MS and inflammatory CNS disorders

Question 1

what is MS?

Answer 1

inflammatory demyelinating disorder of the CNS

plaques are disseminated in time and place

Question 2

who is MS most common in?

Answer 2

females
often presents in 30s and 40s
more common as you move away from the equator (more common further north and south - may be linked to Vit D deficiency)

Question 3

what virus can be associated with MS?

Answer 3

EBV

Question 4

most common form of MS?

Answer 4

relapsing, remitting MS (90%)

Question 5

other types of MS?

Answer 5

secondary progressive
- initially like relapsing, remitting, then becomes s progressive slope
- (vision, walking affected)
progressive relapsing
- has flares/relapsing but progressing fairly rapidly
primary progressive
- progressing rapidly without any real specific relapses

Question 6

clinical features of MS?

Answer 6

pyramidal dysfunction 
optic neuritis
sensory symptoms
Lr urinary tract dysfunction
cerebellar and brain stem features
cognitive impairment

Question 7

how does pyramidal dysfunction present?

Answer 7

increased tone
spasticity
weakness
extensors of upper limbs
flexors of lower limbs

Question 8

how does optic neuritis present?

Answer 8

painful visual loss lasting 1-2 weeks
painful on eye movement
RAPD
most will improve

Question 9

what sensory symptoms might occur in MS?

Answer 9

any

e. g
- pain
- paraesthesia
- proprioception and vibration (dorsal column loss)
- numbness
- trigeminal neuralgia

Question 10

sensory symptoms suspicious of MS?

Answer 10

feeling of water running down the leg

Question 11

how common is sensory presentation in MS?

Answer 11

around half of people

Question 12

how does cerebellar dysfunction present?

Answer 12

DANISH
- dysdiadokinesia
- ataxia
- nystagmus
- intention tremor
- slurred speech (dysarthria)
- hypotonia
past pointing
pendular reflexes

Question 13

brain stem dysfunction may affect which cranial nerves and how may this present?

Answer 13

CN VI = diplopia

CN VII = facial weakness

Question 14

features of internuclear opthalmoplegia?

Answer 14

instead of both eyes moving together, one eye moves and the other drags behind, normal eye then has nystagmus
causes distortion of binocular vision and diplopia

Question 15

where is the problem in internuclear opthalmoplegia?

Answer 15

medial longitudinal fasciculus

Question 16

how can MS affect urinary tract?

Answer 16

frequency
nocturia
urgency
urge incontinence
retention
(can affect detrusor muscle)

Question 17

how is fatigue due to MS managed?

Answer 17

amantadine
modafinil if sleepy
hyperbaric oxygen

Question 18

how is diagnosis made of MS?

Answer 18

at least 2 episodes suggestive of demyelination
dissemination in time and place
exclude alternative diagnosis

Question 19

what investigations are used for MS diagnosis?

Answer 19

Clinical diagnosis
MRI
CSF
neurophysiology
blood tests (to exclude other things which may mimic MS)

Question 20

MS differentials?

Answer 20

vasculitis
granulomatous disorder
vascular disease (inc. stroke)
structural lesion
infection (HIV, syphilis, lyme disease)
metabolic disorder (e.g B12 folate deficiency)

Question 21

what blood tests are done to exclude other cause in expected MS?

Answer 21

PV, FBC, CRP
renal, liver, bone profile
auto antibody screen
borellia, HIV, syphilis serology
B12 and folate
Vit D

Question 22

classical MRI findings in MS?

Answer 22

dissemination in time

Question 23

CSF features in MS?

Answer 23

oligoclonal bands

Question 24

how is MS managed generally?

Answer 24

acute exacerbation/relapse management
symptomatic treatment
disease modifying therapy

Question 25

how is acute relapse managed?

Answer 25

mild = symptomatic treatment
moderate = oral steroids (methyloprednisolone) 
severe = admit/IV steroids (1000mg over 3 days)

Question 26

what symptomatic treatment is used in MS?

Answer 26

pyramidal dysfunction - physio, OT, antispasmodic agent
sensory - anticonvulsants, antidepressants, tens machine, acupuncture, lignocaine infusion
urinary - bladder drill, anti-cholinergics (oxybutynin), desmopressin, catheterisation

Question 27

is spasticity always treated?

Answer 27

no

if patient is weak, spasticity may allow them to stand

Question 28

examples of anti-spasmotic agent?

Answer 28

physio
baclofen
tizanidine
botox
intrathecal baclofen/phenol (if bed bound)

Question 29

how does MS affect bladder dysfunction?

Answer 29

increased bladder tone at neck
detrusor hypersensitivity
detrusor sphyncteric dyssenergia

Question 30

a lot of the problems in MS are due to what?

Answer 30

drug related issues

Question 31

is cannabis effective in MS?

Answer 31

in some

around 50% have cannabinoid receptors which respond well in drug resistant spasticity

Question 32

how does MS progress if untreated?

Answer 32

increasing cognitive dysfunction

decreasing brain volume

Question 33

first line disease modifying therapy?

Answer 33

interferon beta
glatiramer acetate
- decrease relapse rate and severity
- self administered injections
tecfedira aubagio
- oral
- first line indication in RR MS but long term data unknown

Question 34

second line disease modifying therapy?

Answer 34

monoclonal antibody
- e.g tysabri
- used in rapidly evolving RR MS despite interferon treatment
- can cause PML
fingolimod, cladribine
- oral
- reduce relapse rate
- effect disease progression
- but more toxic than 1st line

Question 35

third line disease modifying therapy?

Answer 35

mitoxantrone, lemtrada

HSCT (stem cell transplant)

Question 36

indication to move on to second line therapy?

Answer 36

new lesion formation on imaging or new contrast enhancement despite being on first line treatment

Question 37

how do monoclonal antibodies work in MS?

Answer 37

stop trans-endothelial migration of activated T cells across BBB in EAE mediated by integrins

Question 38

inflamamatory cascade in MS?

Answer 38

immune cells pass through BBB > immune cells may re-activate and produce cytokines > immune cells mount autoimmune attack against myelin