How Does Multiple Sclerosis Affect the Brain? An Expert Explains

Neurologist Barbara S. Giesser, MD, explains how multiple sclerosis affects the brain, spinal cord, and optic nerve. She also looks at the cognitive effects of MS and how to prevent them.

1. Multiple sclerosis (MS) is a condition of the central nervous system, which includes the brain, spinal cord, and optic nerve. How does MS affect these areas, and what are some of the issues MS causes with brain health specifically?

Nerves communicate with each other and with the rest of the body by sending electrical and chemical signals.

To understand how your nerves work, think about how they're similar to electrical cables. Nerves consist of a 'wire,' which we call the axon. The axon is covered by insulating material called myelin.

MS damages the myelin so that the nerve's ability to conduct electrical signals is slowed and uncoordinated. If the axon is also damaged, the electrical signal may be blocked entirely. When this happens, the nerve can't send appropriate information. This produces symptoms.

For example, if a muscle doesn't receive sufficient nerve input, there's weakness. If the part of the brain that's responsible for coordination is damaged, this can cause loss of balance or tremors.

MS lesions in the optic nerve may result in vision loss. Spinal cord damage is usually associated with decreased mobility, impaired or abnormal sensations, and impaired genitourinary (genital and urinary) function.

When it comes to the brain, changes due to MS can contribute to fatigue and other symptoms. MS brain lesions can produce difficulty with thinking and memory. MS brain changes may also contribute to mood disorders such as depression.

2. MS causes lesions in certain areas of the body. Why do these lesions occur? What's the best way to reduce, limit, or prevent lesions?

MS is widely believed to be an autoimmune process. In other words, the immune system, which normally protects your body, goes 'rogue' and begins to attack parts of your body.

In MS, the immune system attacks nerves in the central nervous system, including the brain, spinal cord, and optic nerve.

There are more than a dozen different FDA approved medications — known as disease modifying therapies (DMTs) — that can limit the number of new lesions, or areas of nerve damage, due to MS.

Early diagnosis and timely treatment with these medications is the most important strategy that has been documented to reduce future nerve damage. Life style habits such as regular exercise, not smoking, and maintaining a healthy body weight are also important.

3. Does MS affect different parts of the brain in different ways? What do we know about how MS affects the brain's white matter and grey matter?

MS produces damage in the more heavily myelinated regions of the brain, known as white matter. But MS has also been shown to affect the less myelinated regions closer to the surface of the brain, known as cortical grey matter.

Damage to both white matter and grey matter structures are linked to cognitive impairment. Damage to specific brain regions can produce difficulty with specific cognitive skills.

4. As we age, it's normal to experience brain atrophy (shrinkage) or loss of brain volume. Why is this? Is there anything that can be done to slow the rate of brain atrophy in people with MS?

The rate of brain atrophy in people with MS has been shown to be several times greater than the rate of brain atrophy in people of similar ages who don't have MS. This is because MS causes damage to the brain's white and grey matter and destruction of axons.

People with MS who smoke tobacco have been reported to have more brain atrophy than nonsmokers. Some studies have reported that some DMTs may reduce the rate of brain atrophy.

There are also a few reports that people with MS who are more physically fit have less atrophy than people who are less physically active.

5. What are some of the cognitive symptoms of MS?

The cognitive difficulties that are most common in people with MS tend to be with memory and speed of information processing. There may also be problems with multitasking, sustained memory and concentration, prioritizing, decision-making, and organization.

Additionally, difficulty with verbal fluency, especially word finding — the feeling that 'the word is on the tip of my tongue' — is common.

Cognitive difficulties may be a direct result of lesions. However, cognition may also be impaired by the contributing factors of fatigue, depression, poor sleep, medication effects, or a combination of these factors.

Some cognitive functions are more likely than others to remain healthy. General intelligence and information, and understanding of words tend to be preserved.

6. What's the connection between the cognitive symptoms of MS and where MS affects the brain?

Different cognitive functions tend to be associated with different parts of the brain, although there's a lot of overlap.

So called 'executive functions' — such as, multitasking, prioritizing, and decision-making — are most associated with the frontal lobes of the brain. Many memory functions occur in a grey matter structure called the hippocampus. (It's named after the Greek word for 'seahorse').

Damage to the corpus callosum, a very heavily myelinated bundle of nerves that connects the two hemispheres of the brain, is also associated with cognitive impairment.

MS commonly affects all of these areas.

Overall brain atrophy and loss of brain volume are also highly correlated with cognitive function issues.

7. What screening tools are used to look for cognitive symptoms in people living with MS? How often should people with MS be screened for signs of cognitive change?

There are short tests of specific cognitive functions that can be easily and quickly administered in the doctor's office. These can screen for evidence of cognitive impairment. For example, one such test is called the Symbol Digit Modalities test (SDMT).

If a screening test suggests cognitive problems, your doctor may recommend a more in-depth assessment. This would usually be formally done with tests that are collectively referred to as neuropsychological testing.

It's recommended that people with MS be assessed for cognitive function at least annually.

8. How are cognitive symptoms of MS treated?

When addressing cognitive impairment in people with MS, it's important to identify any contributing factors that may worsen cognitive problems, such as fatigue or depression.

People living with MS may have untreated sleep disorders such as sleep apnea. This can also impact cognition. When these secondary factors are treated, cognitive function often improves.

Research has shown that targeted cognitive rehabilitation strategies are beneficial. These strategies address specific domains — like attention, multitasking, processing speed, or memory — using techniques such as computer training.

9. Are there any lifestyle approaches, such as diet and exercise, that may help people living with MS to reduce or limit cognitive changes?

A growing body of literature suggests that regular physical exercise may improve cognitive function in people with MS. However, a specific regimen for this has yet to be determined.

While no diet has been shown to affect cognition in people with MS per se, a heart-healthy diet may reduce the risk of comorbidities (other diseases) that can contribute to cognitive impairment.

A heart-healthy diet is generally one that primarily contains lots of fruits and vegetables, lean proteins, and 'good' fats such as olive oil. The diet should also limit saturated fats and refined sugars.

Following this type of eating plan may limit comorbidities such as vascular disease, type 2 diabetes, or high blood pressure. All of these conditions can contribute to cognitive impairment and disability in people with MS.

Smoking is a risk factor for brain atrophy, so quitting smoking may help to limit further atrophy.

It's also important to stay mentally active and socially connected.


Barbara S. Giesser, MD received her medical degree from the University of Texas Health Science Center at San Antonio, and completed neurology residency training and MS fellowship at the Montefiore Medical Center (NY) and Albert Einstein College of Medicine. She's specialized in the care of persons with MS since 1982. She's currently Professor of Clinical Neurology at the David Geffen UCLA School of Medicine and Clinical Director of the UCLA MS program.

Dr. Giesser has conducted peer-reviewed research into the effects of exercise in persons with MS. She's also created educational curricula for national organizations such as the National MS Society and the American Academy of Neurology. She's active in advocacy efforts to promote access to care and medications for persons with MS and other neurologic diseases.

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