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Week 13 - neurology > Multiple sclerosis > Flashcards

Multiple sclerosis Flashcards

1
Q

What is MS?

A
  • Idiopathic inflammatory demyelinating disease of the CNS

* Acute episodes of inflammation are associated with focal neurological deficits

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2
Q

Describe the subtypes of MS

A
  • Relapsing remitting MS - unpredictable attacks which may or may not leave permanent deficits followed by periods of remission
  • Primary progressive MS - steady increase in disability without attacks
  • Secondary progressive Ms - initial relapsing remitting MS that suddenly beings to have decline without periods of remission
  • Benign MS
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3
Q

What are the syndromes that may develop into MS?

A
  • Optic neuritis
  • transverse myelitis (spinal cord)
  • Radiologically isolated syndromes/ clinically isolate syndromes
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4
Q

Describe optic neuritis

A
  • Painful visual loss that comes on over a few days in one eye
  • May resolve after a few weeks
  • Myelin of optic nerve becomes damaged
  • Red desaturation
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5
Q

Describe transverse myelitis

A
  • Inflammation of the spinal cord
  • weakness
  • Sensory loss below the level of inflammation
  • Incontinence can be the only symptom
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6
Q

What are clinically isolated syndromes in the context of MS?

A
  • Single episode of neurological disability due to focal CNS inflammation
  • Can include optic neuritis and transverse myelitis or trigeminal neuralgia or hand weakness
  • May be a first attack of MS
  • can also happen after an infection and not be related to MS
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7
Q

When is MS diagnosed?

A

When there is evidence of 2 or more episodes of demyelination disseminated in space and time

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8
Q

What things are thought to factor into getting MS?

A
  • Genetic factors
  • Sunlight/vitamin D
  • Viral trigger - possibly EBV
  • Multifactorial - smoking
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9
Q

When should you suspect MS?

A

•Neurological symptoms that develop over a few days
•History of transient neurological symptoms that have lasted for more than 24 hours and spontaneously resolve
•’Hidden relapse’
- optic neuritis/visual disruption
- bells palsy
- labyrinthitis
- sensory symptoms
- bladder symptoms in young man or women without children

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10
Q

What are the central symptoms of MS?

A
  • Fatigue
  • Cognitive impairment
  • Depression
  • Unstable mood
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11
Q

What are the musculoskeletal symptoms of MS?

A
  • Weakness
  • Ataxia
  • Spasm
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12
Q

What are the bowel symptoms of MS?

A
  • Incontinence

* Diarrhoea or constipation

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13
Q

What are the urinary symptoms of MS?

A
  • Incontinence

* Frequency

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14
Q

What symptoms/signs would make you think that it is something else other than MS?

A
  • Sudden onset (think stroke)
  • Peripheral signs- areflexia, glove and stocking distribution, muscle wasting, fasciculations
  • Major cognitive involvement
  • Reduced level of consciousness
  • Prominent seizure
  • Pyrexia/evidence of infection
  • Normal MRI scan
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15
Q

What is radiologically isolated syndrome?

A
  • MRI scan performed in a patient who doesn’t have signs or symptoms of MS
  • Incidental finding that looks like MS
  • May develop into MS but also may not
  • Can cause unnecessary distress for patient
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16
Q

How should you investigated suspected MS?

A
  • MRI brain and cervical spine with gadolinium contrast
  • Lumbar puncture
  • Bloods to exclude other conditions
  • Visual evoked potentials
  • Chest Xray to exclude sarcoidosis
17
Q

Describe the use of MRI to diagnose MS

A
  • Evidence of demyelination in 2 regions (e.g. periventricular and spinal cord) can indicated dissemination in space
  • If enhancing and non-enhancing areas of demyelination are seen this can indicate dissemination in time (suggestions that damage has occurred more than once)
18
Q

Explain lumbar puncture in MS

A
  • CSF oligoclonal bands (immune proteins in the spinal fluid and not in blood- immune system active behind BBB) - can also be seen in other conditions
  • CSF cell counts to exclude mimics
  • CSF glucose
  • CSF proteins
19
Q

Specifically what bloods should be done in suspected MS and why?

A
  • B12/folate to look for deficiency
  • Serum ACE
  • Lyme serology
  • ESR/CRP
  • ANA/ANCA/Rheumatoid factor
  • Aquaporin-4 antibodies (neuromyelitis optica)
20
Q

What is the role of visual evoke potentials?

A

•Measure the conduction of nerve signals in the optic nerve to look for subclinical optic neuritis
•Conduction will be slower if a patient has had optic neuritis in the past

21
Q

What is the difference between relapse and pseudo-relapse in MS?

A
  • A relapse usually involves a new neurological deficit that lasts for more than 24 hours in the absence of pyrexia or infection
  • A pseudo-relapse is the reemergence of previous neurological symptoms or signs related to an old area of demyelination in the context of heat or infection
  • When body temperature increases, conduction slows leading to dysfunction
22
Q

Explain treatment of relapse of MS

A
  • Not all relapses need treatment and should fully discuss the side effects of high dose steroid with patients
  • Steroids may speed up recovery from relapse with no effect on the progression of the disease
  • If appropriate, physiotherapy +/- occupational therapy
  • Sometimes in RRMS there may be a plan to organise MRI with contrast to look for active disease and change treatment
23
Q

When should steroids not be given to a patient experiencing a relapse of MS?

A

Steroids shouldn’t be given if there is any evidence of infection

24
Q

What is the pharmacological regime for relapse of MS

A
  • 1g of IV methylprednisolone for 3 days or 500mg of oral methylprednisolone for 5 days
  • PPI for gastroprotection (e.g. omeprazole)
  • Ideally prescribe at 9am to avoid sleep disruption
25
Q

What are the disease modifying drugs for RRMS?

A
  • Aletuzumab
  • Natalizumab
  • Anti CD20: ocrelizumab, rituximab, ofatmumab
  • Fingolimod
  • Dimethyl fumarate
  • Cladribine
26
Q

What type of stem cell transplant could be considered in severe RRMS?

A

Autologous haemopoetic stem cell transplant

27
Q

What is the treatment for PPMS?

A

Ocrelizumab

28
Q

What is the treatment for SPMS?

A

Siponimod

29
Q

Describe the use of ocrelizumab

A
  • First licensed treatment for PPMS
  • Slows disability progression in patients with recent active inflammation on scans
  • Patient must be walking to benefit
  • Increased risk of infection/severe COVID
30
Q

Describe the use of siponimod

A
  • First licensed treatment for SPMS
  • For use in people who have active inflammation in their brain scan s
  • Patients must be walking to benefit

Week 13 - neurology (12 decks)

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