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Multiple sclerosis: course
Multiple sclerosis is also known as the “disease with a thousand faces” because it is different and unpredictable for each person affected. This is mainly explained by the fact that each patient affects different parts of the central nervous system (brain and spinal cord) and the damage is different. With increasing duration of the disease, damage and scarring can occur in the brain and spinal cord. The nervous system can partially replace or compensate for this damage. Depending on the course, a distinction is made between relapsing and progressive (continuously progressing) forms of multiple sclerosis.
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- How is the disease going?
- Disease activity and disease progression
How is the disease going?
The underlying mechanisms change as the disease progresses:
- Relapsing course: In the early phases of the disease, inflammatory cells migrate from the bloodstream into the central nervous system. It mainly occurs in the immediate vicinity of certain veins in the white matter - especially those that run towards the large, fluid-filled cavities (ventricles) of the brain - to focal inflammation and demyelinating (loss of the brain and spinal cord). As a result, damage to the nerve fibers occurs. In this phase the barrier function of the blood-brain barrier is disturbed.
- Progressive course: As the disease progresses, the inflammatory cells also accumulate in the soft meninges that surround the brain and the spinal cord and in the CNS tissue. The inflammation in the CNS then seems to be decoupled from the rest of the immune system and can hardly be influenced, for example by drug therapies. This process is also called “compartmentalization” of the inflammatory reaction. De-marrowing is increasing in size, no longer showing typical focal delimitations and spreading into large parts of the brain or spinal cord. Nerve cell damage is becoming more and more important.
In up to 90 percent of patients, the disease begins with an initial attack. This is also known as “clinically isolated syndrome” (CIS). The occurrence of increasing symptoms within hours to days is typical, which lasts for one to several weeks and then gradually disappears partially or completely. As a result - after months or even years - new foci of inflammation can trigger further attacks in a similar or different form. In these cases one speaks of a relapsing course of the disease.
- Primarily chronically progressive course: In ten to 15 percent of those affected, the disease takes a chronic course from the start. The slow, continuous deterioration, very often for example paralysis of the legs, can temporarily stand still (“plateau phase”). There are also minor temporary improvements in symptoms. Flare-ups do not occur with this form.
- Secondary chronic progressive course: After an initially relapsing course, the disease turns into a so-called secondary chronic course with gradual deterioration in over 50 percent of those affected after ten to 15 years. The percentage increases with the duration of the illness. During this phase of the disease, some MS sufferers may have additional (“attached”) relapses.
Disease activity and disease progression
When assessing the course of the disease, the level of disease activity is also taken into account. In the case of the relapsing form, this is decisive for the choice of long-term basic therapy. A highly active course is characterized by frequent, severe relapses or a rapidly increasing neurological deterioration due to inflammatory changes in the CNS. Inflammation-related changes in the brain and spinal cord can be detected using an MRI.
The increase in symptoms over the years is commonly called disease progression. It is either the result of an incomplete restoration of body functions after attacks of the disease or a slowly increasing deterioration. A good resolution of the symptoms is usually only possible at the beginning of the disease.
Note The so-called "radiologically isolated syndrome" (RIS) is a coincidental finding if an MRI of the brain or spinal cord is performed for another reason (eg because of pain) and the imaging unexpectedly reveals inflammatory foci. Neurological monitoring is advisable in these cases, as the clinical picture of MS will develop over the years in 30 to 45 percent of cases.