is still much to be learned about MS, but progress
has been made, particularly in regard to the reliability of available
diagnostic methods, as well as our understanding of its pathology.
Multiple sclerosis is an acute inflammatory disease that causes
focal demyelination of the brain and spinal cord; it also causes
axonal loss. There is evidence for limited remyelination of
indeterminate significance. The disease is characterized by
dissemination in space and time. The lesions involve separate
parts of the central nervous system and thus signs and symptoms
cannot be ascribed to a single lesion. In addition, its clinical
2 AN ILLUSTRATED POCKETBOOK OF MULTIPLE SCLEROSIS
course is most often characterized by exacerbations and

remissions. The usual age of onset is in the third or fourth
decade. In that age group, MS is second only to epilepsy as the
most common disease of the central nervous system (CNS). With
rare exceptions, MS does not involve the peripheral nervous
system.
Epidemiology and genetics
Multiple sclerosis is not evenly distributed throughout the world.

For many years, it had been suggested that the prevalence of MS,
in Europe in particular, was directly related to latitude: the
further from the equator, the more common the disease. However,
wide variations in prevalence between geographical areas of
similar latitude prove this idea to be incorrect, except for the yet
unexplained observations that Tasmania has a prevalence of MS
twice that of southern Australia, despite the fact that the
populations in these two areas have essentially identical ethnic
origins.
The north-south gradient that has been repeatedly
demonstrated in the United States is derived from the fact that the
proportion of multiple sclerosis patients in the population of
people of Scandinavian descent, who seem to have a special
susceptibility, is considerably higher in the northern tier of states
than in the southern. A similar gradient, but at a somewhat lower
level of prevalence, is apparent in black American MS patients
(Figure 1). This may also be explained by the existence of a
gradient, going from the south to the north, that shows an
increasing admixture of Caucasian genetic material in black
Americans, as measured by blood groups.
Three independent epidemiological studies of MS in immigrants
to South Africa, Hawaii and the West Coast of the United States
have all indicated that the disease is acquired some time before
puberty. Therefore, putative dates of acquisition rather than dates
of clinical onset of the disease are more important. This is well
illustrated by the reports of epidemics of MS. Epidemics of MS are
said to have occurred in Iceland and in the Faroe Islands as a
result of a cryptic infection brought by British troops during World
War II, but recalculation of the data on the basis of age of
acquisition revealed that the peak incidence occurred before the
arrival of these troops. This has not prevented the
repeated
references to these alleged epidemics in textbooks and articles.
Figure 1 Prevalence of multiple sclerosis in blacks compared with whites

in the USA. Note that the percentage of racial admixture in blacks, based
on blood group studies, parallels the rate of prevalence in blacks.
Modified from Poser, 1992; reproduced with the permission of Elsevier
Science BV
Racial or ethnic origin plays an important, but not exclusive,

role in determining susceptibility to the disease. No convincingly
documented cases of MS have ever been reported in North and
South American Indians, Eskimos, Lapps, Australian aborigines,
Maoris, Polynesians, Melanesians, and Micronesians. The disease
occurs much less frequently in Orientals and extremely rarely in
black Africans. Because of these indications, numerous studies of
genetic markers have been carried out but, to date, few secure
candidates or regions have been identified. Many studies of the
class II major histocompatibility complex (MHC) alleles of the
human leukocyte antigen (HLA) system and their genotypes have
been carried out. Some of these have suggested an association
between the MHC alleles DR15 and DQ6 (DRB1*1501 and DBQ2
*0602) and the gene for tissue necrosis factor encoded within the
same linkage group. A specifically different 10 association (with
DR4 and its DRB1*0405DQA1*0301DQB1*0302 genotype) is
seen in Mediterranean populations, primarily Sardinians.
There is a familial occurrence rate of about 15%. The ageadjusted risk is higher in siblings (3%), parents (2%), and children
(2%) than for second and third-degree relatives. There is only a
35% concordance in monozygotic twins, but it is the same as in
siblings for dizygotic pairs. Children of conjugal pairs with MS
have a much higher rate (20%), but adopted offspring or other
AN ILLUSTRATED POCKETBOOK OF MULTIPLE SCLEROSIS 5
non-biological relatives have no increased risk. There is strong

evidence to suggest that MS is a poly-genic disease.
In addition to the crucial genetic factor, there is also an
important environmental influence. This has been shown by a
number of reliable investigations such as the one that showed
that Frenchmen living in Africa have a considerably lower
prevalence rate compared with Frenchmen living in France. The
children of West Indian and Asian immigrants to the United
Kingdom are said to have the same levels of incidence and
prevalence as native-born Englishmen, and the Israel-born
children of both Ashkenazi and Sephardic Jews appear to have
the same prevalence rates, although the European-born parents
of the former have a much higher prevalence rate than the Asian
and African-born parents of the latter. The situation in Hawaii
illustrates what appears to be the interplay between genetic and
environmental influences. For subjects of Japanese extraction
living in either Hawaii or the mainland United States, the
environment appears to increase the risk of acquiring MS
compared with that of those living in Japan. For Caucasians,
however, being raised in or moving to Hawaii appears to offer
some protection against MS. This strongly supports the idea that
environmental factors vary from place to place and affect
susceptible populations in different ways. A large number of
studies on an enormous variety of possible agents and factors that
could conceivably influence the acquisition or development of the
disease have been carried out in many countries, with an almost
total lack of results. Most of the agents and factors are really
meaningless since they are completely lacking in biological
plausibility. In summary, epidemiological studies have
demonstrated the primary importance of genetic factors modified
by as yet unrecognized environmental influences.
Etiology
Multiple sclerosis has been described as a disease of unknown

etiology, implying the existence of a single causal organism. A
number of infectious agents have been reported as potential
etiological agents. They include the corona, measles, Epstein
Barr, herpes simplex type 6, and canine distemper viruses, the
human T-cell lymphotrophic virus (HTLV)I, an MS-associated
agent and, most recently, Chlamydia. None of these has been
confirmed, but the idea lingers on, despite exhaustive searches by
competent investigators using sophisticated techniques. From all
of the information that is currently available on the disease, it is
much more likely that MS is the result, in a genetically
susceptible subject, of the activation of the immune system by
different viral agents, thereby initiating a pathogenetic cascade
that eventually leads to the destruction of the myelin sheath and
the axon. Many steps in this process remain unknown.
Pathogenesis
The precise pathogenetic mechanism of MS remains controversial,

but many investigators believe that alterations of the immune
system are responsible. It is likely that some of these changes are,
in fact, the result of the disease process rather than its cause, or
that they coexist. The vast majority of investigators believe that
the pathogenetic process can be initiated only by an
immunological event altering the impermeability of the blood-brain
barrier (Figures 2 and 3). There is evidence to suggest that other,
non-specific events and factors, such as electrical injury, lipid
solvents and trauma, can do the same. This is not to say that the
latter ever cause MS.
Several pathogenetic schemes have been offered, including that
proposed by the author (Figure 4). The surprisingly low
concordance rate of a disease, with a strong genetic component in
monozygotic twins, suggests that what is genetically determined is
a premorbid state that the author has called the MS trait (MST),
analogous to that in sickle cell disease and glucose-6-phosphate
dehydrogenase deficiency. The trait is a systemic non-pathological
condition, a disease waiting to happen. At present, not all of the
components of the MST have been defined nor can it be detected
in the parents, siblings or children of MS patients.
Constituents of the MST include a vigorous antibody response to
a great variety of viral antigens, and inflammatory infiltration of
the capillaries of the brain parenchyma. This does not lead to
changes in the myelin sheaths, but results in minor alterations of
the bloodbrain barrier that cannot be demonstrated by
gadolinium-enhanced magnetic resonance imaging (MRI), but may
allow B-lymphocytes to peri etrate into the CNS, where they
produce oligoclonal bands. These changes have been
demonstrated in the normal white matter of MS patients by
histoimmunological methods, and, more recently, by special MRI
techniques. The enhanced antibody response to many viruses and
the presence of oligoclonal bands in the cerebrospinal fluid (CSF)
Figure 2 Post-mortem perfusion study of a brain from a patient with

