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Neuro > Multiple Sclerosis > Flashcards

Multiple Sclerosis Flashcards

1
Q

Describe some features of multiple sclerosis

A

Disease of young people, has variable severity, diverse presentation and the prognosis is uncertain

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1
Q

What is multiple sclerosis?

A

A central nervous system disease affecting the white matter
Demyelination (inflammation) causing focal disturbance of function
Most patients develop progressive disability

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2
Q

Describe the prevalence of multiple sclerosis

A

190 per 100000 in Scotland
50-60 cases per year in Aberdeen

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3
Q

What is the average age of onset for multiple sclerosis?

A

Around 20-30

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4
Q

Describe the pathogenesis of multiple sclerosis

A

Complex genetic inheritance and has association to autoimmune disease - more females to males
Commoner in temperate climate

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5
Q

What is the initial presentation of multiple sclerosis?

A

Relapse - demyelination
Inflammation which has gradual onset over days and stabilises days to weeks
Gradual resolution - partial or complete recovery

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6
Q

What are some symptoms of a relapse in multiple sclerosis?

A

Optic neuritis, sensory symptoms, limb weakness, brainstem - diplopia, vertigo/ataxia, spinal cord - bilateral motor and sensory symptoms and bladder involvement

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7
Q

Describe optic/ retrobulbar neuritis

A

Subacute visual loss, pain on moving eye, colour vision impaired, resolves over weeks/ months
Initial optic disc swelling, optic atrophy and relative afferent pupillary defect

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8
Q

What is a relative afferent pupillary defect?

A

Dark room, shin torch into eye and constriction
As swing to affected eye then they dilate
Swing light and they constrict

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9
Q

Describe a brainstem relapse

A

CN involvement
Pons - internuclear ophthalmoplegia
Cerebellum - vertigo, nystagmus and ataxia
UMN signs in limbs
Sensory involvement

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10
Q

What is left internuclear ophthalmoplegia?

A

Normal gaze to left
Gaze to right causes left eye to not abduct and nystagmus in right eye

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11
Q

What does a spinal cord lesion cause?

A

Partial or transverse (complete) myelitis
Sensory level is often with band of hyperaesthesia
Weakness/ UMN changes below demyelination
Bladder and bowel involvement

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12
Q

What is the process of demyelination?

A

Autoimmune process - activated T cells cross blood brain barrier causing demyelination
Acute inflammation of myelin sheath causing loss of function

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13
Q

Can demyelination repair?

A

Yes and can have recovery of function
Post inflammatory gliosis may be functional deficit

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14
Q

What is clinically isolated syndrome (CIS)?

A

When no further episodes of demyelination as MS is episodes of demyelination in space and time

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15
Q

Describe further relapes in MS

A

May occur within months or years of first episode
Variable site and severity
Is underlying infection in some
Fewer relapses in pregnancy

16
Q

What does progression of MS cause?

A

Axonal loss - which contributes to persistent disability
Can see black holes on MRI
Later seen as cerebral atrophy

17
Q

What are some progressive phase symptoms and signs?

A

Fatigue, temp. sensitivity, dysesthesia, stiffness or spasm, balance and slurred speech, bladder and bowel, diplopia/ visual loss, dysphagia and cognitive memory affected

18
Q

What can be seen on examination of progressive MS?

A

Afferent pupillary defect, nystagmus, cerebellar signs, weakness, spasticity, hyperreflexia and plantars extensor

19
Q

What are the types of MS?

A

Relapsing remitting (RRMS) 85%
Secondary progressive (SPMS)
Primary progressive (PPMS) 10-15%

20
Q

Describe primary progressive MS

A

Often presents in 5th or 6th decade, no relapses, spinal and bladder symptoms
Prognosis is poor

21
Q

How is MS diagnosed?

A

Evidence of demyelination separated in time and space
Can be clinical or MRI based
Posers criteria - clinical

22
Q

How are active lesions seen on MRI?

A

Add Gadolinium to show active lesions - demyelination

23
Q

What are some other investigations used in MS?

A

Lumbar puncture - normal CSF and protein but few WCC and oligoclonal bands present
CXR, Bloods, visual evoked response

24
Q

What are some differential diagnosis for MS?

A

Acute disseminated encephalomyelitis, autoimmune condition, demyelination conditions, sarcoidosis, vasculitis, infection and adrenoleukodystrophy

25
Q

What are come differential diagnosis of optic neuritis?

A

Neuromyelitis optica, sarcoid, ischaemic optic neuropathy, B12 deficiency, Wegener’s granulomatosis, local compression, infection

26
Q

What are some differential diagnosis for myelitis?

A

Inflammation - sarcoid, SLE, neuromyelitis optica
Infection or post-infection
Tumour, paraneoplastic process, stroke

27
Q

What is the treatment for MS?

A

Treatment for relapse, disease modifying treatment, health and diet, symptomatic control and MDT approach

28
Q

What is the treatment for an acute relpase?

A

Look for underlying infection
Oral prednisolone - IV, rehabilitation and symptomatic treatment

29
Q

What is included in symptomatic treatment of MS?

A

Spasticity muscle relaxants/ antispasmodics, physio
Dysesthesia-amitriptyline, gabapentin
urinary anticholinergic Rx, bladder stimulator
Constipation - laxatives
Sexual dysfunction - sildenafil

30
Q

What are some other symptomatic treatments?

A

Fatigue graded exercise, Depression - CBT and medication, cognitive memory aids, tremor aids, vision - carbamazepine, speech - SALT

31
Q

Who is included in the MDT for MS?

A

MS nurse, physiotherapy, occupational therapy, speech and language therapy, dietician, rehab specialists, continence advisor and psychiatry

32
Q

What are the 2st line treatments for disease modifying treatments?

A

SC or IM injections - beta-interferons and glatiramer acetate
Oral - teriflunomide and dimethyl fumarate

33
Q

What are the 2nd line agents used for treatment?

A

natalizumab, Fingolimod, Cladribine and Ocrelizumab
Alemtuzumab

34
Q

Describe disease modifying treatment

A

Not a cure, reduces relapse rate, does not slow the progression and has side effects

35
Q

What can immunosuppression cause?

A

Progressive multifocal leukoencephalopathy (PML)

Neuro (40 decks)

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