Multiple Sclerosis Flashcards
What is the epidemiology of MS?
- Chronic cell-mediated autoimmune disorder characterised by demyelination of CNS
- 3:1 women
- Common age of onset 20-40yrs
What are the types of MS?
- Relapsing-remitting: most common, acute attacks (e.g. 1-2 months) followed by remission
- Secondary progressive: relapsing-remitting who have deteriorated and developed neurological signs and symptoms between relapses, gait and bladder disorders generally seen
- Primary progressive: progressive deterioration from onset, more common in older people
When can you diagnose MS?
If >/=2 relapses and either; objective clinical evidence of >/=2 lesions or objective clinical evidence of one lesion together with reasonable historical evidence of previous relapse.
What are the visual symptoms of MS?
- Optic neuritis - pain on eye movement, blurring of vision, red colour saturation
- Hemianopia, diplopia
- Uthoff’s phenomenon (worsening of vision after rise in body temp)
- Intranuclear ophthalmoplegia (INO) (lesion in medial longitudinal fasiculus, results in impaired abduction of ipsilateral eye, contralateral eye abducts but with nystagmus)
What sensory symptoms are there in MS?
- Pins/needles
- Numbness
- Trigeminal neuralgia
- Decreased vibration sense
- Lhermitte’s syndrome (paraethesia in limbs on neck flexion)
What symptoms are there in MS?
- Spastic weakness - most common in legs
- Cerebellar ataxia + tremor
- Urinary incontinence
- Sexual dysfunction
- Intellectual deterioration
- Swallowing disorders
What are the investigations for MS?
- MRI: high signal T2 lesions, periventricular plaques, Dawson fingers (hyper intense lesions to the corpus callosum)
- CSF: oligoclonal bands (+ not in serum), increased intrathecal synthesis of IgG
- Visual evoked potentials: delayed but well preserved waveform
What is the management for acute relapse of MS?
High dose steroids e.g. PO or IV methyl prednisolone
- Inpatient: IV methyl prednisolone 1g IV daily for 3 days - given in morning as can cause sleep disturbance
- Outpatient: PO methyl prednisolone 500mg for 5 days
Check for infection before commencing steroids.
Where is the lesion to cause loss of vision in one eye?
Anterior to the optic chias, therefore in the right optic nerve, retina or eye itself (if blind in right eye). A lesion at or behind the chias that causes visual impairment would affect both eyes.
What is a relative afferent pupillary defect (RAPD)?
Sign of optic neuropathy (damage to CNII). Can be detected by swinging light test.
In an eye affected by optic neuropathy the pupil paradoxically dilates when light is shone into that eye as the direct stimulus (light via ipsilateral damaged optic nerve) is weaker than the indirect stimulus (light via intact contra lateral optic nerve).
What does vertigo and nausea show?
- Vestibular pathology: vertigo is principle symptom. Patients may describe spinning or feeling world around them is moving, often associated with nausea. Vertigo can be made worse by head movement in vestibular pathology (also maybe hearing loss +/- tinnitus)
- Cerebellar lesion: patient may be aware their voice has changed (staccato dysarthria), poor coordination in arms, unsteadiness whilst walking, ask if one side of body feels worse than the other, in unilateral Cerebellar lesions patient will have ataxia in ipsilateral arm and leg
What symptoms would sensory ataxia show?
- History of sensory disturbance (numbness, pins + needles etc) in limbs or trunk
- Balance is worse in dark or if they are not looking at their feet
- May find they fall over when close their eyes e.g. when washing face at sink/in shower
- Lesion in spinal cord: Lhermitte’s phenomenon (tingling sensations upon flexion and extension of the neck) or tight band-like sensation around torso
- Bladder urgency and frequency of micturition
What are the side effects of steroids?
- GI irritation (PPI given alongside)
- Common to experience some agitation, restlessness and insomnia
- Steroid psychosis (rare)
- Hyperglycaemia (with prolonged steroid use)
- Avascular necrosis of femoral head
- Hypertension
- Osteoporosis
What is the action of baclofen?
- Used to treat spasticity - common in MS and other CNS disorders. It can be uncomfortable as well as limiting movement.
- Baclofen is effective in treating it but the main drawback is the doses needed to successfully reduce more severe spasticity can be very sedative
- Alternatives are tizanidine or dantrolene
What is neuropathic pain?
Described as burning or stabbing and is often accompanied by other symptoms such as paradoxical numbness, paraesthesia, hyperpathia (increased sensitivity to painful stimuli) and allodynia (when a non painful stimuli is painful).