multiple sclerosis. The plaques are traversed by venules (stained red). The
periphery is stained blue, demonstrating increased permeability of the
bloodbrain barrier. Supravital trypan blue stain. Courtesy of Professor
Tre Broman, University of Gteborg, Sweden
have been found in healthy siblings, including the non-affected

monozygotic twins of MS patients.
The MST is the result of a viral antigenic challenge in a
genetically susceptible person from either an infection or a
vaccine. Such a challenge is non-specific: it may be in the form of
measles in one subject, an adenovirus in another, and a
vaccination against hepatitis B in a third. This initial challenge to
the immune system appears to lead primarily to a response of the
B-lymphocytes that produce antibodies and oligoclonal bands in
the cerebrospinal fluid. The mechanism of the resulting
vasculopathy is unknown, but it most probably increases the
vulnerability of the blood-brain barrier. At the stage of the MST,
the parenchyma of the CNS remains intact. The MS disease may
never develop in a subject with the MST.
It is generally accepted that a major alteration of the blood-brain
barrier is the first step that leads to the development of the MS
lesion. A key role has been suggested for tumor necrosis factor,
immune com plexes and adhesion molecules. The stimulus for
this immunological response is probably a second antigenic
challenge from either an infection or a vaccination, but not
necessarily by the same agent that led to the MST. Activation of
Figure 3 Retinal fluorescein angiography in optic neuritis. Note leakage

from vessels, indicating alteration of permeability of the vessel walls in
the retina, a myelin-free structure. From Lightman et al., 1987;
reproduced with permission of Oxford University Press
Figure 4 Pathogenesis of multiple sclerosis. BBB, bloodbrain barrier; TNF-, tumor necrosis factor-ex; OCB,
oligoclonal bands; MBP, myelin basic protein; MAG, myelin-associated glycoprotein; MOG, myelin-oligodendroglia
glycoprotein; PLP, proteolipid protein. Modified from Poser, 1994b; reproduced with the permission of John Wiley &
Sons
Figure 5 Microscopy showing (upper) lymphocytic infiltration confined to

the venous wall in normal white matter in active multiple sclerosis (MS),
and (lower) lymphocytic infiltration and edematous onion-skin changes in
the venous wall in normal white matter approximately 1.5 cm from an
active MS plaque. From Adams et al., 1985; reproduced with permission
of Elsevier Science BV
Figure 6ad Blood-brain barrier defects in normal white matter in

multiple sclerosis: (a) Section prepared with rabbit antihuman fibrinogentetramethyl rhodamine iso-thiocyanate (TRITC) fluorescein shows
fibrinogen leaking from capillary; (b) same section viewed under polarized
light shows normal myelin birefringence except in the vessel walls
(continued)
Figure 6Continued (c) capillary endothelial cells containing vesicles

positive for IgM fluorescein isothiocyanate (FITC); (d) distribution of BBB
abnormalities associated with two acute plaques. The plaques are defined
by their hypercellularity (nuclear counts, upper) and myelin lysis (dotted
areas). Both plaques (lower) are surrounded by zones of perivascular
fibrinogen leakage (see a) and endothelial cell endocytosis of IgM (see c).
From Gay and Esiri, 1991, reproduced with the permission of Oxford
University Press. For technical details, see Gay et al., 1997
Figure 7 New multiple sclerosis plaques adjacent to brain needle tract

(marked by the X), the result of gross breach of the blood-brain barrier.
Courtesy of Dr Richard Gonsette, Brussels, Belgium
the immune system is through molec-ular mimicry. This is a

phenomenon in which some component peptides of the active
antigenic molecule are immunologically indistinguishable from a
myelin antigen, and hence an appropriate response to infection
generates inappropriate action against some component of the
myelin sheath.
As a result of the alteration in the blood-brain barrier,
immunoactive
T-lymphocytes
penetrate
into
the
brain
parenchyma. For a very long time, investigators focused on the
role of the T-cell in causing the inflammatory reaction, but it is
now known that antibodies against myelin components play an
equally crucial role in pathogenesis. Other immunoactive
substances in serum, including complement, interferon-gamma,
as well as B-lymphocytes and macrophages, also cross the now
permeable blood-brain barrier and play a still unknown role in the
attack on the oligodendroglial-myelin complex. The exact
mechanism by which the myelin sheath is injured is unknown.
Cytokines secreted by T-cells have been proposed as the agents of
myelinoclasia. The role of the oligodendrocyte in the pathogenetic
cascade also remains in dispute, and many claim that it is it,
rather than the myelin sheath, that is the primary target of the
process. Some neuropathologists have claimed the disintegration
of myelin is secondary to the destruction of oligodendrocytes in
early MS lesions, but others have shown that these cells are not
affected until later, as victims of non-specific destruction.
The primary effects of MS are inflammation and edema. Myelin
destruction does not necessarily follow. Spontaneous resolution of
the inflammation and edema without destruction frequently
occurs, and provides a logical explanation for the very short
duration of some symptoms. Remyelination occurs even in the
earliest lesions, but is generally relatively inefficient and much too
slow to account for clin ical improvement within only a few days.
Another explanation is the activation of alternative or
supplementary physiological pathways.
After myelin is destroyed, it is replaced by a glial scar. It is such
scars that have given MS its name. The destruction of myelin
releases a number of its structural components, including
cholesterol, fatty acids, myelin basic protein, myelin-associated
glycoprotein, myelin-oligodendrocyte glycoprotein, proteolipid
protein,
phospholipids,
cerebrosides, sphingomyelin
and
gangliosides. These substances may enter the bloodstream via the
permeable blood-brain barrier and, in turn, provoke an immune
response from systemic lymphocytes, thereby causing a vicious
circle that results in a self-perpetuating condition. This may also
Figure 8 Double-dose (iodinated contrast) delayed CT scans (left) of a 32year-old multiple sclerosis patient who experienced a severe
exacerbation, show numerous areas of enhancement. The MRIs (right),
obtained approximately 2 months later, after recovery, show few areas of
increased signal intensity (AISI). With the possible exception of the
enhanced area at the superior angle of the left ventricle, none of the areas
of BBB alteration seen on CT are evident on MRI. Their disappearance so
soon after clinical recovery suggests that the contrast enhancement
represents edema rather than demyelination, as remyelination does not
occur within such a short period of time. From Poser et al., 1987;
reproduced with permission of the American Society of Radiology
be a possible explanation for the intermittent progression of the

disease. Serial MRI studies with gadolinium enhancement have
shown that the blood-brain barrier may remain permeable for an
indefinite period of time.
Longitudinal imaging and evoked response studies have shown
that the disease is relentlessly progressive, even in the absence of
clinical exacerbations. This may be better understood if the
disease is described as comparable to volcanic island chains, such
as Hawaii, where only the tip of the undersea volcanoes are
apparent, but with activity continuing unseen beneath the surface
of the ocean (Figure 9). It is postulated that, in MS, periods of
immune activity, probably stimulated by non-specific viral
infections, alternate with periods of immunoquiescence.
The current status of our understandingor lack thereofof the
role of the immune system in MS has been thus summarized by
Cedric Raine as follows:
In sum, while no single immune system molecule can be
assigned as unusual to the CSF of MS, and, while there
appears to be nothing unique about the manner in which the
CNS responds to inflammation, the true uniqueness of the
situation in MS is probably related to the many normally
sequestered, specific antigens within the myelin sheath and
the biology of the myelinating cell, the oligodendrocyte.
Figure 9 The disease process in multiple sclerosis can be compared with

volcanic island chains such as the Hawaiian Islands, where only the tips
of the volcanic structures protrude above sea level while unseen activity
continues below
Pathology
Because MS is a disease of the myelin sheath, lesions are mostly

