6a. Multiple Sclerosis Flashcards
Name 4 facts about MS.
- It is the leading cause of non-traumatic neurological disability in young adults.
- It is an autoimmune disease.
- Most cases occur between the ages of 20-40.
- It is more common in woman (3:1) and more common in countries further from the equator.
What are risk factors of MS?
- Genetic factors
- Environmental factors (3x)
Genetic factors: the incidence in first degree relatives is 20 times higher than in the general population. The concordance rate is 30% in mono-zygotic twins, so environmental effects are also involved.
Environmental factors:
- Low vitamin D
- Epstein-Bar Virus
- Smoking
What are the most common symptoms of MS in early stages? (8x)
- Double/blurred vision
- Numbness
- Weakness in extremities
- Instability in walking
- Tremors
- Problems with bladder control
- Cognitive problems
- Mood problems (depression/anxiety)
Course
What 2 phases of MS can you distinguish?
- Relapsing-remitting phase
2. Secondary progressive phase
Explain the relapsing-remitting phase of MS.
Early stage of the disease > autoreactive immune celss traffic into the CNS > results in focal inflammation and demyelination (visible as gadolinium-enhancing lesions on MRI) > relapses are then followed by periods of remission as inflammation resolves and remyelination occurs.
Explain the secondary progressive phase of MS.
Over time chronic inflammation with scar formation (=sclerosis), accumulation of axonal damage, brain atrophy, and inhibition of remyelination contribute to progressive worsening.
Name 5 types of lesions in MS.
- Juxtacortical lesion
- Periventricular lesion
- Lesion in the pons
- Lesion in the spinal cord
- Gadolinium-enhancing lesion
Explain a juxtacortical lesion?
Lesion in or near the cortex
Explain a periventricular lesion
Lesion between cortex and ventricles
Explain a lesion in the pons
Lesion in part of the brain stem (=pons)
Explain lesion in the spinal cord
Lesion in C5, C6
Explain a gadolinium-enhancing lesion
Lesion caused by active inflammation
McDonald 2017 diagnosis MS (based on neurological exam)
Name 2 statements.
- Dissemination in space = 1 or 2 lesions typical of MS present in 2 or more sites within the CNS.
- Dissemination in time = requires that 2 attacks seperated by more than 30 days have occured in different parts of the CNS.
Tests to confirm the diagnosis of MS
Why MRI?
To look for signs of inflammation (T2-hyperintense & gadolinium-enhanced lesions)
Tests to confirm the diagnosis of MS
Why blood test?
To exclude other conditions (vitamin deficiency, lupus erythematosus)
Tests to confirm the diagnosis of MS
Why spinal tap?
To extract CSF to analyze the number of white blood cells (reflect immune system functioning), neurofilaments (reflects axonal damage due to inflammation), or oligoclonal bands (reflects inflammatory activity in the CNS).
Tests to confirm the diagnosis of MS
Why evoked potential tests?
To examen how long it takes for the brain to respond to visual stimulation, since MS often starts with visual problems due to damage to the optic nerves (looking at a flashing chessboard pattern with electrodes).
Which 6 neuropsychiatric problems are very common in MS?
- Major Depression
- Bipolar Affective Disorder
- Euphoria
- Psychosis
- Personality change
- Anxiety disorders
Neuropsychiatric problems in MS
Explain depression
- Why depression in MS?
- Causes (3x)
Many symptoms overlap, such as fatigue, sleep, appetite disturbances, and abnormalities in concentration.
Causes of depression in MS:
- T2 lesions in the prefrontal cortex and temporal lobe
- Less gray matter and greater CSF volume in the temporal lobe.
- Reactive: uncertainty, hope, helplessness, inadequate coping strategies, fatigue.
Neuropsychiatric problems in MS
Explain bipolar disorder
- Prevalention
- Tried of symptoms
- Treatment
Twice as prevalent as in the general population.
Tried of symptoms:
- Elevated or irritable mood
- Grandiose or persecutory thinking
- Increased psychomotor activity
Treatment: mood stabilizing medication & sedation
Neuropsychiatric problems in MS
Explain euphoria
A defixed state of well-being despite the presence of considereable physical morbidity (lack of insight)
Neuropsychiatric problems in MS
Explain psychosis
2-3 times more common and associated with a higher lesion load in medial temporal lobe regions.
Treatment: anti-psychotic medication
Neuropsychiatric problems in MS
Name 2 causes of personality changes in MS.
- Damage in orbitofrontal-subcortical circuits = profane, disinhibited and socially inappropriate behaviors.
- Damage in anterior cingulate-subcortical pathways = apathy & indifference
What are the 2 most commonly affected domains in MS?
Which area is mostly associated with cognitive impairments in MS?
- (Visual) memory
- Information processing speed (=hallmark in MS)
Area: especially thalamic atrophy
It does not correlate with disease duration, only, not al MS patients experience it.
On which 3 areas do cognitive problems affect the quality of life in MS patients?
- Participation: employment, social function, daily activities, physical indepencence
- Relationships: caregivers experience high levels of distress due to the patient’s cognitive problems, and less their physical symptoms
- Safety: falls, driving > information processing speed, spatial learning, and recall are important predictors for driving performance and accidents
Assessment of cognition in MS
Which 4 types of assessments can you distinguish?
- Screening tests (routine in the office)
- Brief batteries (routine in neuropsychological exam)
- Intermediate length batteries
- Comprehensive ad-hoc batteries (for differential diagnoses, work disability questions, and rehabilitation programs)
Which 2 screening tests for cogntion in MS can you distinguish?
- Symbol Digit Modalities Test (SDMT)
2. MS Neuropsychological Screening Questionnaire
Explain the SDMT in MS.
Symbol Digit Modalities Test = the most popular test in MS.
Used as a minimum baseline screening and repeated yearly (5 min duration).
It examines information processing speed and working memory (substitute meaningless symbols by corresponding numbers)
Explain the MS Neuropsychological Screening Questionnaire.
Needs to be filled in by the patient and informant.
Self-reported scores correlate more with depression, informant-reported scores more with cognitive dysfunction.
What is the BRNB in MS?
Brief Neuropsychological Battery
Which 5 tests are included in the Brief Neuropsychological Battery in MS?
- Symbol Digit Modalities Test (SDMT)
- Selective Reminding Test
- 10/36 Spatial Recall Test (SPART)
- Paced Auditary Serial Addition Test (PASAT)
- Word list generation
Brief Neuropsychological Battery in MS
Explain the Selective Reminding Test
To measure verbal learning and memory recall. It’s similar to the 15WT, but here are 12 words and only the words that are missed are given by the test instructor.
Brief Neuropsychological Battery in MS
Explain the 10/36 Spatial Recall Test (SPART)
To assess visuospatial learning and late recall. It’s a board with dots that the subject has to reproduce.
Brief Neuropsychological Battery in MS
Explain the Paced Auditary Serial Addition Test (PASAT)
2nd most popular test in MS.
To assess processing speed and working memory. Patients need to add pairs of digits presented at 2 rates of speed. The 2 second condition is hard for MS patients.
Brief Neuropsychological Battery in MS
Explain the Word list generation test
A semantic fluency test (vegetables, fruits, animals)
Which 3 treatment options for MS can you distinguish? And explain.
- Disease modifying therapies: it might help to preserve intact cognitive functioning and delay the development of cognitive impairment, however, weak positive effects on cognition.
- Acetylcholinesterase inhibitors: promising, but studies with small sample size.
- Behavioral interventions: cognitive/strategy training (limited data on effectiveness, but targeted interventions to improve acquisition in verbal memory and learning show promise)
