Multiple sclerosis: lessons from neuropathology

The focus of multiple sclerosis (MS) research has been on attempts to identify the specific pathogenic mechanism responsible for producing the multifocal central nervous system inflammatory demyelinating lesions. However, extensive in vitro and in vivo evidence suggests that multiple different immunological mechanisms may produce the typical demyelinated plaque. A detailed examination of actively demyelinating MS lesions reveals a profound heterogeneity in the structural and immunopathological patterns of demyelination and oligodendrocyte pathology between different MS patients, suggesting multiple pathogenic mechanisms may contribute to oligodendrocyte and myelin injury in MS. These observations raise the question whether MS may be a neurological syndrome with different immunopathological mechanisms triggering a common pathway rather than a single disease with a uniform mechanism of myelin destruction. With the advent of new tools for neurobiological and immunological research applied to actively demyelinated MS lesions, an opportunity exists to reevaluate MS neuropathology. This review highlights the spectrum of the inflammatory demyelinating diseases, the multitude of effector mechanisms that may produce myelin destruction, and the pathologic heterogeneity observed in MS lesions. A careful evaluation of MS neuropathology should provide important clues regarding the induction, target, evolution, and pathogenesis of this complex disease.