Multiple Sclerosis

Question 1

What is intranuclear opthalmoplegia? What generally causes it?

Answer 1

• Disconnect of CNIII and VI at the MLF
• Presents as ability to gaze in the affected direction, but the affected eye will be unable to adduct and the unaffected eye will have nystagmus on abduction
• Caused bilaterally by MS, unilaterally by MS, stroke

Question 2

How is MS defined?

Answer 2

• Dissemination in time (> 1/12 apart, or difference in radiological age) and space of neurological lesions

Question 3

What are the common presentations of multiple sclerosis?

Answer 3

• Worse with heat, better with cold (Uhthoff’s phenomenon)
• Optic neuritis (40%) - eye pain, visual acuity decrease, red desaturation
• Transverse myelitis (30%) - functional transection of the cord, often described as a tight band at the level
• Brainstem/cerebellar signs (20%) - ataxia, internuclear ophthalmoplegia (classic sign)
• Bladder retention, bowel retention, trigeminal neuralgia, cognitive dysfunction/fatigue/depression, dysarthria/phagia

Question 4

What might you find on examination in someone with MS?

Answer 4

• UMN signs
• Pyramidal weakness (LL flexion weakness, UL extensor weakness)
• L’Hermitt’s sign - neuropathic pain down back when neck is flexed - denotes inflammatory process
• Effects mostly non-cortical (although some small effects can occur)

Question 5

What are the treatment principles of a person with MS?

Answer 5

• Relapses
  
  • High-dose steroids - no impact on overall disease
• DMARDs
  
  • Injectables - interferons B, glatiramer acetate (only used if pregnant), teriflunomide
  • Tablets - fingolimod, dimethyl fumarate
  • Biologicals