Conditions

Question 1

Describe the formation and appearance of plaques in MS (active vs. inactive).

Answer 1

T cell acute inflammation attacking myelin and oligodendrocytes. Plaques form around damaged axons due to incomplete healing. Progressive inflammation occurs since BBB disrupted.
Active plaques = perivascular inflammatory cells, microglia, ongoing demyelination. Yellow/brown, ill-defined edge (blends into white matter).

Inactive plaques = gliosis, few myelinated axons remain, less oligodendrocytes (“burnt out” active plaque). well-demarcated, grey/brown lesions, classically situated around lateral ventricles.

Question 2

Signs of optic nerve involvement in MS?

Answer 2

optic neuritis - unilateral, painful eye movement or visual loss.
Colour desaturation (red)
RAPD on swinging light test
pale optic disc
reduced visual acuity

Question 3

Pyramidal dysfunction signs in MS?

Answer 3

UMN features - spasticity, weakness, hyper-reflexia etc.
Extensors of upper limb and flexors of lower limb.
Tonic spasms of lower limbs.
Pronator drift.

Question 4

Sensory signs in MS?

Answer 4

“water trickling down skin” but dry = pathognomic
loss of DCML, e.g. PC is clumsiness since loss of fine touch, proprioception
numbness, tingling

Question 5

Brainstem signs in MS?

Answer 5

CN signs
ataxia
nystagmus
internuclear ophthalmoplegia (INO)

Question 6

What is internuclear ophthalmoplegia (INO)?

Answer 6

horizontal diplopia - brainstem demyelination affecting the medial longitudinal fascicles (MLF) on one or both sides.
E.g.
A right INO will result in an inability to Adduct the right eye and a nystagmus of the left eye on attempted horizontal gaze.
Bilateral INO is pathognomonic of MS.

Question 7

Risk factors for MS.

Answer 7

high altitude living
previous EBV infection
1st degree relative with MS
HLA DRB1

Question 8

Common places to find plaques in MS?

Answer 8

adjacent to lateral ventricles, corpus collosum, optic nerves & chiasm.

Question 9

Diagnosis of MS.

Answer 9

2 distinct neurological defects occurring at different times.
Multiple distinct CNS lesions on T2 weighted MRI (hyper intense white matter lesions)

Question 10

Supportive features for MS diagnosis?

Answer 10

CSF analysis shows JgG oligocloncal bands

Visual evoked potentials (evidence of slowed conduction)

Question 11

How do you help a patient with MS cope with symptomatic spasticity?

Answer 11

physio, OT + oral anti-spasmodic (e.g. baclofen or tizanidine)

botox; intrathecal baclofen if bed bound

Question 12

What options are there to help a patient cope with sensory symptoms?

Answer 12

TENS machine, acupuncture
gabapentin for neuropathic pain
antidepressant e.g. amitriptylline
lignocaine infusion to reset pain threshold

Question 13

What options are there to help a patient with MS cope with fatigue?

Answer 13

OT
amantidine ± modafinil if excessive daytime somnolence

hyperbaric oxygen - pressure chamber - can help fatigue and bladder symptoms

Question 14

How would you treat a moderate relapse of MS?

Answer 14

PO methylprednisolone 500mg daily for 5 days

Question 15

How would you treat a severe relapse of MS?

Answer 15

hospitalisation and IV steroids

Question 16

What is 1st line disease modifying therapy for MS?

Answer 16

Tecifidera (R-R); interferon beta, glatiramer acetate (pregnant)

Question 17

When would you move to 2nd line disease modifying therapy and what options are there?

Answer 17

if patient is already on interferon but new plaques seen on MRI
Tysabri, fingolimod, cladrabine

Question 18

Which disease modifying drug is 1st line in early primary progressive MS only?

Answer 18

ocrelizumab