found in white matter, but, because myelinated fibers are present
in gray masses, lesions may be seen in gray matter as well. On
gross sections of the brain, plaques appear as yellowish, slightly
shrunken areas that are dense glial scars (Figures 10 and 11).
An important characteristic of MS lesions, as seen by various
myelin sheath stains, is their very well-defined edge, described as
looking as if they have been cut out with a cookie cutter
(Figures 1214). This clearly differentiates the lesions of MS from
those of acute disseminated encephalomyelitis. Inflammatory
reactions, consisting mostly of lymphocytes and edema, are
usually noted around the small blood vessels, especially in acute
cases. Variable amounts of fat-staining lipid material, the socalled myelin abbau, can be observed in macrophages along with
myelin fragments (Figures 15 and 16). The intensity of the fat
staining is a good index of the age of the lesion: younger lesions
contain greater amounts of lipid. Large abnormal astrocytes,
termed gemistocytic astrocytes, are often seen at the sites of
lesions (Figure 17) and may form large masses mimicking
astrocytic tumors, leading to misinterpretation on biopsy. Classical
MS lesions are periaxile in that the axon appears unaffected even
when the myelin sheath has completely disintegrated. In older,
more severe lesions, however, the axon is atrophic or has
disappeared entirely. Necrosis may be seen, especially in acute
lesions. Although axonal, and even neuronal, involvement was
known to occur in MS for 100 years, the extent and significance of
the damage were seriously underestimated until recently. It is now
believed that the destruction of axons accounts for most clinical
disability.
MS lesions vary considerably in size, ranging from only a few
millimeters to plaques involving almost the entire centrum
semiovale. Asymmetry is the rule and no part of the CNS is spared.
Lesions are frequently noted in the spinal cord, especially the
cervical portion, as well as, classically, the brain stem and
cerebellum, and the cerebral hemispheres The optic nerves and optic chiasm
Figure 10 Unstained gross coronal sections of brain. Note the typical

dark-colored periventricular and parenchymatous lesions
Figure 11 Unstained gross axial section of cerebellum. Note the typical

involvement of the dentate nuclei and periventricular lesions (arrows)
Figure 12 Celloidin sections of occipital lobe showing several small

periventricular areas of demyelination. Nissl staining (left) shows reactive
gliosis extending well beyond the plaques; Weigert staining (right) shows
pale-staining, relatively restricted, demyelination. Courtesy of Professor H.
Shiraki, University of Tokyo, Japan
Figure 13 Celloidin section showing different intensities of staining.

There is total loss of myelin in some plaques, represented by the absence
of color, whereas, in other plaques, there is only pallor of the myelin.
These shadow plaques are believed by some to represent remyelination.
Courtesy of Professor H. Shiraki, University of Tokyo, Japan
Figure 14 Weigert staining reveals a well-delineated multiple sclerosis

plaque in the pons (upper) and a large plaque involving nearly the entire
section of the cervical spinal cord (lower). The patient was a black
Senegalese. Courtesy of Professor Michel Dumas, Institute of Neurological
Epidemiology and Tropical Neurology, Limoges, France
Figure 15 Celloidin section of brain shows that the age of multiple

sclerosis lesions can be gauged from the color intensity of the stained fat,
representing the abbau products of myelinoclasia: the redder the fat, the
younger the lesion. Abbau products are no longer present in old lesions.
Combined myelin-fat stains. From Roizin et al., 1946; reproduced with
permission of Williams and Wilkins
Figure 16 Histology (high-powered view of the same section as in Figure

15) shows fat-containing macrophages (arrow) scattered among
degenerating myelin sheaths. Combined myelin-fat stains. From Roizin et
al., 1946; reproduced with permission of Williams and Wilkins
Figure 17 Histology of an early multiple sclerosis plaque shows

gemistocytic astrocytes, seen with H&E-Luxol fast blue (upper) and Golgi
(lower) staining
are frequently involved. The median longitudinal fasciculus is eventually affected

in many cases, causing the almost pathognomonic internuclear
ophthalmoplegia. The basal ganglia, thalamus and hypothalamus,
and dentate nuclei may also be sites of lesions. In exceptional
circumstances, peripheral nerves may become involved. In regard
to cranial nerves, lesions of the sensory nuclei of the trigeminal
nerve, the intra-parenchymal portion of the facial nerve and
connections of the acoustic nerves are not uncommonly
encountered. Tic douloureux, or trigeminal neuralgia, in a subject
of less than 40 years of age, is virtually pathognomonic of MS.
Certain unusual forms of MS have been recognized, mostly on
the basis of their pathological appearance. Balos disease is
characterized by the presence of concentric bands of normallooking myelin alternating with areas of demyelination (Figures 18
and 19). These areas may be relatively large and may occupy a
good part of the centrum semiovale. The clinical course of Balos
disease is usually one of rapid progression. However, similar areas
of concentric alternating demyelination have been seen in
otherwise unremarkable cases of MS and in acute disseminated
encephalomyelitis. Another variant of MS is diffuse sclero sis, or
Schilders disease. True Schilders disease is extremely rare, and is
defined as the presence of very large bilateral, slightly
asymmetrical areas of demyelination in the cerebral white matter
(Figures 20 and 21). Diffuse sclerosis is usually seen in children.
The very large lesions are often associated with the more typical
small disseminated lesions of MS. The nosological situation of
what is often designated as a variant of MSDevics disease or
neuromyelitis opticais the subject of dispute. Lesions affect only
the optic nerves and spinal cord, not necessarily simultaneously.
It is estimated that only approximately one-quarter of cases of
neuromyelitis optica are cases of MS; the rest are most probably
instances of postinfectious encephalomyelitis.
Electron microscopy of the classical lesion of MS reveals a
number of characteristic changes (Figure 22). One of the earliest
changes is separation of the myelin lamellae by edema. This is
often followed by the appearance of macrophages containing
myelin debris or fragments, abrupt tapering of the myelin sheath,
and axonal denudation. Evidence of remyelination may be seen
even in the earliest lesions.
Figure 18 Axial MRI (upper) and gross appearance (lower) of brain in

Bals disease. There is concentric demyelination (arrows) and another
lesion (indicated by the triangles). Courtesy of Dr George Collins, State
University of New York at Syracuse, from Gharagozloo etal., 1994;
reproduced with permission of the Radiological Society of America
Figure 19 Brain section in Bals disease showing (upper) concentric

demyelination in the right centrum semiovale. High-power view of the
same area (lower) shows alternating bands of normal myelin and
remyelmation. Weigert stains. Courtesy of Professor H.Shiraki, University
of Tokyo, Japan
Figure 20 Gross specimen of brain from a patient with Schilders

myelinoclastic diffuse sclerosis shows large bilateral areas of
demyelination
Figure 21 Celloidin section of brain from a patient with Schilders

myelinoclastic diffuse sclerosis shows a large plaque occupying most of
the centrum semiovale. Weigert stain. Courtesy of Professor H.Shiraki,
University of Tokyo, Japan
Figure 22a-h Electron micrographs showing (a) vesicular dissolution of

myelin in acute multiple sclerosis (bar=0.5 m); (b) a naked axon
(indicated by star) enveloped by a macrophage containing fragments of
undegraded (native periodicity) myelin debris (arrows), indicative of recent
uptake (bar=1.0 m) Selected by Professor Ingrid Allen and Dr John Kirk,
Queens University of Belfast and the Royal Victoria Hospital, Belfast,
Northern Ireland. Courtesy of Dr John Kirk (a, b), with permission of
Blackwell Science (a); from Allen, 1991, with permission of Churchill
Livingstone (b) (continued)
Figure 22 Continued Electron micrographs showing (c) various stages of

myelin degradation in a macrophage (bar=1.0 m); (d) lyre bodies and lipid
droplets in a macrophage (bar=0.5 m) Selected by Professor Ingrid Allen
and Dr John Kirk, Queens University of Belfast and the Royal Victoria
Hospital, Belfast, Northern Ireland. Courtesy of Dr Michael Hutchinson (c,
d); from Allen and Kirk. 1992, with permission of Edward Arnold (c, d)
(continued)
Figure 22 Continued Electron micrographs showing (e) an isolated

oligodendrocyte and myelin sheath among naked axons (indicated by
stars) and astrocytic processes (arrows; bar=20 m); (f) periaxial
segmental demyelination, in which loss of myelin internodal segment has
resulted in paranodal axolemmal specialization (between arrows).
Filament-rich astrocytic processes surround the naked axon (bar=2.0
m). Selected by Professor Ingrid Allen and Dr John Kirk, Queens
University of Belfast and the Royal Victoria Hospital, Belfast, Northern
Ireland. Courtesy of Dr John Kirk (e, f); from Allen, 1991, with permission
of Churchill Livingstone (e) (continued)
Figure 24 Continued Electron micrographs showing (g) subcortical white

