MS Flashcards
What is MS?
a chronic, cell-mediated autoimmune disorder characterised by demyelination in the central nervous system
Who gets MS?
3 x more common in women
people aged 20-40 yrs
ppl living in higher latitudes
- typical pt: white woman in 20s
Outline the pathophysiology of MS
Immune mediated (cell infiltration + inflammation) demyelination of CNS neurones > nerve cell degeneration.
Electrical signal travel is disrupted > symptoms of MS
Early stages neurones re-myelinate > clinical remission.
Recurrent episodes > neuronal damage > permanent clinical deficit.
What are the key characteristic features of MS in terms of when symptoms appear?
- Dissemination is space (DIS)
- Dissemination in time (DIT)
- episodic
- relapsing and remitting course
What cells make myelin in the CNS
Myelin is made my oligodendrocytes in the central nervous system.
Schwann = peripheral
Causes of MS
Genetic / Autoimmune / Environment factors
Multiple gene
EBV
Low vitamin D
Smoking
Obesity
What are some common signs in initial presentation of MS (lecture BB)
Optic neuritis
Ataxia
Dizziness (vertigo)
Weakness
Diplopia
Bladder / bowel dysfunction
Neuropathic pain (e.g. trigeminal neuralgia)
sensory loss / disturbance in face or limbs
Other common:
Fatigue
Spasticity
sexual dysfunction
cognitive impairment (later)
What are the names of subtypes of MS?
Relapsing - remitting disease
Secondary progressive disease
Primary progressive disease
What is relapsing-remitting disease in MS?
Most common - 85% pts
acute attacks of disease ( 1-2 months) followed by remission.
further classified by:
- Active- new symptoms/lesions on MRI
-Worsening - disability increasing over time
What is secondary - progressive disease in MS?
Pts who started with relapsing- remitting but have now deteriorated.(65% of R-R get w/in 15 yrs)
Pts have neurological signs and symptoms which are more permanent
Gait and bladder disorders common
What is Primary progressive disease in MS?
10% of pts
Worsening and deterioration from onset on MS
Older pts more likely
How is a diagnosis made in MS?
- multiple lesions of the CNS occurring both in time (recurrent episodes) and space (different sites).
-consultant neurologist and be based upon the 2010 McDonald criteria
What is the MacDonald criteria?
For diagnosis of MS
What is the MacDonald criteria?
For diagnosis of MS (workbook)
- Lesions consistent with an inflammatory process
- No alternative diagnosis
- Multiple lesions in time and space (Relapsing remitting MS)
- Progressive neurological deterioration for 1 year (Primary progressive MS)
How would you diagnose a relapse of MS?
- Develops new symptoms
- Has rapid worsening of existing symptoms
- Symptoms last for more than 24 hours in the absence of infection or other cause after a stable period of one month or
more
What investigations can be used to support a diagnosis of MS?
MRI of brain / spinal cord for demyelination plaques - see high T2-signal intensity lesions on MRI
Analysis of CSF - would see oligocolonal bands on CSF electrophoresis
What type of MRI would you order for MS investigation?
T2 weighted shows high signal (bright) lesions. Varying degrees of contrast show active / recent demyelination.
Also use MRI flair to show lesions (bright)
What findings do you see on MRI with a patient who has MS?
- High signal T2 lesions
- Periventricular plaques
- Dawson fingers (FLAIR) - hyperintense lesions perpendicular (sticking up like mohawk) from corpus callosum.
What does analysis of CSF show in a patient with MS?
Immunoelectrophoresis is performed showing oligoclonal bands of IgG
increased intrathecal IgG synthesis
What visual features do you get with MS?
optic neuritis: common presenting feature
optic atrophy
Uhthoff’s phenomenon: worsening of vision following rise in body temperature e.g. bath
internuclear ophthalmoplegia
What sensory features do you get with MS?
pins/needles
numbness
trigeminal neuralgia
Lhermitte’s syndrome: paraesthesiae in limbs on neck flexion
What motor features do you get with MS?
spastic weakness: most commonly in legs
What cerebellar features do you get with MS?
Ataxia: depending on where the plaque is:
-Sensory (proprioception, Romberg)
- Cerebellar (co-ordinating movement)
Tremor
What are some ‘other’ features of MS ? i.e. not motor, sensory, visual or cerebellar
urinary incontinence
sexual dysfunction
intellectual deterioration
Who is involved in management of MS pt?
MDT
neurologists
specialist nurses
physio
OT
Patient education is key
What is the treatment fo an acute relapse of MS?
High dose steroids
IV/ oral methylprednisolone for 5 days
Shortens relapse (no impact on recovery to baseline)
What disease modifying drugs do you give for MS? And why
Change in management of MS- Disease modifying drug to induce long term remission.
[LECTURE BB]
Immune modulating drugs: 1 st line
– Beta-Interferon
• Interferon beta 1a IM (Avonex)
• Interferon beta 1a SC (Rebif)
• Interferon beta 1b SC (Betaferon)
– Glatiramer acetate (Copaxone)
• 2nd line/ Immunosuppressant drugs
– Natalizumab (Tysabri) e.g. IV
monoclonal AB
What are some of the potential side-effects of interferon-beta?
ques med
- Local inflammatory/hypersensitivity reactions at injection sites
- Influenza-like symptoms
- Malaise
- Mood changes (e.g. depression)
- Fever
- Anaphylaxis
- Alopecia
- Hepatitis
- Myalgia
- Nausea and vomiting
What are options for symptomatic treatment in MS for fatigue common
Once excluded anaemia, thyroid, depression
Then can trial Amantadine
Other: CBT / Mindfullness
What are options for symptomatic treatment in MS for Neuropathic pain?
Amitryptyline
Gabapentin
What are options for symptomatic treatment in MS for Depression ?
Antidepressants / SRi’s
What are options for symptomatic treatment in MS for incontinence
urgency / overflow etc.
US to see bladder emptying
If + residual volume - self catheterisation
If - residual volume - anticholinergics e.g. oxybutynin (can worsen cognitive impairment)
What are options for symptomatic treatment in MS for spasticity?
Baclofen and gabapentin -1st
Physiotherapy
What are options for symptomatic treatment in MS for Oscillopsia ?(visual fields appear to oscillate)
Gabapentin
(maybe ignore this card haha)
Four core presenting syndromes in multiple sclerosis?
from quesmed
- Optic neuritis
- Myelopathy (including partial and transverse myelitis)
- Focal brainstem disease (including INO)
- Cerebellar dysfunction (presenting as subacute ataxia)
What is the second most common ophthalmic presentation of multiple sclerosis?
INO - Internuclear ophthalmoplegia
What factors are associated with a worse prognosis of Multiple Sclerosis?
- Older
- Male
- Motor signs at onset
- Early relapses
- Many MRI lesions
- Axonal loss
