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Neurology > MS > Flashcards

MS Flashcards

1
Q

what is the common group of people affected by MS?

A

Female: male 3:1

30s and 40s

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2
Q

what is MS?

A

autoimmune inflammatory demyelinating disorder the central nervous system

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3
Q

what is the structure of MS lesions?

A

lesions that are a greyish colour, 1mm to several cm in size, present in white matter of the brain and spinal cord

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4
Q

where do MS lesions arise?

A

adjacent to lateral ventricles, corpus callosum, optic nerves, chiasm, brainstem ascending and descending fibre tracts, cerebellum, spinal cord
lesions lie in close relationship to veins – perivenous distribution

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5
Q

what are the 2 overlapping phases of MS?

A

Inflammatory

Degenerative

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6
Q

what is the underlying mechanism of MS?

A

plaques resulting in demyelination, loss of oligodendrocytes and astrogliosis

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7
Q

what are the 3 different types of lesions in MS?

A

Recent Lesions
Old Lesions
Shadow Plaques

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8
Q

what are the cause of MS?

A
  • Genetics – HLA region
  • environmental factors – toxins, viral exposure (EBV), sunlight (VIT D)
  • relapses triggered post-natal
  • immunodeficiency
  • smoking
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9
Q

what do recent MS lesions look like?

A

Are yellow/brown in colour with an ill-defined edge that blends into white matter

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10
Q

what do old MS lesions look like?

A

well-demarcated grey/brown lesions in white matter, classically situated around lateral ventricles

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11
Q

what are the microscopic features of recent MS lesions?

A

myelin destruction, relative axon sparing, perivenous infiltration with mononuclear cells and lymphocytes. interstitial oedema. Breakdown of the BBB which causes myelin destruction. perivascular inflammatory cells, microglia, ongoing demyelination.

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12
Q

what are the microscopic features of old lesions?

A

relatively acellular, bare axons are surrounded by astrocytes. Gliosis, little remaining myelinated axons, oligodendrocytes and axons reduced in number.

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13
Q

what are the microscopic features of shadow plaques in MS?

A

may reflect a degree of remyelination, demonstrate thinned out myelin sheaths at the edge of lesions, results in a less well-defined lesion

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14
Q

what process occurs in the inflammatory phase of MS?

A

T cells enter the CNS via receptors on endothelial cells. Results in a breach in the BBB, causing upregulation of endothelial adhesion molecules and inflammatory cells. T cells produce inflammatory cytokines that cause direct toxicity and attract macrophages that contribute to demyelination.

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15
Q

what is the degenerative process in MS?

A

Demyelination disrupts axonal support and leads to destabilisation of axonal membrane potentials, which causes distal and retrograde degeneration over time. Inflammatory cells, antibodies, and complement also contribute to axonal injury.

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16
Q

what are the clinical features of MS?

A 
•	visual disturbance in one eye
•	peculiar sensory phenomena
•	vague symptoms
•	Pyramidal Dysfunction
•	Sensory Symptoms
•	Cerebellar dysfunction
•	Brain Stem Dysfunction
•	Internuclear
 Ophthalmoplegia
•	Urinary Tract Dysfunction
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17
Q

what are the clinical features associated with visual disturbance in MS?

A

optic neuritis – painful visual loss, 1-2 weeks, most improve, RAPD
ALSO:
o pale optic disc or non-correctable visual loss
o incorrect responses to Ishihara colour blindness test plates
o abnormal eye movements

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18
Q

what are the vague symptoms associated with MS?

A

o fatigue
o headache
o depression
o ache in limbs - cramping

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19
Q

what are the clinical features associated with pyramidal dysfunction n MS?

A

o spasticity/increased muscle tone
o Weakness
o Extensors of upper limbs
o flexors of lower limbs

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20
Q

what are the sensory symptoms associated with MS?

A 
o	pain
o	paraesthesia
o	dorsal column loss – proprioception & vibration
o	numbness
o	trigeminal neuralgia
21
Q

what are the symptoms of cerebellar dysfunction associated with MS?

A 
o	ataxia
o	intention tremor
o	nystagmus
o	past pointing
o	pendular reflexes
o	dysdiadokinesis 
o	dysarthria 
o	imbalance/ incoordination 
o	foot dragging
22
Q

what are the symptoms of brain stem dysfunction in MS?