matter from an area of reduced myelin density at the edge of a plaque.
Many of the axons show abnormally thin (?remyelinated) myelin sheaths;
macrophages are numerous but do not contain recent (normal
periodicity) myelin debris. Astrocytic gliosis is pronounced (bar=2.0 m);
(h) a large periventricular plaque in which naked axons persist along-side
thin remyelinated axons and fine astrocytic processes containing bundled
filaments (bar=2.0 m) Selected by Professor Ingrid Allen and Dr John
Kirk, Queens University of Belfast and the Royal Victoria Hospital,
Belfast, Northern Ireland. Courtesy of Dr John Kirk (g, h)
Physiology
Normal motor and sensory function is dependent upon the rapid

propagation of the nerve impulse along myelinated nerve fibers;
this time is measured in milliseconds. The myelin sheath is
interrupted at regular intervals by nodes of Ranvier, where the
axon is denuded. Because the axon has a high resistance to the
electrical impulse and the speed of conduction is too slow, there is
an alternative mechanism called saltatory conduction. This is
where the electrical impulse jumps from one node of Ranvier to
the next, while achieving the required conduction velocity.
However, if the distance between the available nodes is too great
because of destruction of myelin segments, the impulse cannot
bridge the gap and saltatory conduction is either impaired or
abolished. The electrical impulse must then travel via the slow
axonal route.
Signs and symptoms may appear in some MS patients due to
slowing of nerve conduction caused by a rise in body temperature
as a result of either ambient heat or fever (Uhthoffs
phenomenon). The latter is a common cause of pseudoexacerbations. A body temperature increase of as little as 0.1C
may be sufficient to cause such signs and symptoms, which
disappear upon cooling. By far the most common cause of these
pseudo-exacerbations is an unsuspected urinary tract infection.
Clinical aspects
Multiple sclerosis most frequently affects the optic nerve and

chiasm, brain stem, cerebellum and the cervical spinal cord. The
presence of spondylosis often contributes to the formation of
plaques in that region. This preferential involvement determines
the frequency of the signs and symptoms observed in MS patients
(Table 1). Because it is often difficult, especially on the basis of
patient history, to separate symptoms from signs, the clinical
features listed in Table 1 are presented as symptom/sign
combinations.
Determination of the exact clinical onset of the disease is
important for epidemiological investigations. Often, non-specific
symptoms such as headache, seizure, dizziness or back pain are
mentioned as the first clinical manifestations of the illness. These
onset symptoms of MS may be divided into those which are
definite and those which are possible. These symptoms must
last for at least 24 hours.
The definite symptoms include unilateral optic/retrobulbar
monocular color blindness, oscillopsia, transient scanning speech,
transverse myelitis, Lhermittes symptom, gait ataxia, unilateral
dysmetria/intention tremor/incoordination, sensory useless hand
syndrome, and transient weakness/paresthesias of the entire
limb. The following are also considered to be definite, but only if
the patient is less than 40 years of age: tic douloureux, hemifacial
spasm, acute unilateral diminution of hearing, transient acute
non-positional vertigo, transient painless urinary retention, and
transient painless urinary urgency or incontinence in men.
For the following possible symptoms to be considered markers
of MS onset, they must be followed by a definite symptom within 2
years: unilateral facial palsy, organic erectile dysfunction, and
painful tonic spasms. Transient painless urinary frequency in
men, and transient hemiparesis are acceptable only in patients
under age 40.
Table 1 Initial symptoms, clinical course and predominant clinical

category in 461 MS patients (From Paty and Poser, 1984, reproduced with
permission). Data are given as the number (%) of patients
Clinical course
The course of MS is usually classified as:
(1) Classic relapsing and remitting type (RRMS), which represents
about one-third of the cases;
(2) Primary progressive (PPMS), which is uncommon and
represents about 10% of cases; and
(3) Secondary progressive (SPMS), which follows a relapsing
remitting course.
Burned-out cases are rarely mentioned, yet constitute
approximately 20% of cases. In such a case, the disease seems to
have become arrested. Most of these patients have become
wheelchair-bound, but their upper extremities remain functional.
MS can also follow a hyperacute course, leading to death in a
matter of a few weeks; this type has been called Marburg disease.
Many of those cases are actually cases of acute monophasic

disseminated encephalomyelitis rather than MS.
It is frequently suggested that these various clinical categories
represent separate disease entities, but it is more logical and
correct to consider that they are simply the phenotypic responses
to a single disease of individuals with different genetic endowment
and immunologic history. In every one of these clinical groups, the
end result of the disease process is the same, the sharp-edged
plaque.
Exacerbations of MS often follow on the heels of a viral
infection. Because such infections may be very mild or even
clinically silent, the triggering event may not be recognized. The
role of trauma, electrical injury, vaccinations and emotional stress
in precipitating attacks of MS, although relevant, remains
controversial.
The correlation between the number, site and size of MS lesions,
as revealed by neuroimaging and at autopsy, and clinical
manifestations is poor. Many plaques involve the so-called silent
areas of the brain. The reason why some lesions do not cause
neurological dysfunction is best explained by the theoretical
concept of the safety factor. The disease process must impair
conduction in a critical, minimum number of fibers of motor or
sensory tracts before clinical dysfunction occurs. The number of
available fibers above this minimum number constitutes the
safety factor. If the signs and symptoms are due only to
inflammation and edema, they will be reversible. When the safety
factor is totally abolished by myelinoclasia, the patient will have
permanent signs or symptoms (Figure 23).
Figure 23 Safety factor in the progression of multiple sclerosis: as long as

the required minimum number of nerve fibers remains intact, the patient
is asymptomatic. When symptomatic myelin edema occurs during an
exacerbation, remission may result in either complete or partial recovery,
depending upon functional restoration of the required number of fibers,
or in a permanent deficit, as a result of myelinoclasia. From Poser, 1993;
reproduced with permission of Elsevier Science BV
Diagnosis
Diagnosticcriteria
The diagnosis of MS is a clinical exercise based on the
characteristic dissemination of the lesions in both space and time.
This principle applies to the overwhelming majority of cases. Until
recently, the diagnostic criteria that have been virtually
universally adopted were those first published in 1983. New
criteria (McDonald et al., 2001) have now been published and are
becoming widely accepted. They will be discussed later. Because
they emphasize MRI, which is not readily available in many parts
of the world, a simplified version of the 1983 scheme is
reproduced in Table 2.
The following explanatory comments are an integral part of the
scheme:
Attack (bout, episode, exacerbation): must last at least 24 hours
Paraclinical evidence: demonstration by neuroimaging (CT or
MRI) or evoked potential studies of CNS lesions that may or may
not
Table 2 Diagnostic criteria for multiple sclerosis (From Poser et al., 1983,
with permission)
previously have caused signs or symptoms. Such lesions must be

at locations different from those recorded by history or
examination
Remission: a definite improvement, lasting for at least a month
Laboratory support: this applies only to the examination of CSF
for an increased level of immunoglobulin G (IgG) and the presence
of oligo clonal bands (see CSF below)
The newMSdiagnostic criteria of McDonald
The explosion in the availability and use of MRI has made almost
mandatory the inclusion of imaging criteria. The new scheme is
repro duced in Table 3.
Patients are divided into three groups: MS, non-MS and
possible. It is somewhat difficult to appreciate why the last
category was included. For the first time, primary progressive MS
(PPMS) is carefully characterized, the problem of pseudoexacerbations is mentioned, and the diagnostic value of brain stem
auditory and somatosensory evoked potentials is questioned.
Symptoms are not acceptable. Regarding MRI, the criteria lack a
qualitative dimension which is so important in distinguishing
between MS and disseminated encephalomyelitis, but those for
spinal cord lesions and for dissemination in time are most useful.
Optic fundus and visual fields
Because the optic nerve and the visual system are so frequently
involved, and the optic nerve head is the only externally visible
part of the CNS, examining the optic fundus and plotting the
visual fields provide valuable clinical information (Figures 24 and
25).
Confirmatory laboratory procedures
The following comments apply to both sets of diagnostic criteria.
With few exceptions, the laboratory procedures described below
should be used only if the clinical information and findings on
neurological examination are insufficient to warrant making the
diagnosis of definite MS. Thus, these procedures are intended to
confirm a suspicion of MS or, on rare occasions, rule out
conditions such as disseminated encephalomyelitis (in particular,
the recurrent and multiphasic types), Lyme disease, HTLV-Iassociated paraparesis, sarcoidosis, etc. Contraryto widely held
Table 3 McDonald diagnostic criteria (after McDonald et al., 2001)
opinion, anMRIor a lumbar puncture is not necessary tomake the

