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YR6: NEURO > Multiple Sclerosis > Flashcards

Multiple Sclerosis Flashcards

1
Q

What is MS?

A

Acquired, chronic, immune-mediated, inflammatory disease of the CNS (can affect brain, brainstem, + spinal cord)

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2
Q

What do the inflammatory processes in MS cause pathophysiologically?

A

Areas of demyelination (damage to white matter), gliosis (scarring), + neuronal damage throughout the CNS.

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3
Q

Describe the epidemiology of MS

A

F > M (3:1)
Age of onset: 20-40y
More common at high latitudes

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4
Q

What causes MS?

A

UNKNOWN
Acute then chronic inflammation precipitated by abnormal response to environmental triggers in genetically pre-disposed

Immune-mediated damage to myelin sheaths results in impaired axonal conduction.

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5
Q

List 2 risk factors for MS

A

FH
Female

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6
Q

List 3 types of MS

A

Relapsing-Remitting (RRMS)

Primary Progressive (PPMS)

Secondary Progressive (SPMS)

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7
Q

Describe RRMS

A

Most common, 85% have RRMS at onset
Attacks (1-2 months) with almost complete recovery between attacks

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8
Q

Describe SPMS

A

gradual accumulation of disability after initial relapsing course
2/3 of RRMS progress to SPMS

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9
Q

Describe PPMS

A

Steady progression + worsening of disease from the onset, without remissions.
~10-15% of MS

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10
Q

Define ‘relapse’ of MS

A

Onset of new Sx, or worsening of pre-existing Sx.
Attributable to demyelinating disease.
Lasting >24 h
In absence of infection, or any other cause.
After a stable period of at least a month.

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11
Q

What do symptoms depend on in MS?

A

Site of inflammation

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12
Q

List the 4 most common initial presentations of MS

A

Optic neuritis
Transverse myelitis
Cerebellar-related Sx
Brainstem syndrome

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13
Q

Describe optic neuritis

A

Unilateral deterioration of visual acuity + colour vision
Pain behind eye + on eye movement

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14
Q

Other than optic neuritis, what are the possible visual manifestations of MS

A

Optic atrophy
Uhthoff’s phenomenon
Internuclear ophthalmoplegia

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15
Q

What is Uhthoff’s phenomenon?

A

Worsening of vision following rise in body temperature

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16
Q

Describe fundoscopy in optic neuritis in MS

A

Often normal but disc may appear pale or swollen.
May be RAPD

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17
Q

What is transverse myelitis?

A

focal inflammation within the spinal cord
Sensory Sx (such as paraesthesia) or Motor Sx (such as weakness)
below level of inflammation
Typically develop over hours or days.

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18
Q

How may transverse myelitis manifest?

A

Tight band sensation around the trunk at level of inflammation
Lhermitte’s phenomena
Urinary Sx: urgency, frequency, retention
Focal muscle weakness + reduced sensation below affected spinal level
Muscle tone initially reduced

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19
Q

What is Lhermitte’s phenomena?

A

Shock-like sensation radiating down the spine + into limbs induced by neck flexion

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20
Q

Describe cerebellar-related symptoms that may arise in MS

A

Ataxia
Vertigo
Clumsiness
Dysmetria

21
Q

Describe how brainstem syndromes may manifest in MS

A

Ataxia
Eye movement abnormalities
Bulbar muscle problems resulting in dysarthria/ dysphagia

22
Q

What are 3 sensory symptoms of MS?

A

Pins + needles
Numbness
Burning

23
Q

What 6 general signs are seen on examination in MS?

A

Sensory: Paraesthesia
Motor: Spastic weakness most commonly seen in legs
Cerebellar: Limb ataxia (intention tremor, past-pointing)
Urinary frequency/ incontinence
Sexual dysfunction
Cognitive impairment

24
Q

What is diagnosis based on in MS?

A

Finding 2 or more CNS lesions with corresponding Sx, separated in time + space (McDONALD CRITERIA)
Only a consultant neurologist should make a dx of MS.

