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NEURO > MS > Flashcards

MS Flashcards

1
Q

what is multiple sclerosis

A

demyelinating disease in which the myelin sheaths of nerve cells in the brain and spinal cord (CNS) are damaged

inflammatory

white matter affected

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2
Q

what kind of disturbances does MS cause

A

focal disturbance of function-relapse

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3
Q

what is the general course of MS

A

relapsing remitting course

most patients develop progressive disability

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4
Q

what determines what disability is gained from MS

A

location of the damage

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5
Q

what is demyelination

A

an autoimmune process - caused by activated T cells crossing the blood brain barrier

acute inflammation of the myelin sheath

results in loss of function

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6
Q

what is post inflammatory gliosis and what can it cause

A

non-specific reactive change of glial cells in response to damage - effectively like scarring in the CNS

can cause functional deficits

seen as lesions or plaques on MRI

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7
Q

what can increase your risk of MS

A

having other auto-immune diseases

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8
Q

what is an important part of disease progression

A

axonal loss

probably present from disease onset

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9
Q

what is axonal loss seen as on MRI

A

seen as black holes

later seen as cerebral atrophy

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10
Q

what can lead to MS

A

complex genetic inheritance
autoimmune diseases

female:male 2-3:1

more common in temperate climate

?virus - Epstein Barr virus
?vitamin D exposure

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11
Q

how does MS usually present

A

80% cases present with a relapse

  • gradual onset over days
  • stabilises days to weeks
  • gradual resolution to complete or partial recovery
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12
Q

what are some symptoms of a relapse

A

Optic neuritis
Sensory symptoms
Limb weakness
Brainstem Diplopia/Vertigo/Ataxia-
Spinal cord-bilateral symptoms and signs +/- bladder

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13
Q

what is optic neuritis

A

inflammation of the optic nerve

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14
Q

what are the symptoms of optic neuritis

A

Subacute visual loss
Pain on moving eye
Colour vision disturbed

Usually resolves over weeks

Initial swelling optic disc
Optic atrophy seen later

Relative afferent pupillary defect - ie pupil dilates when light shone onto it

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15
Q

aside from MS what are some other causes of optic neuritis

A 
Neuromyelitis optica
Sarcoidosis
(Ischaemic optic neuropathy)
Toxic/ drugs/ B12 deficiency
Wegeners granulomatosis
(Local compression)
Lebers hereditary optic neuropathy
Infection-borrelia
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16
Q

how does a brainstem relapse present

A

cranial nerve involvement
weakness in the extraocular muscles

cerebellum - vertigo, nystagmus, ataxia

UMN changes in limbs

sensory involvement

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17
Q

what are the types of myelitis in MS

A

partial - incomplete

transverse - complete

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18
Q

how does myelitis present in MS

A

band of hyperaesthesia at sensory level

weakness/UMN changes below level

bladder and bowel involvement

may be painful

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19
Q

aside from MS what are the causes of myelitis

A

inflammation

  • devics (myelitics + optic neuritis)
  • SLE (systemic lupus erythmatosis)
  • sarcoidosis (abnormal collections of inflammatory cells that form lumps known as granulomas

infection
- HIV, HTLV, HSV, TB, borrelia, mycoplasma

tumour

paraneoplastic process

stroke

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20
Q

what are isolated episodes of demyelination

A

when someone presents with an episode but then have no further episodes

named as such retrospectively

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21
Q

when can further relapses occur

A

within months or years of the first relapse

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22
Q

how can further relapses present

A

variable to site and severity

optic neuritis 
sensory
limb weakness
diplopia
vertigo
ataxia
sphincter disturbances
23
Q

what is the progressive phase of relapses

A

accumulation of signs and symptoms

24
Q

what are progressive phase symptoms

A 
Fatigue, temperature sensitivity
Sensory
Stiffness or spasms
Balance, slurred speech
Swallowing
Bladder & bowel
Diplopia/ oscillopsia/ visual loss
Cognitive-dementia/ emotional lability
25
Q

what can be seen on examination of MS

A 
Afferent pupillary defect
Nystagmus or abnormal eye movements
Cerebellar signs
Sensory signs
Weakness
Spasticity
Hyperreflexia
Plantars extensor
26
Q

what are the 2 main ways to diagnose MS

A

evidence of demyelination separated in time and space

clinical - Posers criteria
MRI - Macdonald criteria

27
Q

what is the Macdonald criteria for diagnosing MS

A

for every 10 brain lesions the patient experiences 1 relapse

28
Q

how do you differentiate between T1 and T2 MRI

A

T1 - lipid light, fluid dark

T2 - lipid light, fluid light

29
Q

what other investigations can be used to help aid diagnosis of MS

A

lumbar puncture - oligoclonal bands present in CSF but not serum

visual/somatosensory evoked response

bloods - excuse other inflammatory conditions

chest x-ray - exclude sarcoidosis

30
Q

what are the differential diagnosis for MS

A

Acute Disseminated

Encephalomyelitis (ADEM)

