MULTIPLE SCLEROSIS Flashcards

1
Q

What is multiple sclerosis?

A

An acquired, chronic, immune-mediated inflammatory condition of the central nervous system. It can affect the brain, brainstem and spinal cord

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2
Q

What are glial cells?

A

A type of cell that provides physical and chemical support to neurons and maintain their environment

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3
Q

What is an astrocyte?

A

A type of glial cell that has many roles in supporting the neurones

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4
Q

What are oligodendrocytes and what are their major function?

A

These are a type of glial cell
Wraps myelin around the neuron to allow for a more rapid transmission of the impulse

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5
Q

Pathophysiology of multiple sclerosis?

A

Thought to be inflammation precipitated by an abnormal response to environmental triggers in people who are genetically predisposed.
T cells attack oligodendrocytes which can cause focal or diffiuse areas of inflammation which causes areas of demyelination (plaques), gliosis (scarring) and neuronal damage throughout the CNS

Progressive damage to affected cells in the nervous system leads to irreversible loss of function of affected nerves, resulting in permenant sytmptoms and signs

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6
Q

Do neurones fully repair during remission of MS?

A

No
Remyelination of axons may occur but it will be partial or transient
Axons themselves cannot repair

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7
Q

What are the 3 main patterns of MS?

A

Relapsing-remitting 85%
Secondary progressive - 2/3rds of those with relapsing remitting disease progress to this
Primary progressive 10-15%

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8
Q

What is relapsing-remitting MS?

A

Episodes or exacerbations of symptoms followed by remissions or periods of stability
Can be weeks to decades between episodes! Duration can be days-months
Recovery period can be complete or incomplete

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9
Q

What is secondary progressive MS?

A

Initially relapsing-remitting usually. Later progression with gradual ongoing deterioration. Relapses can still occur by they are less likely!
50% by 10 years but this is very variable

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10
Q

What is primary progressive MS?

A

Steady progression and worsening of disease from onset, without remissions
The rate of deterioration may vary
Usually more spinal cord involvement

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11
Q

What are plaques in MS?

A

These are areas of demyelination that are found in the white matter of the CNS
They usually lie in close relationship to post-capillary venules

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12
Q

Risk factors for MS?

A

Genetics
Vitamin D deficiency
Cigarette smoking
Diet and obesity in early life - possible due to lower vit D levels
Latitude - the greater the distance N or S from the equator - lack of vit D?
EBV
Female gender

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13
Q

Epidemiology of MS?

A

Onset usually 20-50
Affects women: men up to 3:1

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14
Q

Most common initial presentations of MS?

A

Optic neuritis
Transverse myelitis
Cerebellar-related symptoms
Brainstem syndromes

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15
Q

Symptoms of MS?

A

Can be very mild or very severe and symptoms depend on where in the brain is affected

Visual:
- optic neuritis
- optic atrophy
- uhthoffs phenomenon
- inter nuclear ophthalmoplegia

Sensory:
- pins & needles
- numbness
- trigeminal neuralgia
- lhermitte’s syndrome

Motor:
- spastic weakness most commonly legs

Cerebellar:
- ataxia
- tremor

Others:
- 75% have fatigue
- Urinary incontinence
- sexual dysfunction
- intellectual deterioration

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16
Q

How does optic neuritis present?

A

Partial or total unilateral visual loss developing over a few days - e.g. scotoma
Pain behind eye on eye movement
Loss of colour discrimination - esp red

On exam:
Relative afferent pupillary defect
Papilloedema in 30%
Scotoma in 70%

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17
Q

What is transverse myelitis and how does it present?

A

Focal inflammation within the spinal cord
May present with sensory or motor symptoms below the level of inflammation e.,g. Numbness, weakness.
Some people describe a tight band sensation around the trunk or lhermitte’s phenomena.
There may be urinary symptoms

18
Q

What is Lhermitte’s syndrome?

A

Paraesthesia in the limbs on neck flexion

19
Q

What is Uhthoff’s phenomenon?

A

Worsening of vision following a rise in body temperature

20
Q

When can a diagnosis of MS be made?

A

When there are 2 or more relapses + either objective clinical evidence of 2 or more lesions, OR objective clinical evidence of 1 lesions with reasonable historical evidence of a previous relapse

21
Q

MRI findings in MS?

