Multiple sclerosis Flashcards
What is MS
Inflammatory demyelination of CNS
Risk factors for MS
20-50 yes
3 x more in women
FH
Higher latitudes - vit D exposure?
What are attaacks in MS
CNS demyelination develops over days to weeks
At least 24 hours can last weeks to months
What need for MS diagnosis
Multiple attacks disseminated in space and time
Common initial presentations in MS
Optic neuritis
Transverse myelitis
Brainstem inflammation
Who should be investigated for MS
Patinet with 1 or more episodes of inflammatory demyelination
Investigation for MS
MRI brain and spinal cord
What see on MRI in MS
Dawsons fingers
Periventricular plaques - white close ot ventricels
Lesions of different times and areas
What contrast use in MRI
Gadolinium contrast - differntiate between ols and active inflamamtion
What lesionsare enhanced with gadolinium
Active lesions
What suggests MS on LP
Oligoclonal bands ( not present in serum)
Inflammation and immunoglobulin synthesis
Diagnostic criteria for MS
Mcdonald criteria
Mcdonald criteria for MS diagnosis
- If 2 or more attacks and lesions - clinical alone
- If 2 or more attacks, 1 lesion and dissemination in space on MRI
- 1 attack, 2 lesions and disseminated in time on MRI
- 1 attack, 1 lesion and disseminated in space and time
How prove dissemination in time
Simultaneous asymptomatic contrast enhancing and non enhancing lesions at any time
OR
new T2 and/or contrast enhancing lesions on follow up MRI irrespective of timing
OR
await a second clinical attack
How prove dissemination in space
T2 lesion one or more in at least two MS tyical CNS regions:
- Periventricular
- Jaxtacortical
- Infratentorial
- Spinal cord
How diagnosie MS with no attacks
One year of disease progression and at least 2 out of 3 of
Disseminated in space in brain
Space in spinal cord - 2 or more T2 lesions
Positive CSF
Patterns of MS
Relapsing remitting
Primary progressive 4Secondary progressive
Progressive relapsing (steady decline, superimposed attacks)
Primary vs secondary progressive
Primary = steady decline without attacks
Secondary - initally relapsing remitting then decline without remission peridos
What virus has been linked to risk for MS
EBV
What is relapse in MS
Reported symptoms or findings - ms pathology
acute/subacute development
Last longer than 24 hours
absence fever/infection
>30 days clinical stability
Attack, exacerbation and (when it is the first episode) clinically isolated syndrome
What can cause worsening of MS symptoms that isnt a relapse
Infection or fever esp UTI
Stress/heart/over exertion
MRI if clincial uncertainty
How treat an MS flare
IV or oral prednisolone, methylprednisoloin- high dose steroids
Speed recovery time
Purpose of didease modifying treatments in MS
Reduce frequency of relaspese
Reduce progression of neurodisability
Given early when remitting relasping
What disease modifying treatments for MS
First line - interferon beta - SC
Fingolimod - oral
Alemtuzumab, nata,ocrelizumab
Which medications are most effective but also most side effects/risk
Alemtuzumab etc
What risk is esp in MS patients with strong DMTs
Progressive multifocal leukoencephalopathy
What is PML
Reactiveation of JC virus in CNS -> neuro problems
What is uhtoffs phenomenon
Worsening of MS symptoms after heat exposure
How manage fatigue in MS
Cooling, pacing activities, amantaine, CBT, mindfulness
How manage mood and cognition in MS
CBT, SSRIs, duloxetine
Social suppor, sleep/pain/depression education
Treatment for pain in MS
CBT
Amitryptilline
Gabapentin
Pregabalin
Neurogenic bladder treatment
Fluid intake control, regimented rroutine
Oxybutinin
Botox
Intermittent self catheterisation
Constipation treatment MS
- Good diet+fluid, regular laxatives, bowel care, assisted evacuation, good hygeine
Symptoms of neurogenic bladder
Urinary frequncy, urgency, nocutria, frequent UTIs
First line investigation for urinary incontinence MS
US KUB - need to check if any retnetion before treat as determines management plan
What is lhermittes symptom
Electric shock down bac of spine when neck flexion
WHo does MS affect
AI disease 40-50 years peakonset
Female 3:1
Risk factors for multiple sclerosis
EBV - 5x
Smoking
Vit D
Latitiude
Genetics - FH, HLA, IL
How does MS behave in pregnancy
Experience fewer reapses while pregnant and symptoms improve
1/4 -> relapse in 3 months PP -> corticosteroids
First line MS in pregnancy
Interferon beta
Glatiramer acetate
Can do MRI head in pregnancy for MS?
