FFinalistSouthampton · 2027
Neurology
AKT · Neurology/Demyelinating & NMJ

Multiple sclerosis

Autoimmune CNS demyelination (disseminated in time and space)

Overview

A chronic autoimmune demyelinating disease of the CNS, defined by neurological episodes DISSEMINATED IN TIME AND SPACE. Typically a young woman with relapsing-remitting attacks (optic neuritis, sensory, motor, cerebellar). Diagnosis combines clinical episodes, MRI lesions and CSF oligoclonal bands.

Recognise

  • Optic neuritis (painful monocular visual loss, RAPD), internuclear ophthalmoplegia
  • Sensory (numbness, Lhermitte sign), motor/spasticity, cerebellar (ataxia, tremor), bladder dysfunction
  • Uhthoff phenomenon (worse with heat); relapsing-remitting (85%) → secondary progressive

Red flags

  • Acute relapse with disabling features; progressive course; tumefactive/atypical presentations

Differentials & how to tell them apart

Neuromyelitis optica (Devic)severe optic neuritis + transverse myelitis, AQP4 antibodies — different treatment
Vasculitis / SLEsystemic features, autoantibodies
B12 deficiency (SCD of cord)dorsal-column + corticospinal signs, low B12
Functional / migraineno MRI lesions, no objective signs

Investigations

MRI brain + cord (periventricular/juxtacortical/infratentorial/cord lesions — disseminated in space and time); CSF oligoclonal bands; visual evoked potentials; exclude mimics (NMO/AQP4, B12).

Management

Acute relapse: high-dose methylprednisolone; long-term: disease-modifying therapy

  1. 1Acute relapse → high-dose methylprednisolone (shortens the relapse, does not alter the degree of eventual recovery).Gate: Steroids treat the relapse but do NOT modify the disease course — long-term relapse reduction needs a disease-modifying therapy, prescribed by neurology
  2. 2Disease-modifying therapy for relapsing-remitting MS; symptomatic management of spasticity, bladder, fatigue, neuropathic pain; MDT rehab.
High-dose steroids (IV/oral methylprednisolone) — acute relapse — shortens duration, does not change ultimate recovery
Disease-modifying therapies (e.g. natalizumab, ocrelizumab, dimethyl fumarate) — reduce relapse rate in relapsing-remitting MS (specialist)
Symptomatic: baclofen/gabapentin (spasticity), anticholinergics (bladder) — symptom control

Key points

Disseminated in time AND space is the definition. Optic neuritis + internuclear ophthalmoplegia + Lhermitte/Uhthoff in a young woman is the classic picture. Steroids for relapse ≠ disease modification.

Monitor & prognosis

Relapse frequency, MRI lesion burden, disability, DMT safety.

Variable; worse with motor/cerebellar onset and high lesion load.

Source: NICE NG220 (multiple sclerosis)