Multiple Sclerosis

Question 1

what is MS

Answer 1

Multiple sclerosis (MS) is a chronic and progressive condition that involves demyelination of the myelinated neurones in the central nervous system.

Question 2

MS is caused by an _________ process involving the activation of immune cells against the ______.

Answer 2

is caused by an inflammatory process involving the activation of immune cells against the myelin.

Question 3

MS typically presents in ….
symptoms tend to improve in….

Answer 3

MS typically presents in young adults (under 50 years) and is more common in women. Symptoms tend to improve in pregnancy and in the postpartum period.

Question 4

Myelin is provided by cells that wrap themselves around the axons. These are __________ in the peripheral nervous system and _________ in the central nervous system.

Answer 4

Myelin is provided by cells that wrap themselves around the axons. These are Schwann cells in the peripheral nervous system and oligodendrocytes in the central nervous system.

Question 5

Multiple sclerosis typically only affects ……. which NS?

Answer 5

Multiple sclerosis typically only affects the central nervous system (the oligodendrocytes).

Question 6

in MS: There is inflammation around myelin and infiltration of immune cells that cause damage to the _____.

Answer 6

There is inflammation around myelin and infiltration of immune cells that cause damage to the myelin.

Question 7

describe how people initially present with MS?

Answer 7

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 central nervous system, most of which are not causing symptoms.

Question 8

In early disease, _________ can occur and symptoms can resolve

Answer 8

In early disease, re-myelination can occur and symptoms can resolve

Question 9

is MS reversible?

Answer 9

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

Question 10

A characteristic feature of MS is that
The key expression to remember to describe the way MS lesions change is…..

Answer 10

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 to describe the way MS lesions change location over time is that they are “disseminated in time and space”.

Question 11

what are the causes* of MS?

Answer 11

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 (EBV)
Low vitamin D
Smoking
Obesity

Question 12

describe how MS presents (time wise)

Answer 12

Symptoms usually progress over more than 24 hours. At the first presentation, symptoms tend to last days to weeks and then improve. There are a number of ways MS can present.

Question 13

describe optic neuritis (MS presentation)

Answer 13

Optic neuritis is the most common presentation of multiple sclerosis. It involves demyelination of the optic nerve and loss of vision in one eye. This is discussed in more detail below.

Question 14

describe the eye movement abnormalities MS might present with?

Answer 14

Patients may present with double vision due to lesions with the sixth cranial nerve (abducens nerve).

Question 15

There are two key phrases to remember to describe a sixth cranial nerve palsy:

Answer 15

There are two key phrases to remember to describe a sixth cranial nerve palsy: internuclear ophthalmoplegia and conjugate lateral gaze disorder.

Question 16

describe internuclear ophthalmoplegia?

Answer 16

Unilateral lesions in the sixth nerve causes a condition called internuclear ophthalmoplegia. Internuclear refers to the nerve fibres that connect between the cranial nerve nuclei that control eye movements (3rd, 4th and 6th cranial nerve nuclei). The internuclear nerve fibres are responsible for coordinating the eye movements to ensure the eyes move together. Ophthalmoplegia means a problem with the muscles around the eye.

Question 17

describe conjugate lateral gaze disorder

Answer 17

Lesions in the sixth cranial nerve cause a conjugate lateral gaze disorder. Conjugate means connected. Lateral gaze is where both eyes move together to look laterally to the left or right. It is disordered in a sixth cranial nerve palsy. When looking 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 (move towards the nose) and the left eye will remain in the middle as the muscle responsible for making it move laterally is not functioning.

Question 18

give some focal weakness that MS can present with

Answer 18

Bells palsy
Horners syndrome
Limb paralysis
Incontinence

Question 19

give some focal sensory symptoms Ms might present with

Answer 19

Trigeminal neuralgia
Numbness
Paraesthesia (pins and needles)
Lhermitte’s sign

Question 20

what is Lhermitte’s sign?

Answer 20

Lhermitte’s sign is an electric shock sensation that travels down the spine and into the limbs when flexing the neck. It indicates disease in the cervical spinal cord in the dorsal column. It is caused by stretching the demyelinated dorsal column.