A

Soft, fluffy, ovoid areas of high signal on T2 - peri ventricular plaques
common sites include peri ventricular, corpus callosum, posterior fossa and sub-cortical
Dawson fingers - hyperintense lesions perpendicular to the corpus callosum

22
Q

What is a pseudo-relapse of MS?

A

A temporary worsening of existing or old symptms due to decompensation
E.g. infection, stress, tiredness, weather changes

Important to differentiate this between relapses

23
Q

Diagnosing a relapse of MS?

A

New symptoms of existing symptoms have worsened and they have lasted for >24 hours in the absence of infection or any other cause.
Must occur after a stable period of at least 1 month

24
Q

Investigtaions for MS?

A

MRI brain & spinal cord
Lumbar puncture for CSF - usually only done if clinical/investigative evidence is lacking
Electrophysiology - Visual evoked potentials - light patterns are shown to eyes whilst brainwaves are monitored using electrodes - shows delayed VEP indicating optic neuropathy in 85%

25
Q

Lumbar puncture findings in MS?

A

Oligoclonal bands in the CSF but not in the serum - caused by increased intrathecal synthesis of IgG = indicates inflammation
Presents in 70-90% of MS cases

26
Q

Managing relapses of MS?

A

Rule out infections and other causes of pseudo-relapse

If hopsital admission is not indicated:
Short courses of high-dose corticosteroids e.g. IV methylprednisolone - shortens the length of an acute relapse

27
Q

Management to reduce the risk of relapse in pt with MS?

A

Disease-modifying drugs
E.g. natalizumab, ocrelizumab, fingolimod, beta-interferon, glatiramer acetate
(Note this doesn’t affect outcome)

28
Q

What is the goal of MS treatment?

A

NEDA - No Evidence of Disease Activity

29
Q

Management of fatigue in a person with MS?

A

Assess for a cause
Regular aerobic, balance and stretch exercises e.g. yoga
Mindfulness training, CBT, fatigue management educational programmes, supervised exercise programmes etc
Amantadine can be trialled. Modafinil can also be trialled

30
Q

How to manage spasticity in a person with MS?

A

Assess for and treat factors that may aggravate it
Baclofen can be used. Gabapentin is also first line
Consider PT referral

31
Q

Bladder symptoms in MS?

A

Detrusor hyper-reflexia - urgency, frequency, urge incontinence, Nocturia
Sphincter dyssynergia (coordination of bladder contraction and sphincter relaxation issues) - incomplete emptying and frequency

32
Q

Management of bladder dysfunction in MS?

A

US to assess bladder emptying to check for high residual volume of urine in the bladder
If significant residual volume -> intermittent self-catahertisation
If not -> Anticholinergics may improve urinary frequency (these would worsen Sx if high residual volume)

33
Q

How to manage MS-related pain?

A

MSK pain is common usually because of issues with mobility and posture
Refer to PT, analgesia

If neuropathic pain you can use neuropathic drugs e.g. carbamazepine, amitryptiline, gabapentin

34
Q

How common is depression in MS?

A

10-57%!
More common in MS than in other disabling conditions

35
Q

What is MS Society?

A

A charity that funds world-leading research, shares latest information and campaigns for patients with MS

They aim to help people live well with MS, connect people and make sure their voices are heard, and work to find effective Tx and prevent MS

36
Q

How long does it usually take for relapsing-remitting MS to develop into secondary progressive MS?

A

10-20 years

37
Q

Median time from disease onset to needing a walking aid in primary-progressive MS?

A

8 years

38
Q

Complications of MS?

A

Fatigue - 80%
Spasticity - 80% - can cause muscle shortening, permenant contractures and pain
Ataxia and tremor
Visual problems
Reduces mobility e.g gait disturbance
Pain
Bladder problems
Sexual dysfunction
Mental health problems

39
Q

Where do plaques of demyelination tend to occur in MS/

A

Optic nerves
Brainstem and cerebellar connections
Cervical spinal cord - particular posterior columns and spinothalamic tracts

40
Q

When MS causes brainstem demyelination what sympotms do we see?

A

Diplopia
Vertigo
Nystagmus
Pseudobulbar palsy - dysarthria or dysphagia
May cause an internuclear ophthalmoplagia

(Nerve most commonly affected is CN6)