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N - C > Multiple Sclerosis > Flashcards

Multiple Sclerosis Flashcards

1
Q

Give a summary of MS

A 
Relatively common neurological disease
Disease of young people
Variable severity
Diverse presentation
Prognosis uncertain
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2
Q

What is MS?

A 
White matter disease of the CNS
Involves demyelination
Focal distrurbance of function-relapse
Relapsing remitting course
Most patients develop progressive disability
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3
Q

Describe demyelination in MS

A

Autoimmune process
Activated T cells cross blood brain barrier causing demyelination

Acute inflammation of myelin sheath

Repair-Recovary of function
Post inflammatory gliosis

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4
Q

What is post inflammatory gliosis?

A

Mild or significant disability due to relapse not fully recovering

These lesions can be seen as plaques of demyelination on MRI

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5
Q

How does axonal loss play into disease progression?

A

Axonal loss may be important in disease progression and development of persistant disability

Previously thought to be caused by demyelination but now thought to probably be present from disease onset

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6
Q

How is axonal loss seen?

A

Black holes on MRI

Later seen as cerebral atrophy

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7
Q

What is the prevalence of MS?

A

About 190 per 100,000 in Scotland

Approx 5 new cases per week in Scotland

50-60 new cases per year in Aberdeen

Average GP has 2-4 patients
1-3 of whom are significantly disabled

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8
Q

What is the epidemiology of MS?

A

Young: 20-30s
Female:Male 2-3:1

More rare as you head towards the equator

If move north or south from equator at young age, risk is same as population there

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9
Q

What is the initial presentation in MS?

A

80% cases present with a relapse
(“attack of demyelination” or “inflammation”)

  • Gradual onset over days
  • Stabilises days to weeks
  • Gradual resolution to complete or partial recovery
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10
Q

What symptoms may be involved in a relapse?

A

Optic neuritis

Sensory symptoms (pins and needles etc)

Limb weakness

Diplopia/ Vertigo/ Ataxia (brainstem)

Spinal cord- bilateral symptoms and signs +/- bladder
(spasticity etc)

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11
Q

Does an isolated episode of demyelination indicate MS?

A

NO

Sometimes no further episodes

MS = episodes of demyelination disseminated in space and time

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12
Q

Describe further relapses in MS?

A

MAY OCCUR WITHIN MONTHS OR YEARS OF FIRST RELAPSE

Optic nerve
Sensory
Limb weakness
Diplopia
Vertigo
Ataxia
Sphinter disturbance
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13
Q

What is optic neuritis?

A

Subacute visual loss
Eye painful on movement

Colour vision disturbed (red)
Vision becomes cloudy
Initial swelling of optic disc
Optic atrophy seen later
Relative afferent pupillary defect
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14
Q

What is the differential diagnosis of optic neuritis?

A 
Neuromyelitis optica
Sarcoidosis
Ischaemic
B12/ other vit deficiency
Wegeners granulomatosis
Hereditary neuropathy
Herpes simplex
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15
Q

What occurs during the progressive phase of MS?

A

ACCUMULATION OF SYMPTOMS AND SIGNS

  • Fatigue, temperature sensitivity
  • Sensory
  • Stiffness or spasms
  • Balance, slurred speech
  • Swallowing
  • Bladder and bowel
  • Diplopia/ Oscillopsia/ Visual loss
  • Cognitive- dementia/ emotional lability
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16
Q

What should you look for in a clinical examination?

A

Depends on where demyelination has occurred and stage of disease:

  • Afferent pupillary defect
  • Nystagmus or abnormal eye movements
  • Cerebellar signs
  • Weakness
  • Spasticity
  • Hyperflexia
  • Plantars extensor
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17
Q

How do you diagnose MS?

A

Evidence of demyelination separated in time and space

May be clinical or on MRI

  • Posers criteria (clinical)
  • Macdonald Criteria (MRI)
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18
Q

What are lesions or plaques in MS?

A

Areas of demyelination on MRI scan

For 10 lesions (approx) patient experiences 1 relapse

19
Q

Scan and patient symptoms and signs often do not correlate.

What other investigations can back up diagnosis?

A

Lumbar puncture:
-Oligoclonal bands present in CSF but not serum

Visual evoked response:

  • EEG and flash light in eye
  • EEG delay shows demyelination

Bloods:
-Exclude other inflammatory conditions

CXR

20
Q

What will lumbar puncture show in sarcoid?