diagnosis ofMS.
Examination of cerebrospinal fluid
Lumbar puncture as an adjunct for the diagnosis of MS has
become increasingly rare, but remains an essential procedure
when other conditions, such as Lyme disease, sarcoidosis, HTLV-Iassociated paraparesis, AIDS, and neurosyphilis, must be ruled
out. Thus, it remains a useful confirmatory test for MS.
In an acute attack of MS, there is often a slight elevation of
lympho cytes and of total protein. A CSF protein level greater than
75 mg/100 ml should raise serious doubts about the diagnosis of
MS.
Measurement of the level of IgG is an important part of the CSF
examination. The simplest and most reliable measurement is the
percentage of total protein: >15% is considered abnormal.
However, an elevated CSF IgG is non-specific. It is often observed
in many other conditions affecting the nervous system. A more
useful examination is the search for oligoclonal bands in the
gammaglobulin fraction of protein (Figures 26 and 27). To be
significant, there must be at least two bands
Footnote to Table 3: Positive CSF=presence of oligoclonal IgG bands

different from any such bands in serum and/or presence of an elevated
IgG index. Abnormal VEP can be used to supplement information
provided by the clinical examination to give objective evidence of a second
lesion (provided the only clinically expressed lesion did not affect the
visual pathways). Other types of evoked potentials were viewed as
contributing little to the diagnosis of MS
Figure 24 a-d Funduscopy in multiple sclerosis showing (a) papillitis

(upper) vs a normal fundus (lower). Courtesy of Dr Simmons Lessell,
Massachusetts Eye and Ear Infirmary, Boston, MA (continued)
Figure 24 ContinuedFunduscopy in multiple sclerosis showing (b) mild

segmental venous sheathing (arrow); (c) severe optic atrophy. Courtesy of
Dr Jason Barton, Beth Israel Deaconess Medical Center, Boston, MA
(continued)
Figure 24 Continued (d) Pars planitis: watercolor of a flattened retina

showing the optic disk and macula (towards the center) as well as the
most anterior portion of the retina, the pars plana (scalloped yellow
margin), which lies just behind the ciliary body. Periphlebitis is evident in
some of the distal portions of the retinal veins. Inflammatory cells in the
vitreous have settled over the inferior retina, giving the appearance of
snowbanks. Severe cases may also have cystoid macular edema, as
Figure 25 Tangent screen visual field showing a central scotoma due to

optic atrophy subsequent to optic neuritis. Courtesy of Dr Simmons
Lessell, Massachusetts Eye and Ear Infirmary, Boston, MA
Figure 26 Electrophoresis of cerebrospinal fluid showing increased levels

of immunoglobulin G (arrows), a non-specific finding
Figure 27 Electrophoresis of cerebrospinal fluid showing (upper) normal

vs (lower) x80 increased concentration; three oligoclonal bands can be
seen in the IgG fraction (arrow). Coomassie brilliant blue stain. Courtesy
of Dr James Faix, Beth Israel Deaconess Medical Center, Boston, MA
present and none in the serum. The presence of oligoclonal

bands in the CSF is not specific for MS; they may be noted in other
conditions. They never disappear from the CSF in MS, but may do
so in disseminated encephalomyelitis.
Evoked potential studies
Pattern-reversal visual evoked responses are particularly useful in
identifying optic nerve and chiasmatic lesions in patients who
have had no symptoms or signs of involvement of the visual
system, because they may be delayed in 75% of such patients,
including those with normal visual acuity. The critical
measurement is that of the peak, designated as P100 (Figure 28).
The amplitude of the response is of little portent. Interocular
differences in P100 delay are usually meaningless. Because
Figure 28 Visual evoked response in a patient with left optic atrophy. The
P1OO wave on the left is delayed compared with that on the right.
Courtesy of Dr Frank Drislane, Beth Israel Deaconess Medical Center,
Boston, MA
the response is modified by changes in visual acuity, it is

imperative that the patient wears prescribed corrective lenses
during the test. Delay in P100 is far from specific for MS lesions of
the optic system; in addition to poor fixation and changes in
Figure 29 Audiogram (upper) showing acute partial hearing loss in left

ear, specifically, hearing loss at high frequencies; (lower) the brain stem
auditory evoked response shows delay of waves 11 and V in the left ear.
Courtesy of Dr Carl Lieberman, Framingham, MA
visual acuity, many other conditions may give false-positive

results. Among the more common ones are glaucoma, alcohol
ingestion, cerebrovascular disease, spinocerebellar degeneration,
all types of optic atrophy, and the use of many commonly
prescribed drugs.
Brain-stem auditory responses are much less useful because
they are positive in only a small percentage of cases, even in the
presence of overt clinical signs of brain-stem involvement, such as
internuclear ophthalmoplegia. In patients with MS, the most
frequently observed delay is between waves III and V (Figure 29).
Peripheral delays simply indicate acoustic nerve lesions, which are
usually unrelated to MS. Somatosensory evoked responses are
rarely of value and are almost invariably and needlessly performed
in patients who clearly have spinal cord lesions. They are often
painful.
Neuroimaging
Computed tomography
Despite the general availability of MRI in most countries,
computed tomography (CT) scanning will undoubtedly remain, for
many years to come, the only neuroimaging procedure available in
the poorer areas of the world. Although CT resolution is far below
that of MRI, the cost of the equipment is only a fraction of the cost
of the latter (Figures 3032). Doubling, or even tripling, the dose
of intravenous iodinated
Figure 30 Axial CT scan of a multiple sclerosis patient with an acute left

hemiparesis showing a large area of hypodensity in the right hemisphere,
and two smaller areas in the left
Figure 31 Axial CT scan showing severe brain stem and cerebellar

atrophy
Figure 32 Axial CT scan showing bilateral optic atrophy
Figure 33 Axial CT scans, using iodinated contrast and taken after a 60min delay, compare the effects of (a) no contrast with (b) 300 mg and (c)
600 mg of contrast. With 300 mg, the left posterior frontal lesion is only
faintly seen whereas doubling the dose renders the lesion much more
obvious. Courtesy of Drs Fernando Vinuela and George Ebers, University
of Western Ontario, London, Canada
Figure 34 Double-dose contrast delayed axial CT scan shows multiple

lesions in the cerebellum
Figure 35 Axial CT scan, using iodinated contrast, shows lesions

(arrows) at the level of C4 of the spinal cord. Plaques of the spinal cord
are rarely seen by CT
contrast medium and delaying imaging for one or two hours have
greatly enhanced the ability of CT to reveal MS lesions, even in the
spinal cord (Figures 3335).
Magnetic resonance imaging
The introduction of magnetic resonance imaging (MRI) has
completely revolutionized the diagnostic process of MS, but has
proved to be a mixed blessing. The proliferation of MRI machines
has led to their overuse and to misinterpretation of the images. At
present, too often the diagnosis of MS has been based exclusively
on the presence of areas of increased signal intensity (AISIs),
which are most often referred to as lesions, visualized in the
white matter on T2-weighted MRI scans (Figure 36).
Approximately 515% of clinically definite MS patients have
completely normal MRIs on repeated examination. Conversely,
there are patients with insignificant complaints who have MRI
abnormalities that are similar to those frequently seen in
symptomatic MS patients (Figures 3739). The correlation between
the number, site and size of MRI white matter AISIs and the
clinical signs and symptoms of MS is very poor and unreliable.
The often-used term burden of disease, based on the number and
size of lesions, is misleading, as very large AISIs may be seen
which have persisted for years in clinically normal subjects.
Attempts to establish reliable MRI diagnostic criteria have
largely
been
unsuccessful,
because
the
pattern
and
characteristics of images associated with MS are also seen in
many other diseases. There are no MRI patterns of lesions,
including the ovoid periventricular lesion, which are essential or
even diagnostic of MS. The ones included in the McDonald et al.,
(2001) criteria were derived retrospectively from the images of
patients who had had a clinically isolated syndrome who then had
a second episode and thus were deemed to have MS.
A very important, but rarely emphasized, use of MRI is in the
routine visualization of the cervical cord. In a surprisingly large
number of MS patients, cervical cord plaques can be seen
adjacent to areas of compressionwhether actual, potential or
intermittentby spondylosis and/or herniated disks (Figures 40
42). It is possible that pressure from such extrinsic lesions may
aggravate the underlying MS in addition to the myelopathic effects
they produce. Obtaining lateral MRI views of the neck in flexion
may reveal effacement of the ventral subarachnoid space or even
cord compression that is not evident with the neck in a normal
position, in particular in patients who have a neck injury.
Figure 36 a-o T2-weighted (a-h) and proton-density (io) MRIs showing

areas of increased signal intensity (AISI); these are frequently seen in
clinically definite multiple sclerosis, but are not diagnostic (continued on
pages 60 and 61)
Gadolinium enhancement of MRI has limited clinical application.

