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Year Two - Neurology System > Multiple Sclerosis > Flashcards

Multiple Sclerosis Flashcards

1
Q

What is multiple sclerosis?

A

It is a a chronic and progressive autoimmune condition that involves demyelination of the central nervous system

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2
Q

What is myelin?

A

It is the sheath that covers the axons of neurones in the central nervous system

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3
Q

What is the function of myelin?

A

It allows quick transmission of electrical impulses between neurones

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4
Q

What cells produce myelin in the peripheral nervous system?

A

Schwann cells

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5
Q

What cells produce myelin in the central nervous system?

A

Oligodendrocytes

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6
Q

What is the pathophysiological cause of multiple sclerosis?

A

There is inflammation around the myelin sheath, which results in the infiltration of immune T-cells that then cause damage

This affects the transmission of electrical signals along the nerve

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7
Q

What hypersensitivity reaction occurs in multiple sclerosis?

A

Type IV

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8
Q

Which nervous system is affected in multiple sclerosis - central or peripheral?

A

CNS

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9
Q

What are the four classifications of multiple sclerosis?

A

Clinically Isolated Syndrome (CIS)

Relapsing Remitting MS (RRMS)

Secondary Progressive MS (SPMS)

Primary Progressive MS (PPMS)

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10
Q

What is clinically isolated syndrome?

A

It refers to the first, single episode of demyelination, resulting in neurological clinical features that persist for a period greater than 24 hours

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11
Q

Why does clinically isolated syndrome not obtain in a diagnosis of multiple sclerosis?

A

This is due to the fact that the lesions have not ‘disseminated in time and space.’

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12
Q

Does clinically isolated syndrome result in multiple sclerosis?

A

These individuals may or may not go on to develop multiple sclerosis

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13
Q

What clinically isolated syndrome feature estimates a higher risk of multiple sclerosis development?

A

There are features of multiple sclerosis on MRI scans

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14
Q

What is the most common classification of multiple sclerosis at initial diagnosis?

A

Relapsing remitting multiple sclerosis (RRMS)

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15
Q

What is RRMS?

A

It is characterised by relapsing episodes of disease followed by periods of remission

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16
Q

Describe the cycle associated with RRMS

A

During the relapsing episodes, clinical features usually have a gradual onset over a few days, which then stabilise to persistent clinical features for a period of days to months

There is then a period of remission of varying duration

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17
Q

In what two ways can RRMS be classified?

A

Disease activity (active/non-active)

Disease progression (worsening/non-worsening)

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18
Q

What does active disease refer to?

A

The development of new clinical features or the appearance of new lesions on MRI

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19
Q

What does worsening disease refer to?

A

The overall worsening of disability from initial diagnosis

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20
Q

What is SPMS?

A

It is characterised as initial relapsing-remitting disease that has progressed into a state of incomplete remission with worsening clinical features

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21
Q

In what two ways can SPMS be classified?

A

Disease activity (active/non-active)

Disease progression (progressing/non-progressing)

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22
Q

What does progressing disease refer to?

A

The the overall worsening of disease over time (regardless of relapses)

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23
Q

What is PPMS?

A

It is characterised by continuous worsening of disease from initial diagnosis without remission periods

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24
Q

Which age group tend to be affected by PPMS?

A

> 50 yrs old

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25
Q

In what two ways can PPMS be classified?

A

Disease activity (active/non-active)

Disease progression (progressing/non-progressing)

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26
Q

What is different about multiple sclerosis classifications compared to other condition classifications?

A

These classifications are not separate conditions, and instead should be thought of as a spectrum of disease activity

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27
Q

What are the seven risk factors of multiple sclerosis?

A

Female Gender

Young Age (20-40 Years Old)

Family History

Smoking

Obesity

Epstein Barr Virus (EBV)

Reduced Vitamin D Exposure

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28
Q

What are the eighteen clinical features of multiple sclerosis?

A

Optic Neuritis

Sixth Cranial Nerve Palsy

Diplopia

Paraesthesia

Numbness

Trigeminal Neuralgia

Bell’s Palsy

Horner’s Syndrome

Lhermitte’s Sign

Hoffman’s Sign

Intention Tremor

Muscle Spasticity

Erectile Dysfunction

Urinary Incontinence

Urinary Retention

Vertigo

Ataxia

Lethargy

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29
Q

What is the most common clinical feature of multiple sclerosis?

A

Optic neuritis

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30
Q

What is optic neuritis?

A

It refers to demyelination and inflammation of the optic nerve

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31
Q

What are the eight causes of optic neuritis?

A

Multiple sclerosis

Diabetes

Syphillis

Sarcoidosis

SLE

Measles

Mumps

Lyme’s disease

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32
Q

What is the most common cause of optic neuritis?

A

Multiple sclerosis

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33
Q

What are the five clinical features associated with optic neuritis?

