The dominant hypothesis in multiple sclerosis is that it is an autoimmune disease; however, there is
considerable evidence that the immune attack on myelin may be secondary to a cytodegenerative event. Furthermore, the
immune modulating therapies longest in clinical use, although modulating the frequency and severity of exacerbation, do
not affect long-term progression towards disability. Clearly alternative perspectives on the etiology of multiple sclerosis
are warranted. In this paper I outline the commonalities between idiopathic normal pressure hydrocephalus and multiple
sclerosis. These include decreased intracranial compliance as evidenced by increased cerebrospinal fluid volume and
velocity of cerebrospinal fluid flow through the cerebral aqueduct; increased ventricular volume; periventricular
demyelination lesions; increase in size of Virchow-Robin spaces; presence of Hakim’s triad comprised of locomotory
disabilities, cognitive problems and bladder control problems. Furthermore, multiple sclerosis is associated with decreased
arterial compliance. These are all suggestive that there is a pulse wave encephalopathy component to multiple sclerosis.
There are enough resemblances between normal pressure hydrocephalus and multiple sclerosis to warrant further
investigation. Whether decreases in intracranial compliance is a consequence of multiple sclerosis or is a causal factor is
unknown. Effective therapies can only be developed when the etiology of the disease is understood.
Keywords: Arterial compliance, Hakim’s triad, Intracranial compliance, Multiple sclerosis, Normal pressure hydrocephalus,
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