Its routine clinical use is inappropriate and needlessly expensive.
It is unusual to find an enhancing lesion that is not visible on the
T2-weighted image (Figure 43). Treatment decisions of
exacerbations should be based on clinical considerations. At
present, the reliability of evaluating long-term treatment by serial
gadolinium-enhanced MRI has not been completely settled. While
enhancement, which reflects the inflammatory reaction, and
blood-brain barrier alteration, are often considered to be a sign of
activity of the disease, its actuality is deceptive: blood-brain barrier
alterations may have been present for 3 months or longer.
Variations in imaging protocols can help to distinguish separate
components of the underlying pathological process (Figure 44). In
addition to inflammation, demyelination (magnetization transfer
ratio), gliosis (T2-weighting reflecting increased water content),
and axonal damage (reduction in diffusion tensor imaging
Figure 37 T2-weighted (upper) and gadolinium-EDTA-enhanced (lower)

axial MRIs showing a number of ovoid lesions. Although many areas of
increased signal intensity are seen on T2-weighting, other such areas
(arrows) not revealed by T2-weighting are clearly seen with gadoliniumEDTA enhancement. This phenomenon is relatively uncommon
Figure 38 Sagittal proton density MRI of the spinal cord shows a

completely extruded disk compressing the cord at the level of T78. Note
the areas of increased signal intensity extending both above and below
the site of compression. There is also cord compression at the T910
level. The patient had suffered from a fall around 2 months previously
Figure 39 Axial (left) and sagittal (right) T2-weighted MRIs show severe
spondylosis at C45 with cord compression. Note the areas of increased
signal intensity immedi-ately below the compression site (arrow; right).
Spondylosis at C56 has obliterated the subarachnoid space anteriorly.
The cord is shoved backwards, causing narrowing of the subarachnoid
space posteriorly from C34 downwards. The axial view of C45 shows
compression of the cord clearly
anisotrophy and N-acetyl-aspartate spectra with chemical shift

imaging, or the presence of black holes with T1-weighting).
Imaging differential diagnoses
Many diseases of the nervous system that result in white-matter
lesions seen by MRI are often erroneously diagnosed as MS. By far
the
most
common
of
these
is
acute
disseminated
encephalomyelitis (ADEM) (Figure 45). However, the distribution
and the size of the lesions in ADEM are quite characteristic and
should rarely be confused with MS (Figures 4648). Conversely,
the AISIs may look the same as those often seen in MS. More
difficult is the clinical differentiation of the
rarer types of
disseminated encephalomyelitisthe chronic, recurrent (RDEM),
and the multiphasic (MDEM) (Figure 49). The changes are of the
same type as those seen in ADEM and may be the only means of
differentiation from MS.
Figure 40 a-c Sagittal T2-weighted MRI taken 8 months after a whiplash

injury to the neck shows loss of the normal cervical lordosis due to
cervical muscle spasm (a). A posterior area of increased signal intensity is
seen at the level of C3; another, larger and more dense, lies anterior to
and below it. There is attenuation of the anterior subarachnoid space at
C45, C56 and C67 levels. Sagittal T2-weighted MRIs taken 14 months
later show less muscle spasm, and the area of increased signal intensity
at C4 appears to be less dense (b). There is attenuation of the
subarachnoid space posteriorly at the level of C3 due to a fold in the
ligament, which corresponds to the area of increased signal intensity at
that level. With the neck in flexion (c), the anterior subarachoid space is
markedly attenuated, especially at C45 and C56 levels, whereas the
posterior space is greatly enlarged, presumably as a result of pressure on
the cerebrospinal fluid surrounding the tethered cord. The posterior
indentation at C3 persists. It is thought that violent hyperflexion of the
neck at the time of whiplash injury was responsible for the formation of
the C4 plaque. Courtesy of Dr Gerald OReilly, CHEM MRI, Stoneham, MA
Figure 41 T2-weighted coronal (upper) and axial (lower) MRIs showing

lesions resulting in right optic neuritis (arrows). Courtesy of Drs Simmons
Lessell and Judith Warner, Massachusetts Eye and Ear Infirmary, Boston,
MA
Figure 42 MRI of the brain stem shows areas of increased signal intensity
in a patient with right facial palsy
Other diseases which are frequently mistaken for MS on the

basis of their MRI appearances include Lyme disease (Figure 50),
HTLV-I-associated paraparesis (Figure 51), AIDS (Figure 52),
cerebral arteritis such as lupus erythematosus, complicated
migraine (Figure 53), trauma (Figures 54, 55), cerebrovascular
disease (Figure 56), neurosarcoidosis (Figure 57), and chronic
fatigue syndrome (CFS). This last syndrome, occurring mostly in
young women, shares with MS the same characteristic fatigue as
well as some of the more typical symptoms and signs. In contrast,
the following symptoms are useful in establishing the diagnosis of
CFS rather than MS: migratory myalgia, arthralgia and painful
paresthesias, sleep disturbance, anhedonia, and unusual and
paradoxical reactions to medications (Figure 58).
Single-photon emission computed tomography
Single-photon emission computed tomography (SPECT) uses
radioactive tracers with computerized reconstruction of the
isotopic emission recorded by a rotating gamma camera to
measure cerebral perfusion. The applicability of SPECT to MS is
limited to specialized research (Figure 59).
Figure 43 Audiogram (upper graphs), auditory evoked response (middle

graphs) and MRI (lower) of a patient who had a sudden partial loss of
hearing in the left ear. The audiogram shows decreased perception of all
frequencies; the brain stem auditory evoked response shows absence of
wave V; and the MRI shows areas of increased signal intensity in the left
brain stem just above the superior olive (arrow)
Figure 44 a-c MRI appearances of Bals disease. Courtesy of Dr Chi-Jen

Chen, Chang-Gung Medical College, Taipei, Taiwan, from Chen et al.,
1996, reproduced with permission of LippincottRaven (a); and Dr George
Collins, State University of New York at Syracuse, from Gharagozloo etal,
1994, reproduced with permission of the Radiological Society of America
(b, c)
Figure45 Pseudo-Bals disease. MRI of a patient with recurrent

disseminated encephalomyelitis. A number of similar cases have been
erroneously published as examples of Bals disease. Courtesy of
Professor Vesna Brinar, University of Zagreb, Croatia
Positron emission tomography

Using radiolabeled deoxyglucose, positron emission tomography
(PET) has been reported to show as much as a 2030% reduction
in oxygen or glucose consumption in various parts of the brain in
MS patients. PET is a research tool and requires close proximity to
a cyclotron (Figures 60, 61).
Figure 46 Sagittal (upper) and axial (lower) T2-weighted MRIs of a patient

with ADEM showing a single, very long, area of increased signal intensity
restricted to the posterior columns of the upper cervical cord. The
patients only complaint was clumsiness due to loss of positional sense in
her hands
Figure47 Coronal T2-weighted MRIs of a patient with postvaccination

