MS Flashcards
What is MS?
Inflammatory demyelinating disorder the central nervous system
Female >Men
30-40 yrs
MS plaques occurring in multiple parts of the central nervous system (CNS) and over the course of time
- Much more common in white populations and with increasing distance from the equator
- Causes of MS are not completely understood but the autoimmune process appears to be caused both by genetic and environmental factors
-Environmental factors which have been implicated include viral infections (e.g. EBV), and vitamin D deficiency
MS courses?
- Relapsing-remitting MS (RRMS) (85-90%) - symptoms occur in attacks (relapses) with a characteristic time course: onset over days and typically recovery, either partial or complete, over weeks
- Secondary progressive MS - this late stage of MS consists of gradually worsening disability progressing slowly over years; some 75% of patients with relapsing-remitting MS will eventually evolve into a secondary progressive phase by 35 years after onset
- Primary progressive MS (PPMS) (10-15%) - characterized by gradually worsening disability without relapses or remissions
Pyramidal dysfunction; Clinical presentation?
- Increased tone
- Spasticity
- Weakness
- Affects extensors of upper limbs and flexors of lower limbs
Optic neuritis;Clinical presentation?
- Painful visual loss over 1-2 weeks - blurred vision in one eye and loss (or reduction) in colour vision
- Most improve
- RAPD (relative afferent pupilary defect) on examination
Sensory symptoms;Clinical presentation?
“Feeling that water going down my legs”
- Pain
- Paraesthesia
- Dorsal column loss - proprioception and vibration
- Numbness
- Trigeminal neuralgia
Cerebellar dysfunction; Clinical presentation?
- Dysarthria
- Ataxia
- Intention tremor
- Past pointing
- Pendular reflexes
- Dysdiadokinesis
Brainstem dysfunction; clinical presentation?
- Diplopia - CN VI palsy
- Facial weakness - CN VII palsy
Lower urinary tract dysfunction; clinical presentation?
- Increased frequency and urgency
- Nocturia
- Urge incontinence
- Retention
- increased tone at bladder neck
retention - detruser hypersensitivity
frequency, urgency, nocturia, urge incontinence - detruser sphyncteric dyssenergia; i.e. inappropriate involuntary urethral sphincter contraction
Internuclear opthalmoplegia; clinical presentation?
-When two eyes don’t move together
-VERY COMMON in MS
- Involves the medial longitudinal fasciculus
- Distortion of binocular vision
- Failure of adduction - diplopia
- Nystagmus in abducting eye
- Lag
What is the most complain MS patient would have?; clinical presentation
FATIGUE
To diagnose MS consider 3 facts. what are they?
Clinical episode suggestive of demyelination
Dissemination in time and place
Alternative diagnosis excluded
what are the common diff diagnosises?
Vasculitis
Granulomatous disorder
Vascular disease
Structural lesion
Infection
Metabolic disorder
Investigations?
Bloods
- Before referring to a neurologist, exclude differential diagnoses by checking FBC, inflammatory markers, U&E, LFT, TFT, glucose, HIV serology, calcium and B12 levels, vitamin D
Neurophysiology
- Can detect demyelination in apparently unaffected pathways with characteristic delays
MRI
- Periventricular lesions
- Discrete white matter abnormalities
- Areas of focal demyelination
- Active inflammatory plaques can be distinguished from inactive ones by using a contrast agent
CSF
- Oligoclonal bands present in 90+% of cases - distinct bands of IgG on Western blot that are unmatched with serum testing
Managemet for acute relapse?
- Mild - symptomatic treatment
- Moderate - oral steroids (5mg)
- Severe - admit/IV steroids (100ml)
Mx for Pyramidal dysfunction?
- Physiotherapy
- Occupational therapy
- for spasticity: Anti-spasmodic agent e.g. oral baclofen, oral tizanidine, botulinum toxin, intrathecal baclofen
Mx for the sensory symptoms?
- Anticonvulsant e.g. gabapentin
- Antidepressant e.g. amitriptyline
- TENS machine
- Acupuncture
Mx of Lower urinary tract dysfunction
- Bladder drill
- Anti-cholinergics e.g. oxybutynin
- Desmopressin
- Catheterisation
Mx for fatigue?
- Amantadine
- Modafinil if sleepy
- Hyperbaric oxygen
Disease modifying therapy; 1st line?
- Tecfedira, aubagio; tablet form; First line indication in RR MS
- Interferon beta; injectable
- Glitiramer acetate; injectable
Disease modifying therapy; 2nd line?
- Monoclonal antibody : (highly active in RRMS)
- Anti CD 20 ocrelizumab (comonest)
- Anti CD 50 alemtuzemab (high toxicity;no use)
- Anti integrin natilizumab (Very safe as long as the JC virus is negative)
- Fingolimod, cladrabine; reboosting IS
Note: The monoclonal antibodies have greatest efficacy but also highest side effect profile
MRI report
The imaging of this brain is abnormal.
There are several areas which give a high signal on the T2 weighted sequences
within the white matter. These are infratentorial, juxtacortical and
periventricular in site. They each measure between 1 and 2.5cm.
The appearance is highly suggestive of a diagnosis of multiple sclerosis.
infratentorial-pic below
juxtacortical-sort of near the cortex
periventricular- situated or occurring around a ventricle, especially a ventricle of the brain
