Multiple sclerosis

Question 1

What is multiple sclerosis?

Answer 1

A cell-mediated autoimmune condition characterised by repeated episodes of inflammation of the nervous tissue in the brain and spinal cord resulting in loss of insulating myelin sheath

Question 2

Aetiology of MS?

Answer 2

Greater incidence in females (3:1)

Presents typically between 20 to 40 years of age.

More common in white populations and with increasing distance from the equator.

Causes of MS not completely understood but autoimmune process appears to be caused both by genetic and environmental factors. Some genes include HLA and MHC polymorphisms.

Question 3

What factors indicate a worse prognosis for MS?

Answer 3

Older
Male
Motor signs at onset
Early relapses
Many MRI lesions
Axonal loss

Question 4

Pathophysiology of MS?

Answer 4

T cell mediated autoimmune disease that causes inflammatory process mainly within white matter of brain and spinal cord.

Plaques of demyelination occur anywhere in CNS white matter but have a preference for certain sites including:
- Optic nerves
- Brainstem + cerebellar connections
- Cervical cord (corticospinal tract + posterior columns).

Question 5

Patterns of MS?

Answer 5

Relapsing-remitting MS (most common 85-90%)
Secondary progressive MS
Primary progressive MS (10-15%)

Question 6

What is the definition of a relapse in MS?

Answer 6

The appearance of new symptoms, or the return of old symptoms, for a period of 24 hours or more – in the absence of an infection or a change in your core body temperature.

Question 7

What is relapsing-remitting MS?

Answer 7

Symptoms occur in attacks (relapses) with a characteristic time course: onset typically occurs over days and recovery (whether partial or complete) occurs overs weeks.

Question 8

What is primary progressive MS?

Answer 8

Occurs in 10-15% of cases

Characterised by gradually worsening disability without relapses or remission.

Question 9

What is secondary progressive MS?

Answer 9

A late stage of MS consisting of gradually worsening disability progressing over years.

Around 75% of patients with relapsing-remitting MS will progress to secondary progressive by 35 years from onset.

Question 10

Relapse vs pseudorelapse?

Answer 10

A relapse is considered any new or acutely worsening neurological symptoms with objective evidence that: last more than 24 hrs, not related to infection, fever or other stresses and has no other explanation.

A pseudorelapse is a temporary worsening of symptoms without actual myelin inflammation or damage, brought on by other influences e.g. fatigue, overexertion, fever and infection.

Question 11

Pyramidal dysfunction features of MS?

Answer 11

Increased tone (hypertonia)
Spasticity
Weakness
Affects extensors of upper limbs and flexors of lower limbs.

Question 12

Optic neuritis features of MS?

Answer 12

Painful visual loss over 1-2 weeks - blurred vision in 1 eye and loss (or reduction) in colour vision.

RAPD (relative afferent pupillary defect - pupils react differently to light being shone on eye) will be present on affected side

Pale optic disc on affected side

Most improve

Question 13

Sensory symptoms of MS?

Answer 13

Pain
Paraesthesia (abnormal sensation i.e. tingling)
Dorsal column loss (fasciculus gracilis and cuneatus) - proprioception and vibration
Numbness
Trigeminal neuralgia

Question 14

Lower urinary tract dysfunction in MS symptoms?

Answer 14

Increased frequency and urgency
Nocturia (urinaration at night)
Urge incontinence
Retention

Question 15

Brainstem (cranial nerve palsy) dysfunction in MS symptoms?

Answer 15

Diploplia (double vision) - CN 6 palsy
Facial weakness - CN 7 palsy

Question 16

Fatigue in MS symptoms?

Answer 16

Physical and cognitive
Sense of exhaustion

Question 17

Investigations for MS?

Answer 17

Bloods
- Before neurological referral, exclude differential diagnoses by checking FBC, inflammatory markers, U+E’s, LFT’s etc.

Neurophysiology
- Can detect demyelination in apparently unaffected pathways with characteristic delays.

MRI
- Periventricular lesions
- Discrete white matter abnormalities

CSF
- Oligoclonal bands present in 90+% of cases - distinct bands of IgG on western blot that are unmatched with serum testing.

Question 18

Management of acute relapse?

Answer 18

Mild - symptomatic treatment

Moderate - oral steroids

Severe - admit/IV steroids

Question 19

Symptomatic treatment for pyramidal dysfunction?

Answer 19

Physioterapy
Occupational therapy
Anti-spasmodic agent e.g. oral baclofen, botulinum toxin.

Question 20

Symptomatic treatment for sensory symptoms?

Answer 20

Anticonvulsants i.e. gabapentin
Antidepressants i.e. amitriptyline
Acupuncture

Question 21

Symptomatic treatment for lower urinary tract dysfunction?

Answer 21

Bladder drill
Desmopressin
Anti-cholinergics e.g. oxybutynin
catheterisation

Question 22

Symptomatic treatment for fatigue?

Answer 22

Amantadine
Modafinil (if sleepy)
Hyperbaric oxygen

Question 23

Red colour desaturation is a buzzword for what?

Answer 23

Optic neuritis

Question 24

Most common presentation (associated ocular condition) of MS?

Answer 24

Optic neuritis

Question 25

What is optic neuritis?

Answer 25

involves demyelination of the optic nerve and presents with unilateral reduced vision, developing over hours to days.

Question 26

Key features of optic neuritis?

Answer 26

Central scotoma (an enlarged central blind spot)
Pain with eye movement
Impaired colour vision
Relative afferent pupillary defect

Question 27

What is RAPD?

Answer 27

Relative afferent pupillary defect

where the pupil in the affected eye constricts more when shining a light in the contralateral eye than when shining it in the affected eye.

When testing the direct pupillary reflex, there is a reduced pupil response to shining light in the eye affected by optic neuritis.

Question 28

Some other causes of optic neuritis?

Answer 28

Sarcoidosis
Systemic lupus erythematosus
Syphilis
Measles or mumps
Neuromyelitis optica
Lyme disease

Question 29

For optic neuritis, patients presenting with acute loss of vision need urgent ophthalmology input. true/false?

Answer 29

True

Question 30

Treatment of optic neuritis?

Answer 30

High dose steroids i.e. prednisolone

Question 31

What determines which patients with optic neuritis will go on to develop MS?

Answer 31

Changes on an MRI scan

Question 32

Focal weakness symptoms of MS?

Answer 32

Incontinence
Horner syndrome
Facial nerve palsy
Limb paralysis

Question 33

Focal sensory symptoms of MS?

Answer 33

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

Question 34

What is Lhermitte’s sign in MS?

Answer 34

a sudden brief pain or electrical buzzing sensation. It runs down your neck into your spine and might then spread into your arms or legs.

Can be described as an “electrical shock” sensation in some patients.

Question 35

Signs of MS in MRI of head and spinal cord?

Answer 35

Juxtacortical and paraventricular lesions, in addition to spinal cord lesions.

Question 36

What is internuclear ophthalmoplegia?

Answer 36

Presents with ipsilateral impairment of the adducting eye and nystagmus of the abducting eye.

Multiple sclerosis is particularly a cause in younger patients.

Question 37

Horner syndrome can have an association with MS. What are the triad of symptoms for Horner’s?

Answer 37

Triad of:
partial ptosis (upper eyelid drooping)

anhidrosis (complete absence of sweating)

miosis (excessive constriction of pupil)