A

o diplopia – R VI palsy

o Facial weakness – R VII palsy

23
Q

what are the symptoms of Internuclear Ophthalmoplegia in MS?

A 
o	Medial longitudinal fasciculus
o	Distortion of binocular vision
o	Failure of adduction- diplopia
o	Nystagmus in abducting eye
o	Lag
24
Q

what are the symptoms of urinary tract dysfunction associated with MS?

A 
o	frequency
o	 nocturia
o	 urgency
o	 urge incontinence
o	 retention
25
Q

what are the 5 different types of disease progression?

A
  1. relapsing remitting
  2. secondary progressive
  3. primary progressive
  4. progressive with relapses
  5. benign multiple sclerosis
26
Q

what is the diagnostic criteria of MS?

A

o At least 2 episodes suggestive of demyelination

o Dissemination in time and place

27
Q

what does dissemination in time mean?

A

LESIONS OCCUR WITH SYMPTOMS

28
Q

what does dissemination in space mean?

A

AREA OF BRAIN EFFECTED

29
Q

what criteria is used for MS diagnosis?

A

McDonald criteria

30
Q

what is the criteria associated with 2 or more attacks with 2 more more lesions?

A

None

31
Q

what is the criteria associated with 2 or more attacks with 1 lesion?

A

Dissemination in space on MRI

32
Q

what is the criteria associated with 1 attack with 2 lesions?

A

dissemination in time on MRI

33
Q

what is the criteria associated with 1 attack with 1 lesion?

A

Dissemination in space and time

34
Q

what is the criteria needed with 0 attacks in MS?

A

one year disease progression and 2 out of the 3 criteria
• dissemination in space in the brain
• dissemination in space in the spinal cord based on 2 or more T2 lesions
• Positive CSF

35
Q

what investigations are used in the diagnosis of MS?

A
  • Clinical
  • MRI
  • CSF
  • Neurophysiology
  • Blood Tests
36
Q

what are the diagnostic features of CSF in MS?

A

presence of igG oligoclonal bands

37
Q

what blood tests are used in MS investigations?

A 
o	Plasma viscosity, FBC, CRP
o	Renal liver bone profile
o	Auto anti body screen
o	Borellia, HIV, syphilis serology
o	B12 and folate
38
Q

what is the management of mild acute exacerbations?

A

symptomatic treatment

39
Q

what is the management of moderate acute exacerbations?

A

oral steroids

40
Q

what is the management of severe acute exacerbations?

A

admit/IV steroids

41
Q

what is the management of pyramidal symptoms in MS?

A

o physiotherapy
o occupational therapy
o anti-spasmodic agent

42
Q

what is the management of spasticity symptoms in MS?

A

Physiotherapy
Oral medication - baclofen, tizanidine
Botulinum toxin
Intrathecal baclofen / phenol

43
Q

what is the management of sensory symptoms in MS?

A 
anti-convulsant eg. gabapentin
anti-depressant eg. amitriptyline
tens machine
Acupuncture
Lignocaine infusion
44
Q

what is the management of urinary tract dysfunction symptoms in MS?

A

bladder drill
anti cholinergics eg., oxybutynin
Desmopressin
catheterisation

45
Q

what is the management of fatigue in MS?

A

amantadine
modafinil if sleepy
hyperbaric oxygen

46
Q

what is the 1st line disease modifying therapy for MS?

A 
Interferon Beta – Avonex, Rebif, Betaseron, Extavia
Glitiramer Acetate (Copaxone)	Tecfedira
47
Q

what is the 2nd line disease modifying therapy for MS?

A

Monoclonal antibody – Tysabri, Lemtrada, Zymbrata

Fingolimod

48
Q

what is the mechanism of tysabri?

A

binds to the alpha 4 integrin, preventing the binding of VCAM-1 preventing

  1. leukocyte migration from blood to tissue
  2. leukocyte priming and activation
  3. modulation of leukocyte apoptosis
49
Q

what is the 3rd line disease modifying therapy for MS?

A

Mitoxantrone

Neurology (18 decks)

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