(influenza) encephalomyelitis
Figure 48 a and b Axial MRIs of ADEM in a 17-year-old girl who had a

grand mal seizure accompanied by aphasia. Recovery was complete
within 24 hours. MRI (a) showed enormous bilateral areas of increased
signal intensity (AISI). The patient was asymptomatic for a year, until she
had another seizure after discontinuing her anticonvulsant medication.
Her neurological examination was normal, but MRI showed the same
AISI. Three years later, the follow-up MRI (b) in this completely
asymptomatic subject still showed the same AISI
Figure 49 (a-f) Axial MRIs of a 29-year-old man with multiphasic

disseminated encephalomyelitis (MDEM). The patient had a rapidly
progressing right hemiparesis. The initial scan (a) revealed two large AISI
in the left hemisphere, and a small one in the right hemisphere
posteriorly. Biopsy of the left frontal AISI revealed inflammation and
demyelination. AISI of this size are typical of ADEM. The patient recovered
without treatment within 4 months. A follow-up scan taken 6 months
later (b) showed shrinkage of the AISI and, 1 year later (c), two small AISI
were all that remained. Three years later, following a flu-like illness, the
patient complained of a moderately severe left hemiparesis. MRI at that
time (d) showed a large new AISI in the right frontal area. A follow-up
study 2 weeks later (e) showed what appeared to be reactivation of the
two left hemisphere AISI despite the absence of right-sided symptoms.
The patient recovered after treatment with methylprednisolone. A final
scan 3 months later (f) showed considerable regression of all AISI. This
case is a good example of the value of MRI in ruling out multiple sclerosis
in a patient whose history is compatible with such a diagnosis. Courtesy
of Dr Saeed Bohlega, King Faisal Specialists Hospital, Riyadh, Saudi
Arabia; modified from Khan et al., 1995 (continued on page76)
Figure 49Continued
Figure 50 Coronal (upper) and

patient with Lyme disease show
signal intensity similar to those
Hibberd, Massachusetts General
axial (lower) proton density MRIs of a

large periventricular areas of increased
seen in ADEM. Courtesy of Dr Patricia
Hospital, Boston, MA
Figure 51 Axial T2-weighted MRI of a patient with HTLV-1-associated

paraparesis. Courtesy of Dr Gustavo Roman, San Antonio, TX
Figure52 Axial proton-density MRIs of a patient with cerebral AIDS.

Nearly all of the lesions lie at the periphery rather than in the
periventricular area; this pattern is similar to that seen in ADEM
Figure 53 Axial (left) and coronal (right) proton-density MRIs of a patient

who had complicated migraine. The pattern is similar to that seen in
ADEM. Large cortical areas of increased signal intensity can be seen
Figure 54 Axial proton-density MRI of a 42-year-old man who had

suffered head trauma, specifically, a concussion. The patient complained
of triple vision in the right eye and anxiety attacks. He had bilateral
Babinskis signs, but had no other neurological symptoms or signs. He
was diagnosed as having multiple sclerosis on the basis of the MRI. Note
the markedly enlarged left ventricle. Further history disclosed that he had
been comatose for a month after a car accident several years earlier
Figure 55 Axial T2-weighted MRI of a patient who had suffered a mild

concussion without loss of consciousness. His only complaint was
headache. Multiple areas of increased signal intensity are present in the
cerebral white matter
Figure 56 Axial proton-density MRIs of a patient with hypertensive

cerebrovascular disease (Binswangers) show scattered punctate and
linear periventricular areas of increased signal intensity (arrow)
Figure 57 Coronal T2-weighted MRI of a patient with neurosarcoidosis.

The lobar areas of increased signal intensity are similar to those seen in
ADEM (see also Figure 47). Increased signal intensity of the meninges is
highly characteristic
Figure 58 a and b T1-weighted MRI using gadoliniumEDTA injection (a)

and proton-density MRI (b) of a patient with chronic fatigue syndrome
(CFS). An enhancing lesion in the right parasagittal frontal cortex (a,
arrow) corresponded to the patients left-sided Babinskis sign. Despite
the presence of neurological abnormalities, the patient fulfilled the
diagnostic criteria for CFS
Figure
59
SPECT
of
the
brain,
using
technetium-99
hexamethylpropyleneamine oxime, of two multiple sclerosis patients
(upper) compared with a control (lower). Both patients clearly show a
reduction in perfusion. Courtesy of Dr Jan Lycke, Sahlgrenska University
Hospital, Gteborg, Sweden. For technical details, see Lycke et al., 1993
Figure 60 Axial post-gadolinium T1-weighted (a, b) and T2-weighted (c)

MRIs, overlaid by cobaltPET displays. Areas of non-enhancing
hypodensity seen in (a) (arrow). CobaltPETenhanced lesions may
coincide (yellow and red arrows), but long-standing confluent lesions are
neither enhanced nor show cobalt uptake (blue arrows). There is an
enhanced lesion in (b) (magenta arrow) which does not show cobalt
uptake. In general, there is good, but not complete, correlation between
disease activity (gadolinium-enhanced) and cobaltPETenhanced
lesions. Unpublished results, courtesy of H.Jansen, D.de Coo, J. De
Reuck, J.Korf and J.Minderhoud, Groningen, The Netherlands, and
Ghent, Belgium; courtesy of Dr Jakob Korf, University Hospital,
Groningen, The Netherlands. For technical details, see Jansen et al., 1995
Figure 61 Axial contrast-enhanced MRI (a, left) compared with an 18 Flabeled deoxyglucose (FDG)PET scan (a, right) of the brain. The color
scale represents glucose consumption from 0 (black) to 45 (white) mol/
100 ml/min. Areas of abnormal cortical glucose consumption (arrows)
may be considered a consequence of the subcortical demyelinating
lesions seen on the MRI. The significantly (p=0.005) lower differences of
glucose metabolism in multiple sclerosis patients with (n=19) vs without
(n=16) fatigue are superimposed on axial MRIs of a healthy subject (b).
Differences are most prominent in the frontal cortex, striatum and
adjacent white matter. Courtesy of Drs U. Roelcke and K. Leenders, Paul
Scherrer Institute, Villigen, Switzerland; from Roelcke et al., 1997;
reproduced with permission of Lippincott-Raven (b)
Treatment
Details of acute and long-term treatment of MS are beyond the

scope of this volume. Five drugs have won government approval
(in the United States). Three of them are forms of -interferon
(Avonex, Betaseron, Rebif), one is a mixture of amino acids
(Copaxone), and one is an immunosuppressant (Novantrone).
Other drugs such as azathioprine are in wide use, especially in
Europe. All of them reduce the frequency of relapses and of new
T2-weighted and enhancing lesions on MRI in relapsing and
remitting and secondary progressive MS. No clear-cut evidence
has emerged to suggest that any of them significantly delays the
progression of the disease.
Conclusion
Despite major gaps in our knowledge of the pathogenesis,

epidemiology and genetics of multiple sclerosis, much progress
has been made, not only in those areas of research, but also in
refining confirmatory laboratory diagnostic procedures and
improving methods of symptomatic treatment. Therapeutic trials
for long-term treatment have shown encouraging results, but as
yet unproved results over the long term. What remains
unchallenged is the primary role played by the astute and
experienced clinician in the diagnosis and treatment of the
disease.
Bibliography
Books
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Index
abbau18, 22
acoustic nerves24
acute disseminated
encephalomyelitis (ADEM)18, 35,
61, 65, 6768
adhesion molecules14
age of acquisition23
age of onset1
AIDS39, 68, 72
antibody response614
antigenic challenge614
areas of increased signal intensity
(AISIs)15, 52, 5355, 61, 68
astrocytes, gemistocytic18, 23
astrocytic gliosis31
axonal damage18, 28, 3031, 61
azathioprine82
cerebrovascular disease47, 69, 76

