Multiple Sclerosis Flashcards
Define mutliple sclerosis
Inflammatory demyelinating disease characterised by the presence of episodic neurological dysfunction in at least 2 areas of the CNS (brain, spinal cord, optic nerves) disseminated in time and space
What are the classifications of multiple sclerosis
Relapsing-remitting (80%) RRMS
Primary progressive (10%) PPMS
Secondary progressive* SPMS
Progressive relapsing PRMS
Aetiology of multiple sclerosis
Immune mediated inflammatory process which results in demyelination and axonal degeneration in the brain and spinal cord
T cells trigger attacks on the myelin sheath in the CNS
Risk factors for multiple sclerosis
Female
HLA-DLRB1*15
Smoking
Vitamin D deficiency
Hx autoimmune disease
EBV
Epidemiology of multiple sclerosis
Females 20-50
Most common cause of neurological disability among young adults
European descent individuals are most commonly affected
Black Americans may have more aggressive courses
Symptoms of multiple sclerosis
Fatigue
CNS disturbance:
- optic neuritis (blurring/graying in one eye), pain on moving eye, loss of colour vision
- Diploplia
- Ascending sensory disturbance/weakness
- Imbalance/incoordination
Sensory phenomena:
- “patch” of wetness/burning
- Sensory loss or tingling
- Symptoms worsen when warm (Uhtoff’s)
- Shock sensation from neck to limbs on neck flexion/extension
- Trigeminal neuropathy
Food dragging/slapping
Leg cramping
Urinary frequency or bowel dysfunction (constipation)
Differentials for multiple sclerosis
Stroke
Tumour
CNS sarcoidosis
SLE
Devic’s syndrome (neuromyelitis optica/NMO)
Signs of multiple sclerosis on examination
Limb (UMN)
- Spasticity
- Hypertonia
- Hyperreflexia, especially in the deep tendons
- Imbalance/incoordination - WIDE BASED GAIT and/or limb ataxia = cerebellar dysfunction
- Lhermittes’
Fundoscopy
- blurred optic disc (optic neuritis)
- Pale optic disc
CN
- Colour blindness (ishihara)
- Abnormal eye movements: internuclear ophthalmoplegia (INO) = slow adduction of the right during saccadic movements (rapid movement from extreme right to extreme left)
- Leading eye nystagmus with preserved adduction on convergent gaze
- RAPD
Investigations for multiple sclerosis
Clinical Diagnosis: 2 separate events that are disseminated in TIME and SPACE, and the absence of an alternative diagnosis (Revised McDonald criteria)
Antibodies: anti-MBP and NMO-IgG
FBC, TFTs, B12 and folate
MRI brain/spinal cord (Gadolinium-enhanced. T2 weighted): Periventricular white matter lesions (hyperintensities, demyelinated plaques) that may not match the clinical picture
- Acute - blood vessels are more fragile + permeable -> gadolinium contrast enters -> brighter
- Chronic - darker
LP: IgG oligclonal bands in CSF ONLY (Unmatched)
Management for an acute multiple sclerosis attack
Consider hospital admission if:
- Relapse is severe.
- Comorbidities such as diabetes or mental health conditions require monitoring.
- Oral steroids have failed or not been tolerated.
- It is difficult for the person to have their care needs met at home.
Methylprednisolone 0.5g daily for 5 days (1g, IV/PO, OD for 3 days) reduces duration + severity of attacks
Chronic management of multiple sclerosis
MDT: Neurologist, specialist MS nurse, physiotherapy, occupational therapy
Conservative:
- Regular exercise, supervised exercise programmes
- Stop smoking
- Control comorbidities e.g. depression, anxiety, vascular
- Inform DVLA
- Avoid stress, heat and overexertion
- Mindfulness training, CBT, fatigue management educational programmes
- Consider avoiding live vaccinations if using DMARDs
Pharm:
DMARDs:
- IFN-beta
- Glatiramer
- Natalizumab (1st line RRMS)
- Alemtuzumab
Symptomatic management
What is the management for the following symptoms in Ms: fatigue, depression, pain, spaticity, oscillopsia, urgency/frequency, Erectile dysfunction, tremor
Fatigue modafinil (CI in pregnancy), amantadine
Depression SSRI (citalopram)
Pain amitryptyline, gabapentin
Spasticity 1st: baclofen 2nd gabapentin 3rd: dantrolene
Oscillopsia 1st:gabapentin 2nd Memantine 3rd: Refer to neuro-ophthalmologist
Urgency/frequency oxybutynin, tolterodine
ED sildenafil
Tremor clonazepam
Complications of multiple sclerosis
Fatigue (>80%)
Spasticity → contractures, muscle shortening, pain, spasms
Ataxia, tremor → unable to carry out ADLs
Visual problems: optic neuritis, intranuclear ophthalmoplegia, nystagmus, diplopia
Reduced mobility, weakness, disordered balance, poor coordination
Pain
Bladder: frequency, urgency, incontinence (detrusor overactivity)
Sexual dysfunction
Mental health: depression, anxiety, emotional lability, cognitive impairment
Prognosis for multiple sclerosis
No cure, neurological disability accumulates over time
Most (85-90%) have a relapsing remitting pattern
Treatment of a relapse with steroids may shorten the length and severity of the relapse, but does not alter the overall course or prognosis of the disease.
10–20 years after onset on relapsing-remitting MS, over half of people develop progressive disease (secondary progressive MS).
Cognitive impairment affects 43–70% of people with MS
Good signs: female, <25, sensory signs, long intervals, few MRI lesions
Bad: Male, older, motor signs, sensory signs, short interval, many MRI lesions, axonal loss
