Dissemination In Space And Time

Definition: chronic autoimmune T cell mediated inflammatory Type of MS

disorder of CNS

Multiple plaques of demyelination of the brain and spinal cord

(mainly white matter)

CNS sites: optic nerves, periventricular region, corpus callosum,

brainstem, cerebellar connections to spinal cord (corticospinal and
dorsal column)

Plaques: 2-10mm in size (cardinal features)

Occur sporadically over years (dissemination in space and time)

Risk factor

Woman more common (2:1)

1. Relapsing remitting (85-90%)
Age 20-40 years (rare in 60)
2. Secondary progressive (75% relapsing remitting will
Viral infection i.e. EBV, HHV-6 progress)
3. Primary progressive (10-15%)
Lack of vitamin D and sunlight exposure
 REQUIRE TWO OR MORE ATTACKS AFFECTING DIFFERENT PARTS OF
CNS
Clinical presentation (History taking in relapse)
First episode suggestive of neuro-inflammation – termed as clinically
3 characteristics: optic neuritis, brainstem demyelination, spinal isolated syndrome
cord lesion
An abnormal brain MRI at presentation, with multiple inflammatory
1. Optic neuritis type lesions, confers an 85% chance of developing MS over
a. Subacute visual loss unilateral
subsequent years (50% if presenting with optic neuritis).
b. Vary from mild fogging of central vision with colour
desaturation to a dense central scotoma repeat MRI brain scan at least
c. Aggravated: heat or exercise (Uhthoff phenomenon)
d. Associated symptoms: retro-orbital or ocular pain, 1 month later showing either a new lesion or a gadolinium
phosphenes/flashes, pulfrich phenomenon
e. 50% patients app develop MS enhancing lesion is sufficient to show dissemination in time
2. Brainstem demyelination
a. Diplopia, vertigo, facial numbness/weakness, and space and confirm the diagnosis even in the absence of
dysarthria/dysphagia
new symptoms.
b. Pyramidal signs (corticospinal) – sudden diplopia,
vertigo with nystagmus but without tinnitus or
deafness.
c. Bilateral internuclear ophthalmoplegia –
pathognomonic
3. Spinal cord lesion
a. Paraparesis over days or weeks
b. Lhermitte’s sign may present
c. Tight band sensation around abdomen or chest –
thoracic lesion

Refer senior long case

Investigations

Diagnosis of MS
1. MRI of brain and cord – shows areas of demyelination with b. HIV, HTLV-1, B12 def
high sensitivity
 Multiple scattered plaques
 Oval in shape 2mm to 2cm in diameter and ofter orientated
Principle of management
perpendicular to the lateral ventricles
 Acute lesion shows gadolinium enhancement for 6-8 weeks General
 Lower specificity
o Age> 50 – small ischeamic lesions 1. Educate patient
o Younger patients – sarcoidosis, behcet’s syndrome 2. Provision of appropriate written material and support from
and vasculitis may produce the similar imaging MDS team
appearance 3. OT
 High specificity 4. Physiotherapist
o In spinal cord lesion: less common in ischaemic 5. Refer to ophthal and neuro
lesions 6. IV steroid for acute relapse
2. CSF examination a. IV methylprednisolone 1g/d for 3 days or high dose
a. Oligoclonal IgG bands (90%) oral steroids for severe relapse
3. Evoked responses i.e. visual evoked responses in optic nerve 7. Disease modifying drugs
lesions a. Immunomodulatory drugs – beta interferon &
4. Blood test glatiramer acetate
a. To rule other inflammatory disorder i.e. SLE, 8. Monoclonal antibodies
sarcoidosis a. Natalizumab, alemtuzumab, oral fingolimod