Question 21

describe the ataxia MS might present with

Answer 21

Ataxia is a problem with coordinated movement. It can be sensory or cerebellar:

Sensory ataxia is the result of loss of the proprioceptive sense, which is the ability to sense the position of the joint (e.g. is the joint flexed or extended). This results in a positive Romberg’s test and can cause pseudoathetosis.
Cerebellar ataxia is the result of problems with the cerebellum coordinating movement. This suggestions cerebellar lesions.

Question 22

describe the disease course for MS patients

Answer 22

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 pattern of MS in an individual. These patterns are not separate conditions but part of a spectrum of disease activity.

Question 23

what is clinically isolated syndrome?

Answer 23

This describes the first episode of demyelination and neurological signs and symptoms. MS cannot be diagnosed on one episode as the lesions have not been “disseminated in time and space”. Patients with clinically isolated syndrome may never have another episode or develop MS. If lesions are seen on MRI scan then they are more likely to progress to MS.

Question 24

describe the relapsing-remitting pattern of MS?

Answer 24

Relapsing-remitting MS is the most common pattern at initial diagnosis. It is characterised by episodes of disease and neurological symptoms followed by recovery. In MS the symptoms 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 are 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

Question 25

describe secondary progressing in MS

Answer 25

Secondary progressive MS 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 permanent. Secondary progressive MS can be further classified based on whether the disease is active and/or progressing.

Active: new symptoms are developing or new lesions are appearing on MRI
Not active: no new symptoms or MRI lesions are developing
Progressing: there is an overall worsening of disease over time (regardless of relapses)
Not progressing: there is no worsening of disease over time

Question 26

describe primary progressive MS

Answer 26

Primary progressive MS 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.

Question 27

how do we diagnose MS?

Answer 27

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 the symptoms need to be excluded.

Question 28

which investigations can support MS diagnosis

Answer 28

Investigations can support the diagnosis:

MRI scans can demonstrate typical lesions
Lumbar puncture can detect “oligoclonal bands” in the cerebrospinal fluid (CSF)

Question 29

how does optic neuritis present?

Answer 29

Optic neuritis presents with unilateral reduced vision developing over hours to days. Key features are:

Central scotoma. This is an enlarged blind spot.
Pain on eye movement
Impaired colour vision
Relative afferent pupillary defect

Question 30

what is the main cause of optic neuritis

Answer 30

MS

Question 31

Multiple sclerosis is the main cause of optic neuritis, however it can also be caused by:

Answer 31

Multiple sclerosis is the main cause of optic neuritis, however it can also be caused by:

Sarcoidosis
Systemic lupus erythematosus
Diabetes
Syphilis
Measles
Mumps
Lyme disease

Question 32

Patients presenting with acute loss of vision should be seen urgently by an….

Answer 32

Patients presenting with acute loss of vision should be seen urgently by an ophthalmologist for assessment

Question 33

how do we treat optic neuritis?
do people with optic neuritis go on to get MS

Answer 33

It is treated with steroids and recovery takes 2-6 weeks.
Around 50% of patients with a single episode of optic neuritis will go on to develop MS over the next 15 years. Changes on an MRI scan help to predict which patients will go on to develop MS.

Question 34

how do we manage MS?

Answer 34

Multiple sclerosis is managed by a specialist multidisciplinary team (MDT) including neurologists, specialist nurses, physiotherapy, occupational therapy and others. Patient should be fully educated about their condition and treatment.

Question 35

describe the aim for using drugs to alter the disease pathway?

Answer 35

try to induce long term remission, where there is no evidence of disease activity.
There are many options that target various mechanisms such as interleukins, inflammatory cytokines and various immune cells.

Question 36

how do we treat relapses of MS?

Answer 36

Relapses can be treated with steroids. NICE recommend methylprednisolone:

500mg orally daily for 5 days
1g intravenously daily for 3–5 days where oral treatment has failed previously or where relapses are severe

Question 37

how do we treat the symptoms that accompany MS?

Answer 37

It is important to treat the symptom that result from the disease process along with treating the disease process itself:

Exercise to maintain activity and strength
Neuropathic pain can be managed with medication such as amitriptyline or gabapentin
Depression can be managed with antidepressants such as SSRIs
Urge incontinence can be managed with anticholinergic medications such as tolterodine or oxybutynin (although be aware these can cause or worsen cognitive impairment)
Spasticity can be managed with baclofen, gabapentin and physiotherapy