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Neurology > Multiple Sclerosis > Flashcards

Multiple Sclerosis Flashcards

1
Q

What is multiple sclerosis?

A

It is a chronic and progressive condition that involves demyelination of the myelinated neurones in the central nervous system

This is caused by an inflammatory process involving the activated immune cells against myelin

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2
Q

What type of reaction is multiple sclerosis?

A

Type IV hypersensitivity reaction = cell mediated

It is an autoimmune condition

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3
Q

Explain the pathophysiology of multiple sclerosis?

A

Myelin covers the axons of neurones in the CNS

  • this is myelin helps the electrical impulse move faster along the axon
  • myelin is provided by cells that wrap themselves around the axons

Multiple sclerosis typically only affects the CNS - the oligodendrocytes
- There is inflammation around myelin and infiltration of immune cells that cause damage to the myelin
○ This affects the way electrical signal travel along the nerve leading to symptoms of multiple sclerosis

When a patient presents with symptoms of a clinical “attack” of MS, for example, an episode of optic neuritis, there are usually other lesions of demyelination at the same time throughout the CNS, most of which are not causing symptoms

In early disease, re-myelination can occur and symptoms can resolve
- In later stages of the disease, re-myelination is incomplete and symptoms gradually becomes more permanent

A characteristic feature of MS is that lesions vary in their location over time, meaning that different nerves are affected and symptoms change over time
- The key expression to remember the way MS lesions change location over time is that they are “disseminated in time and space”

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4
Q

What is the aetiology of multiple sclerosis?

A

The cause of the demyelination is unclear, but there is growing evidence that it is influenced by a combination of:

- Multiple genes 
- Epstein-Barr virus 
- Low vitamin D
- Smoking 
    - Obesity
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5
Q

When does multiple sclerosis present?

A

Early onset = 20-30s
Typically presents in young adults - under 50’s
More common in women
Symptoms tend to improve in pregnancy and in the postpartum period

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6
Q

What is the initial presentation?

A

Initial presentation

- Relapse - demyelination and inflammation 
- Gradual onset over days 
- Stabilises days to week 
- Gradual resolution 
- Partial or complete recovery
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7
Q

What is the relapse phase presentation?

A 
Optic neuritis - most commonly
Sensory symptoms 
Limb Weakness 
Brainstem problems 
Spinal cord problems 
Myelitis
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8
Q

What is optic neuritis?

A

It involves the demyelination of the optic nerve and loss of vision in one eyes

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9
Q

What are the clinical signs of optic neuritis?

A 
Pain on moving eye
Colour vision disrupted
Initial swelling of optic disc
Optic atrophy 
Relative afferent pupillary defect
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10
Q

What are the sensory symptoms that can present in multiple sclerosis?

A

Trigeminal Neuralgia
Numbness
Paraesthesia - pins and needles

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11
Q

What are the brain stem problems that can present in multiple sclerosis?

A

Cranial nerve involvement
Diplopia
Pons-internuclear ophthalmoplegia - disorder of horizontal ocular movement due to a lesion in the brainstem
Vertigo / ataxia - problem with coordinated movement
Upper motor signs

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12
Q

What are the the spinal cord problems that can present in multiple sclerosis?

A

Bilateral motor and sensory symptoms
Bladder involvement
Myelitis
- inflammation of the spinal cord

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13
Q

What is the clinical presentation of myelitis?

A

Weakness / upper motor neurone changes below level of demyelination
Bladder and bowel involvement

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14
Q

What are some signs and symptoms of progressive phases of multiple sclerosis?

A 
Fatigue 
Temperature sensitivity
Sensory symptoms 
Stiffness or spasms 
Balance problems 
Slurred speech 
Bladder and bowel 
Diplopia/oscillopsia/visual loss
Swallowing
Cognitive dementia/emotional liability
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15
Q

What can be found in the examination of MS, where signs observed depend on where the demyelination has occurred and the stage of disease?

A 
Afferent pupillary defect
Nystagmus 
Cerebellar signs
Sensory signs 
Weakness
Spasticity 
Hyperreflexia
Plantar extensor
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16
Q

What is Charcot’s neurologic triad?

A

Triad of symptoms related to multiple sclerosis

17
Q

What symptoms present as part of Charcot’s neurologic triad?

A

Dysarthria

  • difficulty or unclear speech
  • plaques in brainstem interfere with conscious movements - eating and talking, or unconscious movements - swallowing

Nystagmus

  • involuntary rapid eye movements
  • plaques in nerves of the eyes
  • can affect the optic nerve - loss of vision or optic neuritis , or eye movements - pain or double vision

Intention tremor

  • plaques along motor pathways
  • muscle weakness
  • tremors
  • ataxia
  • paralysis
18
Q

What are the symptoms if there are plaques in sensory pathways from skin?

A

Numbness
Pins and needles
Paraesthesia

19
Q

What are the symptoms if there are plaques in the autonomic nervous system?