chronic fatigue syndrome (CFS)69,
78
clinical aspects3337
clinical coursev1, 1516, 3435
computed tomography (CT)4852
concentric alternating
demyelination24, 2526
concordance, in monozygotic
twins4, 6
concussion7475
course of diseasev1, 1516, 3435
cranial nerves24
cystoid macular edema43
cytokines14
demyelination1516, 20, 24, 28
31, 61
concentric alternating24, 2526
see also myelinoclasia
dentate nuclei20, 24
Devics disease24
diagnosis3781
confirmatory laboratory
procedures3948
evoked potential studies4748
lumbar puncture39
see also neuroimaging
diagnostic criteria3739
new diagnostic criteria of
McDonald39, 39, 52
diffuse sclerosis24, 27
disease coursev1, 1516, 3435
disk herniation53, 57
-interferon82
B-lymphocytes6, 7
Bals disease24, 2526, 63
basal ganglia24
Binswangers disease76
blood-brain barrier deficits6, 7, 11
16
brain stem18, 33, 49
auditory responses47, 62
burden of disease52
burned-out MS35
cerebellum18, 33, 49, 51
cerebral arteritis68
cerebral hemispheres1824
cerebrospinal fluid examination39,
45
90
disseminated encephalomyelitis
see encephalomyelitis edema14,
15, 24
cystoid macular edema43
encephalomyelitis
disseminated39, 68
acute (ADEM)18, 35, 61, 65,
6768
multiphasic (MDEM)39, 68
recurrent (RDEM)39, 64, 68
postvaccination66
environmental influence4
epidemics23
epidemiology24
etiology5
evoked potential studies47, 47
facial nerve24
facial palsy61
familial occurrence4
fibrinogen leakage1112
gadolinium-enhanced MRI5358
gemistocytic astrocytes18, 23
genetics34, 6
geographical variation23
glaucoma47
glial scars16, 18
gliosis20, 61
astrocytic31
head trauma7475
herniated disks53, 57
HTLV-I-associated paraparesis39,
68, 71
human leukocyte antigen (HLA)
system34
hypothalamus24
immune complexes14
inflammation15, 18, 61
internuclear ophthalmoplegia24,
47
laboratory tests see diagnosis
lumbar puncture39
lupus erythematosus68
Lyme disease39, 68, 70
lymphocytic infiltration6, 10, 14
McDonald diagnostic criteria39,
39, 52
macrophages18, 22, 24, 2828, 31
magnetic resonance imaging (MRI)
5261
gadolinium enhancement5358
major histocompatibility complex
(MHC)34
Marburg disease35
median longitudinal fasciculus24
migraine, complicated68, 73
molecular mimicry14
monozygotic twins, concordance4,
6
MStrait (MST)614
multiphasic disseminated
encephalomyelitis (MDEM)39, 68
myelin abbau18, 22
myelin sheath32
see also demyelination;
myelinoclasia;
remyelination
myelinoclasia15, 22, 3536
see also demyelination
neuroimaging4881
computed tomography (CT)48
52
imaging differential
diagnoses6178
magnetic resonance imaging
(MRI)5261
positron emission tomography
(PET)8081
single-photon emission
computed tomography (SPECT)
79
neuromyelitis optica24
neurosarcoidosis69, 77
neurosyphilis39
nodes of Ranvier32
oligoclonal bands6, 7, 45
oligodendrocytes15, 30
onset
age at1
symptoms33
optic atrophy42, 44, 47, 49
optic chiasm24, 33, 47
optic fundus39
optic nerve24, 33, 39, 42, 47
optic neuritis8, 44, 60
papillitis41
parenchymatous lesions20
pathogenesis617
pathology1831
periphlebitis43
periventricular lesions2020, 31
physiology32
plaques7, 1213, 18, 2021, 23,
32
features of35
formation33
neuroimaging51, 5253
Schilders disease27
shadow plaques20
spinal cord51, 5253, 54
pons21
positron emission tomography
(PET)8081
postvaccination
encephalomyelitis66
prevalence2
geographical variation23
primary progressive MS (PPMS)34,
39
pseudoBals disease64
pseudo-exacerbations32
Raine, Cedric16
reactive gliosis20
recurrent disseminated
encephalomyelitis (RDEM)39, 64,
68
relapsing and remitting MS (RRMS)
34
remyelinationv, 1416, 20, 24, 31
safety factor35, 36
saltatory conduction32
sarcoidosis39
Schilders disease24, 27
scotoma44
secondary progressive MS (SPMS)
34
shadow plaques20
signs32, 33, 34
single-photon emission computed
tomography (SPECT)79
somatosensory evoked responses48
spinal cord18, 21, 24, 33
compression5253, 5758
plaques51, 5253, 54
whiplash injury54
spondylosis33, 52, 58
symptoms32, 33, 34
T-lymphocytes14
thalamus24
tic douloureux24
trauma68, 74
treatmentv, 82
trigeminal nerve24
trigeminal neuralgia24
tumor necrosis factor14
Uhthoffs phenomenon32
viral antigen response5, 613
visual evoked responses47
visual fields39
whiplash injury54

An Illustrated Pocketbook of Multiple Sclerosis

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An Illustrated Pocketbook of Multiple

The Parthenon Publishing Group

Published in the USA by

ISBN 0-203-59620-X (Adobe eReader Format)

Epidemiology and genetics

The newMSdiagnostic criteriaof McDonald

Optic fundus and visual fields

Confirmatory laboratory procedures

Examination of cerebrospinal fluid

Evoked potential studies

Magnetic resonance imaging

Imaging differential diagnoses

Single photon emissioncomputed tomography

Positron emission tomography

Multiple sclerosis (MS) has fascinated physicians ever since it was

2 AN ILLUSTRATED POCKETBOOK OF MULTIPLE SCLEROSIS

course is most often characterized by exacerbations and

Epidemiology and genetics

Multiple sclerosis is not evenly distributed throughout the world.

4 AN ILLUSTRATED POCKETBOOK OF MULTIPLE SCLEROSIS

Figure 1 Prevalence of multiple sclerosis in blacks compared with whites

Racial or ethnic origin plays an important, but not exclusive,

AN ILLUSTRATED POCKETBOOK OF MULTIPLE SCLEROSIS 5

non-biological relatives have no increased risk. There is strong

Multiple sclerosis has been described as a disease of unknown

The precise pathogenetic mechanism of MS remains controversial,

8 AN ILLUSTRATED POCKETBOOK OF MULTIPLE SCLEROSIS

Figure 2 Post-mortem perfusion study of a brain from a patient with

have been found in healthy siblings, including the non-affected

AN ILLUSTRATED POCKETBOOK OF MULTIPLE SCLEROSIS 9

Figure 3 Retinal fluorescein angiography in optic neuritis. Note leakage

10 AN ILLUSTRATED POCKETBOOK OF MULTIPLE SCLEROSIS

AN ILLUSTRATED POCKETBOOK OF MULTIPLE SCLEROSIS 11

Figure 5 Microscopy showing (upper) lymphocytic infiltration confined to

12 AN ILLUSTRATED POCKETBOOK OF MULTIPLE SCLEROSIS

Figure 6ad Blood-brain barrier defects in normal white matter in

AN ILLUSTRATED POCKETBOOK OF MULTIPLE SCLEROSIS 13

Figure 6Continued (c) capillary endothelial cells containing vesicles

14 AN ILLUSTRATED POCKETBOOK OF MULTIPLE SCLEROSIS

Figure 7 New multiple sclerosis plaques adjacent to brain needle tract

AN ILLUSTRATED POCKETBOOK OF MULTIPLE SCLEROSIS 15

the immune system is through molec-ular mimicry. This is a

16 AN ILLUSTRATED POCKETBOOK OF MULTIPLE SCLEROSIS

AN ILLUSTRATED POCKETBOOK OF MULTIPLE SCLEROSIS 17

be a possible explanation for the intermittent progression of the

18 AN ILLUSTRATED POCKETBOOK OF MULTIPLE SCLEROSIS

Figure 9 The disease process in multiple sclerosis can be compared with

Because MS is a disease of the myelin sheath, lesions are mostly

20 AN ILLUSTRATED POCKETBOOK OF MULTIPLE SCLEROSIS

Figure 10 Unstained gross coronal sections of brain. Note the typical

Figure 11 Unstained gross axial section of cerebellum. Note the typical

AN ILLUSTRATED POCKETBOOK OF MULTIPLE SCLEROSIS 21

Figure 12 Celloidin sections of occipital lobe showing several small

Figure 13 Celloidin section showing different intensities of staining.

22 AN ILLUSTRATED POCKETBOOK OF MULTIPLE SCLEROSIS

Figure 14 Weigert staining reveals a well-delineated multiple sclerosis

AN ILLUSTRATED POCKETBOOK OF MULTIPLE SCLEROSIS 23

Figure 15 Celloidin section of brain shows that the age of multiple

Figure 16 Histology (high-powered view of the same section as in Figure

24 AN ILLUSTRATED POCKETBOOK OF MULTIPLE SCLEROSIS