Multiple Sclerosis

Question 1

What is MS? progress of Disease?

Answer 1

Demyelinating neurological condition where discrete plaques of demyelination occur throughout the CNS due to a T-cell mediated immune response.

Most common patter is relapsing-remitting caused by incomplete healing of demyelination. Prolonged demyelination causes axonal loss and SECONDARY PROGRESSIVE MS. (happens in 80% - of which 50% by 10 years)

EPIDEMIOLOGY: 20-40 years, F3:M1, caucasians far from equator

Question 2

Presenting Symptoms:

Answer 2

ATTACK = neurological deficit lasting > 1 h and with >30 days between them

usually present with one symptom:

• arm or leg weakness
• limb paresthesia
• Optic Neuritis 20% of 1st presentations = unilateral pain on eye movement with reduced VA
• Ataxia/Dysarthria/tremor = Charcot’s triad
• Band sensation around trunk or limbs

less common: vertigo, CN, urinary urgency, fecal incontinence, impotence, depression, euphoria

Usually full recovery between attacks that gradually become incomplete

Question 3

Other Hx to ask

Answer 3

Precipitating factors: Heat, infection, fever, exercise, post partum
FHx: 7x more likely in immediate relatives
Social Disability
Ix and Tx so far

Question 4

Examination

Answer 4

Motor: spastic paraparesis
Sensory: posterior column loss (fine, vibration, proprioception)
Cerebellar signs: nystagmus, slurred speech, impaired coordination
CN: decreased VA, central scotoma, internuclear ophthalmoplegia (adduction weakness with nystagmus in abducted eye - bilateral finding)
Lhermitte’s sign: neck flexion causes electric shock in trunk/limbs

Question 5

Diagnostic Criteria

Answer 5

McDonald Criteria:
2 acute neurological episodes separated in time or place
OR
1 acute neurological episode + MRI evidence of typical lesion in separate region

Question 6

Ix

Answer 6

MRI +/- gadolinium T1, T2 weights - looking for demyelinated sites
Evoked Response testing (visual- delayed in 80%, auditory or somatosensory)
CSF - oligoclonal IgG bands on electrophoresis

Question 7

NP Management:

Answer 7

MDT
Support Groups
Bed rest with nursing during relapses
Regular exercise, stop smoking and avoid stress

Question 8

P Management:

Answer 8

Steroids (methylprednisolone) for acute relapses - shortens relapse but doesn’t alter prognosis

Interferons and monocolonal AB reduce relapse freq

Dimethyl fumerate + immunosuppressives (methotrexate and azathioprine) can be trialed

SYMPTOMATIC: 
spacticity = baclofen (GABA agonist) 
Bladder dysfunction = ocybutynin + amitriptyline 
Facial spasm = carbamazipine 
Tremor = clonazepam or propanolol