A

Unilateral Central Vision Loss

Colour Vision Impairment

Painful Eye Movements

Relative Afferent Pupillary Defect (RAPD)

Central Scotoma

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34
Q

What colour vision impairment is associated with multiple sclerosis?

A

Red desaturation

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35
Q

What is red desaturation?

A

It involves patients visualising red objects as pink

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36
Q

What is RAPD?

A

It is a condition in which pupils respond differently to light stimuli shone in one eye at a time

Specifically, when shining light into one eye, both pupils should constrict

This constriction should remain when the light is then shone into the other eye

However, in RAPD, when the light is then shone into the other eye, dilatation occurs

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37
Q

What is central scotoma?

A

It refers to an enlarged blind spot

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38
Q

What two investigations are used to diagnose optic neuritis?

A

Fundoscopy

MRI of Brain & Orbits With Contrast

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39
Q

What are the two signs of optic neuritis on fundoscopy?

A

Optic disc swelling, or in severe cases optic disc atrophy

RAPD

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40
Q

How do we manage optic neuritis?

A

We urgently refer patients to ophthalmology

It is then treated with high dose steroids

41
Q

How long does it take to recover from optic neuritis following treatment?

A

4-6 weeks

42
Q

What is the general function of CN VI?

A

It innervates the lateral rectus muscle to allow lateral eye movement

43
Q

What are the three clinical features of CN VI palsy?

A

Conjugate Lateral Gaze Disorder

Papilloedema

Internuclear Opthalmoplegia

44
Q

What is another term for conjugate lateral gaze disorder?

A

Horizontal diplopia

45
Q

What is conjugate lateral gaze disorder?

A

It is defined as defective abduction (medial deviation)

Specifically, when individuals look laterally in the direction of the affected eye, the affected eye will not be able to abduct

For example, in a lesion affecting the left eye, when looking to the left, the right eye will adduct and the left eye will remain in the middle as the muscle responsible for making it move laterally is not functioning

46
Q

What is intranuclear ophthalmoplegia?

A

It refers to incoordination of eye movements

47
Q

What is Bell’s palsy?

A

It is is defined as idiopathic facial nerve palsy, in which there is no known cause for the damage caused to the facial nerve

48
Q

What is Horner’s syndrome?

A

It is a condition in which there is disruption of the sympathetic nerve pathway between the brain stem and the face/eyes

49
Q

What is Lhermitte’s sign?

A

It is an electric shock sensation travelling down the spine and into the limbs when flexing the beck

50
Q

What does Lhermitte’s sign indicate in terms of multiple sclerosis?

A

It indicates disease in the dorsal column of the cervical spine

51
Q

What causes Lhermitte’s sign?

A

It is caused by stretching the demyelinated dorsal column

52
Q

What is Hoffman’s sign?

A

It involves flexion and adduction of the thumb and flexion of the index finger following a foreceful flick of the examiners thumb on the patient’s middle finger nail

53
Q

What is intention tremor?

A

It refers to a tremor that becomes obvious and often exaggerated as the need for precise motor movement increases

54
Q

What is ataxia?

A

It is defined as uncoordinated movements

55
Q

What are the two classifications of ataxia?

A

Sensory

Cerebellar

56
Q

What is sensory ataxia?

A

It refers to a loss in proprioceptive sense

57
Q

What is a clinical sign of sensory ataxia?

A

Positive Romberg’s test

58
Q

What is cerebellar ataxia?

A

It refers to problems with the cerebellum coordinating movement

59
Q

What phenomenon do multiple sclerosis features follow?

A

Uhthoff’s phenomenon

60
Q

What is Uhthoff’s phenomenon?

A

It means that clinical features worsen in hot conditions, for example when a patient is taking a hot bath or during exercise

61
Q

What two things are known to improve the clinical features of multiple sclerosis?

A

Pregnancy

Postpartum period

62
Q

What is a key characteristic of multiple sclerosis clinical features? What does this mean?

A

The lesions disseminate in time and space

In multiple sclerosis, lesions vary in their location over time, resulting in different nerves becoming affected and therefore different clinical features

63
Q

In most cases, how is multiple sclerosis diagnosed?

A

Clinically

64
Q

What clinical criteria is used to aid diagnosis of multiple sclerosis?

A

Posers criteria

65
Q

What do we have to remember when diagnosing multiple sclerosis clinically?

A

A diagnosis can only be made with evidence of at least two separate attacks, although this may include signs of attacks on an MRI scan

66
Q

In PPMS, how long do clinical features need to progress for before a diagnosis to be obtained?

A

> 1 year

67
Q

What three investigations can be used to confirm multiple sclerosis diagnosis?

A

MRI Scan

Lumbar Puncture

Visual Evoked Potential Tests

68
Q

What are the five features of multiple sclerosis on MRI scans?