Yes BUT not with gadolinium scan
Histopathology of MS nerve cells
Multifocal demyelination
Loss of oligodendrocytes
Astrogliosis and loss of axons in mostly white matter
Clinical features of MS
Visual problems - optic neuritis inital presentaiton
Fatigue
Pain - neuropathic nociceptive, altered sensation
Muscle spasticity, stiff + weak
Mobility problems
Bladder and bowel dysfunction
Sexual dysfunction
Depression and anxiety
Congitive impairment - exec function, learning + short term mem
Speech and swallowing issues
Optic neuritis symptoms
Tmpeorary vision loss incl scotoma, colour blindness, painful eye movements
Optic neuritis on fundoscope
Internuclear opthalmoplegia or pale optic disc
What pain experienced in MS
neuropathic and nociceptive
Trigeminal neuralgia
Optic neuritis
Chest tightness Lhermittes sensation
How does spasticitiy and weakness presnet in MS
Spasticity in legs > arms
Weakness - both lower limbs>one lower limb>upper
AND lower limb same side>upper limb
Spasms disturb sleep
Mobility symptoms MS
Demyelination of cerbeallar pathways -> ataxia
Upper limb intention tremor - thalamus and basal anglia involvement
Features of bladder and bowel dysfunction
Increased frequency and urgency
Urinary retention
Recurrent UTIs
Constipation is the most common bowel complaint
What causes speech and swallowing issues MS
Bulbar muscle problems -> dysarthria, dysphagia
First line blood tests MS
FBC
Inflam markers (CNS infections, vasculitides)
LFTs - chronic LD -> neuropathy, HE
U+Es
Calcium
Glucose
TFTs - hypo - fatigue, weak, constipated, slow thought
Vit B12 - SACD
HIV serology
Differentials from FBC for MS
Anaemia - amcrocytic B12
Malignancy - thrombocytopenia lymphoma
Why test calcium when sus MS
Can present with paraesthesia and tetany
Why do HIV serology when sus MS
PML due to reactivation of JCV virus
Lesions occur anywhere in CNS + mimc MS
When is LP recommended for MS
Insufficient clinical of MRI evidence to diagnose MS
Any presentation other than CIS
Atypical clinical, imaging or lab findings of MS
MS in atypical demographic
Neuromyelitis optica vs optic neuritis
NO = + for anti aquaporin antibody +/or +ve ant myelin oligodendrocyte glycoprotien
Transverse myelitis vs MS
Upper motor neurone signs (hyperreflexia, Babinski sign and spasticity)
T2 + Gd lesions in spinal cord but NOT brain
Increased WCC LP
Indications for DMARDs MS
Relapsing remitting disease + 2 relapses past 2 years + able walk 100m unaided
OR
secondary progressive disease + 2 relapses in past 2 years + walk 10m aided or unaided
What drug use for faituge
Amantadine
First line for spasticity
Baclofen and gabapentin
2nd - diaxepam, dantrolene, tizanidine
Bladder dysfunction how treat if significant residual volume vs if none
Intermittent self catheterisation if residual colume
If no signif residual volume -> anticholinergics eg oxybutinin
Complications of MS
Recurrent UTIs
Osteopenia, osteoprosis
Depression
Visual impairment
Cognitive impairment
Impaired mobility
Progosis
Less frequent initial relapses esp if years between first two = better prognosis