Other Auto-immune conditions eg SLE

Sarcoidosis

Vasculitis

Infection eg Lyme disease, HTLV-1

Adrenoleucodystrophy etc etc

31
Q

what are the different types of MS

A

relapsing remitting

primary progressive

secondary progressive

sensory

malignant

32
Q

what is the course of MS in relapsing remitting

A 
initial episode
second episode larger
third episode smaller
fourth episode even smaller 
etc
33
Q

what is the course of MS in secondary progressive MS

A

initial episode
second episode smaller
third episode starts very small but progressively worsens - doesn’t go away

34
Q

what is the course of sensory MS

A

small, few equally spaced episodes

not as much impairment as motor affected ones

35
Q

what are prognostic indicators for MS

A

very difficult to predict

GOOD:
female
Present with optic neuritis
Long interval between 1st and 2nd relapse
Few relapses in 1st 5 years
BAD:
male
Older age
Multifocal symptoms and signs
Motor symptoms and signs
36
Q

what is the course of primary progressive MS

A

initial onset gets progressively worse - no remission - no relapses

37
Q

what are the symptoms for primary progressive MS

A

spinal symptoms

bladder symptoms

38
Q

what is devics disease

A

neuromyelitis optica spectrum disorder

optic neuritis + myelitis

autoimmune if aquaporin-4 antibodies present

unknown cause if antibody negative

39
Q

what is the treatment for devics disease

A

immunosuppression

40
Q

what are the broad groups of treatment for MS

A

general health and diet
treatment of relapse
symptomatic treatment
multi-disciplinary approach

disease modifying treatment

41
Q

what are the first steps to take in an acute relapse of MS

A

look for underlying infection

exclude worsening of usual symptoms with intercurrent illness

42
Q

what are the treatments for acute relapse of MS

A

oral prednisolone (IV)
rehabilitation
symptomatic treatment

43
Q

what medical precaution is advised for people with MS

A

vaccinations - underlying viral infection s the cause of 25-30% further relapses

44
Q

when do women sometimes have a period of fewer relapses followed by a period of increased risk of elapses

A

fewer relapses during pregnancy

increased risk in the first 3 months post partum

45
Q

what do disease modifying drugs do

A

do not stop progression of disease but can reduce number and severity of relapses

46
Q

what are the first line disease modifying drugs in MS

A

s/c or i/m injections:
Beta-interferons
glatiramer acetate

Oral treatments:
Teriflunomide
Dimethyl Fumarate

47
Q

what are the side effects of first line disease modifying treatments

A

flu-like symptoms
injection site reactions
abnormalities of blood count and liver function

48
Q

how effective are first line disease modifying treatments

A

reduce relapse rate by ~1/3
BUT non effect on progression of disability

NOT a cure

49
Q

what are the second line disease modifying treatments for MS

A

Natalizumab

  • Reduce relapse rate ~2/3
  • Monthly infusion

Fingolimod- tablets
- Cardiac

Alemtuzumub
- Autoimmune thyroid disease/ Goodpastures/ immune thrombocytopenic purpura

50
Q

what causes progressive multifocal leukencephalopathy (PML)

A

JC virus

51
Q

what are the treatments and management for PML

A

immunosuppression

  • Natalizumab
  • Dimethyl fumarate
  • Fingolimod

MRI annual
JC antibody blood and urine 6 monthly

52
Q

what are some of the individual treatments for symptoms of MS

A

Spasiticity-muscle relaxants/ antispasmodics/ physiotherapy

Dysaesthesia-amitriptyline, gabapentin etc.

Urinary-anticholinergic Rx, bladder stimulator/ catheterisation

Constipation-laxatives

Sexual dysfunction-sildenafil

Fatigue-graded exercise, medication

Depression-CBT, medication

Cognitive-memory aids etc

Tremor-aids/ pharmaceutical

Vision/ oscillopsia-carbamazepine

Speech/ swallowing-SALT

Motor/ sensory impairment- multi-disciplinary team

53
Q

who is involved in the multi-disciplinary team

A 
MS nurse
Physiotherapy
Occupational therapy
Speech and language therapy
Dietician
Rehabilitation specialists
Continence advisor
Psychology/psychiatry

NEURO (51 decks)

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