25
Q

What is seen on brain MRI in MS?

A

High signal T2 lesions
Periventricular plaques
Dawson fingers: hyper intense lesions perpendicular to corpus callosum

26
Q

What is seen on spine MRI in MS?

A

Demyelinating lesions
esp. in the cervical spinal cord
Gadolinium enhancement shows active lesions

27
Q

What is seen on CSF evaluation in MS?

A

Oligoclonal bands (+ not in serum)
Increased intrathecal synthesis of IgG

28
Q

What investigation can be performed in MS when MRI is contraindicated?

A

Visual evoked potentials: prolongated of conduction (preserved waveform)

Also can perform auditory + somatosensory (painful) evoked potentials but are less commonly abnormal

29
Q

Why may LP be performed in MS?

A

r/o infection/ inflammatory causes

30
Q

What are 4 motor symptoms of MS?

A

Limb weakness
Spasms
Stiffness
Heaviness

31
Q

What are 4 autonomic symptoms of MS?

A

Urinary urgency
Hesitancy
Incontinence
Impotence

32
Q

What may be found on visual fielding testing in MS?

A 
Central scotoma (if optic nerve is affected) 
Scotoma = a blind spot in the normal visual field 
Field defects (if optic radiations are affected)
33
Q

What occurs in internuclear ophthalmoplegia?

A

Nystagmus of abducting eye with absent adduction of the other eye
Indicates lesion of contralateral medial longitudinal fasciculus

34
Q

What is Clinically Isolated Syndrome?

A

Single clinical attack of demyelination (does NOT count as MS)
10-50% progress to develop MS

35
Q

Describe management of acute relapse in MS

A

PO/ IV Methylprednisolone for 3-5 days

36
Q

Describe the effect of steroids in acute relapse of MS

A

Shorten duration of relapse but don’t alter degree of recovery

37
Q

What are the indications for using disease modifying drugs in MS?

A

RRMS + 2 relapses in past 2y + able to walk 100m unaided
SPMS + 2 relapses in past 2y + able to walk 10m (aided or unaided)

38
Q

List 5 disease modifying drugs that can be used in MS

A

Natalizumab
Ocrelizumab
Fingolimod
Beta-interferon
Glatiramer acetate

39
Q

Describe management of fatigue in MS once other causes have been excluded

A

Amantadine (specialist initiated)
Mindfulness training + CBT

40
Q

Alongside PT, which drugs are used first line for spasticity in MS?

A

Baclofen
Gabapentin
(diazepam, dantrolene + tizanidine)

41
Q

Describe management of bladder dysfunction in MS

A

US to assess bladder emptying

Significant residual volume → intermittent self-catheterisation

No significant residual volume → anticholinergics may reduce frequency

42
Q

What is Oscillopsia?
What drug can be used to manage this in MS?

A

Where visual fields appear to oscillate
Gabapentin (2nd: memantine)

43
Q

What is Natalizumab? What is the MOA?

A

Recombinant monoclonal antibody
Antagonises alpha-4 beta-1-integrin found on surface of leucocytes
Inhibits migration of leucocytes across the BBB

44
Q

Which disease modifying drug has the strongest evidence base for preventing relapse in MS? What is the mode of delivery?

A

Natalizumab
Often given first line
IV

45
Q

What is Ocrelizumab?

A

Humanized anti-CD20 monoclonal antibody
High-efficacy, often used first-line
IV

46
Q

What is Fingolimid?

A

Sphingosine 1-phosphate (S1P) receptor modulator
Prevents lymphocytes from leaving LNs

PO

47
Q

Describe use of beta interferon in MS

A

Not considered to be as effective as alternative disease-modifying drugs

SC / IM

48
Q

What is Glatiramer acetate?

A

Immunomodulating drug: acts as an ‘immune decoy’
SC
‘older drug’ with less effectiveness

YR6: NEURO (47 decks)

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