Multiple Sclerosis

Question 1

What is Multiple Sclerosis?

Answer 1

A chronic and progressive condition that involves demyelination of the myelinated neurones in the CNS.

Question 2

Epidemiology of Multiple Sclerosis (3).

Answer 2

1. Young (20-40).
2. Women > Men.
3. Improvement in Pregnancy and Postpartum Period.

Question 3

Anatomy of Neurones (3).

Answer 3

1. Myelin covers axon of neurones in CNS to help transmit electrical impulses faster.
2. Schwann cells in the PNS and Oligodendrocytes in the CNS.
3. MS only affects the CNS - Oligodendrocytes.

Question 4

Pathophysiology of MS.

Answer 4

Inflammation around Myelin and Infiltration of Immune Cells that cause damage to the Myelin.

Question 5

Pathological Feature of MS.

Answer 5

Lesions are disseminated in Time and Space (lesions vary in location over time, affecting different nerves and causing different symptoms).

Question 6

Aetiology of MS (5).

Answer 6

Associations :
1. Multiple Genes.
2. EBV.
3. Low Vitamin D.
4. Smoking.
5. Obesity.

Question 7

Clinical Features of MS (8).

Answer 7

1. Optic Neuritis (commonest).
2. CNVI (Abducens) Palsy = Internuclear Ophthalmoplegia and Conjugate Lateral Gaze Disorder.
3. Focal Weakness.
4. Focal Sensory Symptoms.
5. Ataxia.
6. Lethargy.
7. Uhthoff’s Phenomenon (Worsening of Vision following a rise in Temperature).
8. Incontinence, Sexual Dysfunction and Intellectual Deterioration.

Question 8

What is Intranuclear Ophthalmoplegia?

Answer 8

The internuclear nerve fibres connect the cranial nerve nuclei that control eye movements (3, 4 and 6) to co-ordinate eye movements - failure of this.

Question 9

What is Conjugate Lateral Gaze Disorder?

Answer 9

Disordered movement of both eyes when moving to look laterally.

Question 10

Give 4 examples of focal weakness in MS.

Answer 10

1. Bell’s palsy.
2. Horner’s Syndrome.
3. Limb Paralysis.
4. Incontinence.

Question 11

Give 4 examples of focal sensory symptoms in MS.

Answer 11

1. Trigeminal Neuralgia.
2. Numbness.
3. Paraesthesia (Pins & Needles).
4. Lhermitte’s Sign.

Question 12

What is Lhermitte’s sign?

Answer 12

An electric shock sensation travelling down the spine and into the limbs when flexing the neck, indicating disease in the cervical spinal cord’s dorsal column (stretching of the demyelinated dorsal column).

Question 13

Give 2 types of ataxia in MS.

Answer 13

1. Sensory (loss of proprioceptive sense) = Positive Romberg’s Test ad Pseudoathetosis.
2. Cerebellar.

Question 14

Presentations of MS Disease (4).

Answer 14

1. Clinically Isolated Syndrome (1st presentation).
2. Relapsing-Remitting (commonest).
3. Secondary Progressive (with gait and bladder disorders).
4. Primary Progressive (commoner in older people).

Question 15

What is Relapsing-Remitting Disease?

Answer 15

Episodes of disease and neurology followed by recovery, with symptoms occurring in different areas.

Question 16

How can Relapsing-Remitting Disease be further classified (2)?

Answer 16

1. Active / Not Active.
2. Worsening / Not Worsening.

Question 17

What is Secondary Progressive Disease?

Answer 17

Initially Relapsing-Remitting Disease has become a progressive worsening of symptoms with incomplete remissions (symptoms are permanent).

Question 18

What is Primary Progressive Disease?

Answer 18

Worsening of disease and neurology from the point of diagnosis without initial relapses and remissions.

Question 19

How can Secondary/Primary Progressive Disease be further classified (2)?

Answer 19

1. Active/Not Active.
2. Progressing / Not Progressing.

Question 20

Diagnosis & Investigations of Multiple Sclerosis (3).

Answer 20

1. Clinical Diagnosis suggesting lesions that change location over time.
2. MRI Scan - Typical Lesions.
3. Lumbar Puncture - Oligoclonal Bands in CSF.

Question 21

MRI Findings in Multiple Sclerosis (3).

Answer 21

1. High-Signal T2 Lesions.
2. Periventricular Plaques.
3. Dawson’s Fingers (Hyperintense Lesions Perpendicular to Corpus Callosum).

Question 22

Management of MS (4).

Answer 22

1. Specialist MDT.
2. Disease Modification.
3. Treating Relapses.
4. Symptomatic Treatment.

Question 23

Disease Modification in MS.

Answer 23

Disease-Modifying Drugs and Biologic Therapy to induce long-term remission with no evidence of activity.

Question 24

Treating Relapses in MS (2).

Answer 24

1. 1st line : 500mg Oral Prednisolone daily for 5 days.
2. 2nd line 1g IV Methylprednisolone daily for 3-5 days.

Question 25

Symptomatic Management in MS (6).

Answer 25

1. Exercise.
2. Neuropathic Pain.
3. Depression.
4. Urge Incontinence (Intermittent Self-Catheterisation if Significant Residual Volume or Anticholinergics if not).
5. Spasticity (Baclofen, Gabapentin, Physiotherapy).
6. Fatigue - Amantadine.