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Neurology 2 > ClinMed - MS > Flashcards

ClinMed - MS Flashcards

1
Q

What is MS?

A

-immune mediated response by the body’s own immune system directed against the CNS

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2
Q

pathology progression of MS

A
  • system attacks the myelin, fatty covering of nerve fibers
  • myelin is damaged and scars form leading to degeneration and axonal death
  • scars or degenerated area interrupt the electric signal conduction of the nerve
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3
Q

what are the 3 areas effects in MS?

A
  • brain
  • SC
  • optic nerves
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4
Q

type of disease that classifies MS

A

demyelination

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5
Q

triad of risk factors for MS

A
  • genetic risk
  • environmental risk
  • immunologic risk
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6
Q

enviromental risk factors

A
  • low vit. D
  • northern latitude
  • smoking
  • obesity
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7
Q

immunologic risk

A
  • virus (EBV) trigger

- infectious agent

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8
Q

interesting stat about the epidemiology of MS

A

1:3 chance in monozygotic twins (not just genetic)

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9
Q

how to make the diagnosis of MS

A
  • no single test
  • best thing is MRI
  • and get a good hx
  • must be multiple events
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10
Q

criteria of MS diagnosis

A

-evidence of damage to at least 2 and separate areas of CNS
AND
-evidence that damages occurred at least 1 month apart
AND
-r/o other possibilities

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11
Q

what are the 3 possibilities to consider before establishing secure diagnosis?

A
  1. definite MS: meets mcdonald criteria
  2. probable MS: close to meeting mcdonalds + fam hx
  3. possible MS: doesn’t meet clinical or radiological criteria for definite diagnosis - this is a waiting game
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12
Q

mcdonald criteria

A
  • review this in slides

- not sure if it would be testable?

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13
Q

Dawson fingers

A
  • very classic MS lesions
  • demyelinating plaques through corpus callosum
  • right angles along medullary veins
  • present as T2 hyper-intensities
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14
Q

Black holes

A
  • hypointense lesions commonly seen in MS
  • indicates destruction, axonal loss and relatively severe CNS damage
  • seen in T1 modality
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15
Q

GAD enhancing lesions

A
  • during active inflammation, the BBB is disrupted
  • allows the gadolinium to pass through
  • GAD can enter CNS and leak into the new lesion
  • “new lesion” = in the past 6-8 weeks
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16
Q

describe an acute cord lesion

A
  • GAD enhancement

- spinal cord spelling

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17
Q

describe a chronic cord lesion

A
  • cord atrophy

- greater disability

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18
Q

Ddx in MS

A
  • AVM
  • other autoimmune: lupus, sjogren’s, sarcoidosis, ADEM, NMO
  • B12 or Cu deficiency
  • infection: lymes, syphilis, HIV
  • malignancy
  • migraine
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19
Q

general clinical manifestation categories of MS

A
  • eye
  • vertigo
  • ataxia
  • SC sx
  • cortical signs
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20
Q

clinical manifestions of MS in the eye

A
  • optic neuritis
  • nystagmus
  • diplopia
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21
Q

optic neuritis

A
  • painful eye movement
  • decrease in visual field
  • decrease in color saturation
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22
Q

clinical manifestation of vertigo

A
  • associated w/ adjacent structures
  • increased/decreased hearing
  • facial numbness
  • diploplia
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23
Q

clinical manifestations of ataxia

A
  • truncal: poor sitting balance

- limb: finger to nose, intention tremor

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24
Q

clinical manifestations of SC

A
  • nerve pain
  • L’Hermitte sign (when they tuck chin they feel electric shock over cape distribution)
  • neurogenic bladder > bowel
  • sexual dysfunction
  • weakness then spasticity
  • hyperreflexia
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25
Q

clinical manifestations of cortical signs in MS

A
  • poor mood
  • migraine
  • seizure
  • cognitive changes
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26
Q

sub types of MS

A
  • relapsing remitting (MS)
  • secondary progressive
  • primary progressive
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27
Q

relapsing course of MS can be . .

A
  • active or inactive

- worsening or not worsening

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28
Q

progressive courses of MS can be . .

A
  • active w/ or w/o progression

- non active w/ or w/o progression

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29
Q

what falls under the umbrella term of probable or possible MS?

A
  • CIS (clinically isolated syndrome)

- RIS (radiologically isolated syndrome)

30
Q

CIS

A
  • first attack
  • one scar seen
  • one exam finding
31
Q

RIS

A
  • incidental finding when MRI is done for another reason
  • immuno therapy is a weighted decision here
  • +/- fam hx of MS is helpful
32
Q

what is the goal of immuno therapy?