A

Demyelination

Myelin Sheath Inflammation

High Signal T2 Lesions

Periventricular Plaques

Dawson Fingers

69
Q

What is Dawson fingers?

A

It refers to hyper-intense lesions perpendicular to the corpus callosum

70
Q

What criteria is used to interpret multiple sclerosis on an MRI scan? Why?

A

MacDonald criteria

It allows collation of clinical features and scan features to make a diagnosis

71
Q

What MRI contrast is used to aid diagnosis of multiple sclerosis?

A

Gadolinium

72
Q

What is a lumbar puncture?

A

It involves the insertion of a needle into the subarachnoid space of the spinal cord, specifically between L3 and L4 vertebrae, to collect a sample of CSF

73
Q

What is a sign of multiple sclerosis on lumbar puncture?

A

Oligoclonal bands

74
Q

What are oligoclonal bands?

A

They are bands of immunoglobulins

75
Q

The oligoclonal bands should only be present in CSF not serum for a diagnosis of multiple sclerosis. Why?

A

This indicates that there is inflammation of the central nervous system only

76
Q

What are visual evoked potential tests?

A

They are tests used to test optic nerve conduction

It involves the monitoring of brainwaves whilst a patient is shown light patterns

77
Q

What is a sign of multiple sclerosis in visual evoked potential tests?

A

There is a decreased transmission rate of electrical signals from the eye to the brain, however preserved waveform

78
Q

How do we manage acute MS relapses?

A

High dose steroids

79
Q

What steroid is used to treat acute MS relapses?

A

Methylprednisolone

80
Q

What are the two prednisolone regimes that can be used to treat acute MS relapses?

A

500mg orally for 5 days, which can be administered at home

1g IV for 3-5 days, which has to be administered in hospital

81
Q

In which two cases would we chose IV prednisolone over oral to treat acute MS relapses?

A

In individuals where oral treatment has failed previously

In individuals where relapses are severe

82
Q

In order to reduce the risk of side effects, what is the maximum times a year that steroids should be prescribed to multiple sclerosis patients?

A

3 times per year

83
Q

What is the aim of acute MS relapse treatment?

A

To shorten the period of relapse

They are unable to prevent further relapse or prevent disease progression

84
Q

Why is it important that we conduct blood tests and urinalysis when MS patients have an acute relapse?

A

To investigate for underlying infection

If positive, antibiotics can be administered, which will in turn resolve the relapse clinical features

85
Q

In what way do we symptomatically manage fatigue?

A

Amantadine

However, other underlying causes such as anaemia, thyroid disease and depression need to be excluded first

86
Q

In what two ways do we symptomatically manage muscle spasticity?

A

We can administer antispasmodics, such as baclofen, gabapentin, diazepam, dantrolene and tizanidine

We can offer physiotherapy

87
Q

Which two pharmacological management options are first line to symptomatically manage muscle spasticity?

A

Baclofen

Gabapentin

88
Q

How do we symptomatically manage neuropathic pain?

A

We can administer medications, such as duloxetine, amitriptyline, gabapentin or carbamazepine

89
Q

In what two ways do we symptomatically manage urinary problems?

A

We can administer anticholinergic medications, such as tolterodine or oxybutynin

We can advise intermittent self catheterisation

90
Q

How do we determine which management option should be used for urinary problems?

A

US scan - to assess bladder emptying

In cases where there is a significant residual volume, then intermittent self-catheterisation is recommended

In cases where there is no significant residual volume, anticholinergics are recommended

91
Q

How can we symptomatically manage constipation?

A

We can administer laxative medications, such as senna, sodium picosulfate or bisacodyl

92
Q

How can we symptomatically manage erectile dysfunction?

A

We can administer medications, such as sildenafil

93
Q

What is a side effect of sildenafil?

A

Blue vision

94
Q

What are two contraindications of sildenafil?

A

Nitrates - isosorbide mononitrate

Nicorandil

95
Q

In what two ways do we symptomatically manage depression?

A

We can administer antidepressant medications, such as sertraline, fluoxetine or citalopram

We can offer cognitive behavioural therapy

96
Q

What is the aim of disease modification therapies?

A

To induce long term remission with no evidence of disease activity

They don’t slow down the progression of disease

97
Q

In which two circumstances, is disease modification therapy considered?

A

In relapsing-remitting multiple sclerosis, in which there has been two relapses within the past two years and individuals are able to walk 100m unaided

In secondary-progressive multiple sclerosis, in which there has been two relapses within the past two years and individuals are able to walk 10m aided or unaided

98
Q

What are five disease modification therapies used in multiple sclerosis?

A

Natalizumab

Ocrelizumab

Fingolimod

Beta-Interferon

Glatiramer Acetate

99
Q

What is the first line disease modification therapy?

A

Natalizumab

Year Two - Neurology System (25 decks)

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