A

Bowel and bladder problems

Sexual dysfunction

20
Q

How can multiple sclerosis affect higher order activities?

A

Poor concentration and critical thinking

Depression and anxiety

21
Q

What are the disease patterns of multiple sclerosis?

A

The disease course is highly variable between individuals - Some patients may have mild relapsing-remitting episodes for life whereas others have primary progressive MS that progresses without any improvement in symptoms

  • There are certain classifications used to describe the of MS in an individuals
  • These patterns are not separate conditions but part of the spectrum of disease activity

Disease patterns are

  • Clinical isolated syndrome
  • Relapsing - remitting MS
  • Primary progressive MS
  • Secondary progressive MS
22
Q

What is the clinical isolated syndrome?

A

Refers to the first episode of neurologic symptoms that last at least 24 hours, first episode of demyelination

Sometimes there are no further episodes

23
Q

How does clinical isolated syndrome progress?

A

Further relapses are due to underlying infection

Progression
- Axonal loss is important for disease progression and development of persistent disability

24
Q

Can lesions be seen in clinical isolated syndrome?

A

If lesions are seen on MRI it means that they are more likely to progress to MS

MS cannot be diagnosed on one episode as lesion have not been “disseminated in time and space”

25
Q

What is relapsing-remitting MS?

A

most common pattern at initial diagnosis

Bouts of immune attack happening months or years apart

It it characterised by episodes of disease and neurological symptoms followed by recovery

26
Q

Where do symptoms occur in relapsing-remitting MS?

A

Symptoms can occur in different areas with different episodes

This can be further classified based on whether the disease is active and / or worsening:

ACTIVE - new symptoms are developing or new lesions appearing on MRI
NOT ACTIVE - no new symptoms or MRI lesions are developing
WORSENING - there is an overall worsening of disability over time
NOT WORSENING - there is no worsening of disability over time

27
Q

What is primary progressive MS?

A

It is where there is a worsening of disease and neurological symptoms from the point of diagnosis without initial relapses and remissions

This can be further classified in a similar way to secondary progressive based on whether it is active and/or progressing

Constant attack on myelin which causes a steady progression of disability over a lifetime

28
Q

What is the presentation of primary progressive MS?

A

50/60s

No relapses occur

Spinal and bladder problems

29
Q

What is the diagnosis of primary progressive MS?

A

Evidence of demyelination separate in time and space

Clinical or MRI based diagnosis

  • posers criteria
  • macdonalds criteria
30
Q

What is secondary progressive MS?

A

It is similar to relapsing remission but over time causes a steady progression of disability

It is where there was relapsing-remitting disease at first, but now there is a progressive worsening of symptoms with incomplete remissions

Symptoms become more and more apparent

Can be further classified based on whether the disease is active and / or worsening

ACTIVE - new symptoms are developing or new lesions appearing on MRI
NOT ACTIVE - no new symptoms or MRI lesions are developing
WORSENING - there is an overall worsening of disability over time
NOT WORSENING - there is no worsening of disability over time

31
Q

How do you diagnoses MS?

A

MRI

  • Shows multiple CNS multiple system lesions
  • White matter plaques = Loss of myelin

Lumbar puncture

  • CSF shows high levels of antibodies = autoimmune disease
  • Can detect “oligoclonal bands” in the CSF

Visual / somatosensory evoked response
- Measures the CNS response to visual stimuli

Bloods to exclude other inflammatory conditions

Chest x-ray

Diagnosis is made by a neurologist based on the clinical picture and symptoms suggesting lesions that change location over time

  • Symptoms have to be progressive over a period of 1 year to diagnose primary progressive MS
  • Other causes for symptoms need to be excluded
32
Q

What are the forms of MS treatment?

A

Treatment of relapse
Disease modifying drugs
Symptomatic treatment
General health and diet

33
Q

What is the treatment of relapses?

A

Acute relapse

  • Look for underlying infection
  • Exclude worsening of usual symptoms with intercurrent illness
  • Oral prednisolone IV
  • Rehabilitation
  • Symptomatic treatment

They can also be treated with steroids

34
Q

What are disease modifying drugs?

A

They reduce relapse rate, do not slow down progression

1st line

  • S/M or I/M injections = beta-interferons, glatiramer acetate
  • Immunosuppressants

2nd line
- Natalizumab etc.

35
Q

What is symptomatic treatment?

A 
Spasticity - muscle
- Relaxants/antispasmodics/physiotherapy 
Dysesthesia 
- Amitriptyline
- Urinary anticholinergic, bladder stimulator 
Constipation 
- laxatives
Sexual dysfunction
- Sildenafil 
Fatigue
- Graded exercise
Depression 
- CBT
Cognitive
- Memory aids 
Tremor
- Aids/medication
Vision 
- Carbamazepine 
Speech/swallowing
- SALY 
Motor/sensory impairment 
- MDT

Neurology (5 decks)

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