A
  • decrease future disability
  • reduce future lesion formation

*no cure for MS and even w/ immunotherapy there can still be further lesion formation

33
Q

MS tx options

A
  • injections
  • oral
  • infusions
  • vitamins
  • IMT
34
Q

injection txs

A
  • Avonex 30 mg im q week
  • Betaserone .25 mg sc QOD
  • Copaxone 40 mg sc M/W/F
  • Rebif 22, 44 mcg sc M/W/F
35
Q

oral meds

A

–  Fingolimod (Gilenya) 0.5mg qd
–  Dimethyl fumerate (Tecfidera) 120, 240mg bid
–  Teriflunomide (Aubagio) 7, 14mg qd

36
Q

infusion tx options

A
  • lemtrada: destroys T, NK cells and monocytes
  • tysabri: prevents CNS lymphoctes migration through the BBB
  • ocrevus: destroys b cells
  • novantrone: destroys t cells
  • rituxan: destroys b cells
37
Q

vitamin supplement tx

A
  • cholecalciferol (D3)

- 2,000 - 4,000 IU daily

38
Q

what is the lab value goal for vit. D3?

A

70+

nl is lower than that but want these pts high

39
Q

making a decision on using IMT tx

A
  • pts disease course
  • benefits vs risk of each med
  • co morbitities
  • contraindications
  • cost
  • pt preference
  • pt readiness
40
Q

acute relapse

A
  • new sx or sudden change in old sx lasting at least 24 hrs w/ an objective neurological change on exam
  • get GAD enhancing MRI
41
Q

what to r/o in relapse

A
  • r/o pseudo relapse

- ie: infectious, metabolic or psychologic stressor which mimics an acute relapse

42
Q

Uhthoff’s phenomenon

A
  • the worsening of neurologic sx in MS when the body gets over heated
  • could be d/t: hot weather, exercise, fever, saunas, hot tubs
  • keep in mind for psuedo relapse
43
Q

tx of acute relapse

A
  • 3-5 day admission for IV methylprednisolone

- PT/OT to restore function

44
Q

scale used for MS disability

A
  • Kurtzke scale
  • 1-10
  • 6 is the cut off for increasing disability
45
Q

MS accessory sx

A
  • widely variable from person to person and time to time

- inclue: fatigue, sensory loss, visual changes, pain, depression, and many more

46
Q

common temp issue in MS?

A

heat sensitivity

47
Q

heat sensitivity in MS

A
  • often causes increased fatigue, weakness, visual disturbance
  • any previous sx may be temporarily worsened w/ heat exposure
  • cold sensitivity could also occur
48
Q

muscle weakness in MS

A
  • often in distal upper extremities
  • common in lower extremities: hip and knee flexion, ankle dorsiflexion
  • disuse weakness
49
Q

tx for muscle weakness

A
  • rehab/exercise
  • dalfampridine
  • mobility aids
50
Q

ataxia in MS

A
  • lack of voluntary coordination of muscle movements
  • clumsiness, unsteady gait, impaired eye and limb movemens and speech problems
  • might be seen as tremor
51
Q

tx of ataxis

A

dalfampradine in some cases

52
Q

fatigue in MS

A
  • exclude non-MS reasons
  • review meds
  • energy management
  • exercise program
53
Q

meds used off label for fatigue in MS

A
  • amantadine
  • monafinil, armodafinil
  • CNS stimulants
54
Q

mobility in MS

A
  • need early referral to rehab

- goal is to promote function, comfort, and independence

55
Q

mobility aids

A
  • they conserve energy, enhance safety and allow people to remain active
  • cane, crutches, walker, etc.
56
Q

drug approved to improve walking speed in MS

A

dalfampridine

57
Q

bladder dysfunction in MS

A
  • check for infection
  • assess lifestyle
  • consider early referral to urologist
58
Q

small bladder issue (failure to store) tx

A
  • Anticholinergic
  • pelvic flood PT
  • botox
  • nerve stimulation
59
Q

large bladder issue (failure to empty) tx

A

-intermittent self cath

60
Q

tx for contipation in MS

A
  • regular bowel regimen
  • high fiber diet
  • sufficient liquids
  • bulk formers
  • stool softeners
  • avoid harsh laxatives and enemas
61
Q

tx for incontinence in MS

A
  • possible need for GI consult
  • Anticholinergic meds used for bladder
  • fiber w/ small amounts of water
62
Q

pharmacological tx for dysesthsia and paresthesia pain in MS

A
  • gabapentin
  • lamotrigine
  • carbamazepine
  • amitriptyline
  • pregabalin
  • others
63
Q

other tx for pain in MS

A
  • gloves, counter irritants
  • acupuncture
  • biofeedback
64
Q

orthopedic / spasticity pain tx

A
  • PT

- NSAIDs, acetaminophen, baclofen

65
Q

depression in MS

A
  • suicide much more common
  • over half will have major depressive episode
  • need to be regularly screened for MS
66
Q

cognitive impairment in MS

A
  • mild is common
  • MS affects:
  • brain volume
  • gray matter
  • cerebral cortex (the scars pull it down)
67
Q

overall prognosis

A
  • no definite one

- highly variable and unpredictable

68
Q

favorable prognostic factors

A
  • early visual or sensory sx
  • onset before age 40
  • female
  • relapsing forms
69
Q

unfavorable prognostic factors

A
  • early cerebellar or motor sx
  • onset after 40
  • male
  • progressive forms
70
Q

primary care provider role in MS

A
  • early recognition for timely diagnosis
  • referral to specialty:
  • neuro
  • mental health
  • urologist
  • rehab
  • speech/language/path
71
Q

review

A

case studies at end of lecture

Neurology 2 (21 decks)

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