Patient Care

Multiple sclerosis is a chronic autoimmune disease in which the immune system attacks myelin, the insulating sheath around nerve fibers in the brain and spinal cord. Damage to myelin slows or blocks electrical signals between the brain and the body. MS affects approximately 1 million people in the United States and is one of the most common causes of non-traumatic neurological disability in adults aged 20 to 50. 

Clinically isolated syndrome is a first episode of neurological symptoms caused by inflammation and demyelination in the central nervous system that lasts at least 24 hours and occurs without fever or infection. It represents the earliest possible clinical presentation of MS. CIS can be monofocal, affecting one region, or multifocal, affecting two or more regions simultaneously. The most common presentations are optic neuritis, a partial myelitis causing limb symptoms on one side, and a brainstem syndrome causing double vision or dizziness.

Radiologically isolated syndrome describes the incidental discovery of brain or spinal cord MRI lesions that are characteristic of demyelination in someone who has no history of neurological symptoms consistent with MS. It is most often found when imaging is performed for an unrelated reason, such as evaluation of headaches or trauma. The lesions must meet specific spatial criteria, including involvement of periventricular, juxtacortical, infratentorial, or spinal cord regions, to qualify as RIS.

Neuromyelitis optica spectrum disorder is an autoimmune astrocytopathy in which antibodies target aquaporin-4 (AQP4), a water channel protein concentrated on astrocyte foot processes at the blood-brain barrier. Antibody-mediated destruction causes severe inflammation, primarily in the optic nerves, spinal cord, and area postrema. NMOSD is distinct from MS and must be distinguished from it, as several MS treatments can worsen NMOSD.

Optic neuritis is inflammation of the optic nerve that disrupts transmission of visual signals from the retina to the brain. It most commonly presents in adults aged 20 to 45 and is the initial symptom in approximately 25% of MS cases and a presenting feature of NMOSD and MOG antibody-associated disease (MOGAD). Typical MS-associated optic neuritis is unilateral, painful with eye movement, and recovers substantially within weeks to months. Atypical features such as bilateral involvement, no pain, or severe visual loss that does not recover raise concern for NMOSD or MOGAD.

Transverse myelitis is inflammation spanning the full or partial width of the spinal cord at a discrete level, causing loss of motor, sensory, and autonomic function below that segment. It can arise from MS (where it tends to be short-segment and asymmetric), NMOSD (where it is typically longitudinally extensive, spanning 3 or more vertebral segments), MOGAD, or as an isolated idiopathic condition, sometimes following viral infection or vaccination. Spinal MRI is essential to characterize lesion extent and guide diagnosis.

Acute disseminated encephalomyelitis is a monophasic, immune-mediated inflammatory demyelinating disease of the brain and spinal cord that typically follows a viral infection or, less commonly, vaccination. It is significantly more common in children, where it accounts for up to 40% of acquired demyelinating syndromes. The hallmark feature distinguishing ADEM from a first MS attack is encephalopathy, defined as altered consciousness or behavioral change, which must be present for the diagnosis. MOG-IgG antibody is detected in a substantial portion of ADEM cases, particularly in children.

Autoimmune encephalitis encompasses a group of conditions in which antibodies directed against neuronal surface proteins or synaptic receptors cause brain inflammation. The most common form, anti-NMDA receptor encephalitis, often begins with psychiatric symptoms before progressing to seizures and decreased consciousness. Other well-defined subtypes involve antibodies against LGI1, CASPR2, GABA-B, and AMPA receptors, each with distinct clinical presentations. Some cases are paraneoplastic, triggered by an underlying tumor (most commonly ovarian teratoma in anti-NMDAR encephalitis), while others occur without a detectable cancer.

Central nervous system vasculitis is inflammation of the blood vessel walls supplying the brain and spinal cord. Primary angiitis of the central nervous system (PACNS) is confined to the CNS without systemic involvement and is rare. Secondary CNS vasculitis occurs in the context of systemic autoimmune diseases (such as lupus or Sjogren syndrome), infections (such as varicella-zoster or syphilis), or drug exposure. Vessel inflammation leads to stenosis, thrombosis, and ischemia, causing strokes and diffuse neurological dysfunction.

Brain MRI abnormalities discovered unexpectedly, without a targeted clinical indication, are common and represent a wide spectrum of pathology. Reported findings may include white matter lesions, unidentified bright objects (UBOs), lacunar infarcts, enlarged perivascular spaces, microhemorrhages, arachnoid cysts, and incidental meningiomas. The clinical significance ranges from entirely benign and age-appropriate changes to early markers of vascular disease, demyelinating disease, or rarely, neoplasm. 

White matter disease refers to areas of T2 or FLAIR hyperintensity in the cerebral white matter seen on brain MRI. These lesions arise from a variety of causes. In older adults with vascular risk factors (hypertension, diabetes, smoking), periventricular and subcortical lesions most commonly represent small vessel ischemic disease. In younger adults or those with neurological symptoms, white matter lesions may indicate a demyelinating condition such as MS, NMOSD, or MOGAD. Other causes include migraine, vasculitis, CADASIL, Lyme disease, and metabolic or toxic injury. Lesion location and pattern are critical to narrowing the differential.

MRI (Magnetic Resonance Imaging) is a scan that uses magnets and radio waves to create detailed pictures of the brain, spine, and other parts of the body. It helps doctors look for signs of disease, injury, or inflammation.

Optical Coherence Tomography (OCT) is a quick, painless eye scan that takes detailed images of the retina and optic nerve. It helps doctors detect changes that may be related to neurological or eye conditions.

Spinal Tap (Lumbar Puncture) is a procedure that collects a small sample of fluid from around the spinal cord using a thin needle in the lower back. The fluid is tested for signs of infection, inflammation, or other neurological conditions.

A blood test is a laboratory test that analyzes a sample of blood to look for markers of disease, inflammation, infections, vitamin deficiencies, or other health conditions that may be affecting your symptoms.