Signs and Symptoms of Multiple Sclerosis
Multiple sclerosis (MS) presents with a diverse range of neurological signs and symptoms that reflect damage in different parts of the central nervous system, with the most common manifestations including visual disturbances, sensory abnormalities, motor weakness, and balance problems.
Core Clinical Manifestations
Visual Disturbances
- Optic neuritis: Most common afferent visual pathway manifestation 1
- Retrochiasmal or retrogeniculate visual field defects 1
- Ocular motor disorders 3:
- Internuclear ophthalmoplegia (INO) - most frequent and specific manifestation
- Diplopia due to ocular misalignment
- Nystagmus (gaze-evoked, pendular)
- Saccadic hypermetria
Sensory Symptoms
- Numbness and tingling (paresthesias) 4
- Sensory disturbances developing over several days 2
- Lhermitte's sign (electric shock-like sensation down spine with neck flexion)
Motor Symptoms
Brainstem Symptoms
- Internuclear ophthalmoplegia 3
- Facial weakness or numbness
- Vertigo
- Hearing loss
Bladder, Bowel, and Sexual Dysfunction
- Urinary urgency, frequency, or incontinence 4
- Constipation
- Sexual dysfunction
Other Common Symptoms
Disease Patterns
Relapsing-Remitting Pattern
- Discrete episodes ("attacks" or "relapses") 4
- Symptoms develop over days
- Relative stability between attacks
- Most common initial presentation pattern 2
Progressive Pattern
- Insidious worsening of neurologic function 4
- Gradual accumulation of disability
- May occur with or without superimposed relapses
- Accounts for most long-term disability 4
Diagnostic Features on Testing
MRI Findings
- Periventricular lesions: Abutting lateral ventricles 5
- Juxtacortical lesions: Touching or within the cortex 5
- Infratentorial lesions: Brainstem, cerebellar peduncles, cerebellar hemispheres 5
- Spinal cord lesions: Multiple discrete focal lesions, typically small 5
- Lesion characteristics:
- Ovoid/round shape
- At least 3 mm along main axis
- Asymmetric distribution 5
Cerebrospinal Fluid
- Presence of oligoclonal IgG bands different from serum 6
- Elevated IgG index
- Lymphocytic pleocytosis less than 50/mm³ 6
Visual Evoked Potentials
- Delayed but well-preserved waveform typical of MS 6
Red Flags That Suggest Alternative Diagnoses
- Symmetric distribution of lesions (suggests leukodystrophy) 5
- Linear-shaped lesions (suggests perivascular spaces) 5
- Periaqueductal or periependymal lesions surrounding lateral ventricles (suggests NMOSD) 5
- Longitudinal extensive transverse myelitis affecting ≥3 vertebral segments (suggests NMOSD) 5
- Leptomeningeal/root enhancement (suggests neurosarcoidosis) 5
Diagnostic Criteria
The McDonald criteria require evidence of:
- Dissemination in space: Evidence of damage in different parts of the nervous system 6
- Dissemination in time: Evidence of damage occurring at different times 6
- No better explanation for the clinical presentation 6
Impact on Quality of Life
- Vision loss has a major impact on quality of life in MS 1
- Physical disability, cognitive impairment, and other symptoms affect quality of life 2
- Work performance is often affected, with many patients needing to modify or change jobs 5
Clinical Pearls
- MS typically presents in young adults (mean age 20-30 years) 2
- More commonly affects women (female to male ratio of nearly 3:1) 2
- Prevalence increases with higher latitudes (ranges from 5 to 300 per 100,000 people) 2
- Obesity in adolescence and early adulthood increases MS risk (relative risk 2.25) 6
- Low vitamin D levels are associated with increased MS risk 6
Early recognition of these signs and symptoms is crucial for prompt diagnosis and treatment, which can help reduce the frequency of relapses and slow disease progression, ultimately improving long-term outcomes for patients with multiple sclerosis.