A

Oligoclonal bands present in both CSF and blood

21
Q

What is the differential diagnosis in MS?

A

Depends on symptoms and signs and on whether a first relapse or progressive disease:

  • Acute Disseminated Encephalomyelitis
  • Other Auto-immune conditions (e.g. SLE)
  • Sarcoidosis
  • Vasculitis
  • Infection (e.g. Lyme disease, HTLV-1)
  • Adrenoleucidystrophy
22
Q

What are the different types of MS?

A 
Relapsing Remitting (85% at onset)
Secondary progressive
Primary Progressive (10-15%)
Sensory (5%)
Malignant
23
Q

What is relapsing remitting MS?

A

No progressive disease (always a possibility in future though)

Relapses followed by recovery then relapses

24
Q

What is secondary progressive MS?

A

Relapses eventually lead to progressive disease

25
Q

What is primary progressive MS?

A

Progressive disease from the onset

Often presents in 5th and 6th decade
No relapses
Often spinal problems (lower limbs)
Prognosis poor
M:F = 1:1
26
Q

What is sensory MS?

A

Relapsing remitting

Mild symptoms which are confined to sensory

27
Q

What is malignant MS?

A

VERY aggressive

28
Q

Describe the course of MS

A

Most patients who present with a relapse go on to develop secondary progressive disease

  • 25% 10 years from onset
  • 50% 20 years
  • 75% after 35 years
29
Q

How does progression of MS effect patients QoL?

A

1/4 MS never affects activities of daily living (ADL)

15% severely disabled quickly

1 in 4 will require a wheel chair at some point

30
Q

What are the good signs for prognosis in MS?

A

VERY DIFFICULT TO PREDICT

  • Female
  • Present with optic neuritis
  • Long interval between 1st and 2nd relapses
  • Few relapses in 1st 5 years
31
Q

What are the bad signs for prognosis in MS?

A

VERY DIFFICULT TO PREDICT

  • Male
  • Older age
  • Multifocal symptoms and signs
  • Motor symptoms and signs
32
Q

What is the pathogenesis of MS?

A

Complex genetic inheritance

Association with autoimmune disease

Commoner in temperate climate

Age of exposure

  • ?relationship to virus (e.g. EBV)
  • ? Vitamin D exposure
33
Q

What is the treatment for MS?

A

Disease modifying agent

General health and diet
Treatment of relapse
Symptomatic treatment
Multi-disciplinary approach

34
Q

Describe disease modifying treatments

A

Beta-interferons/ galtiramer acetate

  • Reduce relapse rate by 1/3
  • No effect on progression of disability
  • Not a cure
  • daily-weekly im/ sc injection

Also tablets:

  • Teriflunomide
  • Dimethyl Fumarate
35
Q

what are the risks from Tablet disease modifying treatments?

A

Teriflunomide
-Progressive Multifocal Leukoencephalopathy

Dimethyl Fumarate:
-Catastrophic liver failure

36
Q

What are the side effects of DMTs?

A

Flu-like symptoms

Injection site reaction

Abnormailities of blood count and liver function

37
Q

What are the second line agents in the treatment of MS?

A

Natalizumab

  • Reduce relapse rate 2/3
  • Monthly infusion
  • 1:1000 risk progressive multifocal leukoencephalopathy

Fingolimod - tablets
Alemtuzumub

38
Q

Describe the approach in an acute relapse in MS

A

LOOK FOR UNDERLYING INFECTION
Exclude worsening of usual symptoms with intercurrent illness

Treatment:

  • Oral prednisolone (IV)
  • Rehabilitation
  • Symptomatic treatment
39
Q

What is a common cause for further relapses in MS?

A

Underlying viral infection (25-30%)

Vaccination usually advised

40
Q

How does pregnancy effect relapses?

A

Fewer relapses during pregnancy

Increased risk in first 3 months post partum

41
Q

What is the symptomatic treatment for MS?

part 1

A

Spasticity (muscle relaxants/ antispasmodics/ physio)

Urinary (anticholinergic Rx, Bladder stimulator/ catheterisation)

Constipation (laxatives)

Sexual dysfunction

Dysaesthesia (amitriptyline, gabapentin etc)

42
Q

Whats the importance about asking about urinary and bladder symptoms in MS?

A

Something you can treat quite effectively

Very common

If struggling to empty bladder this can be a site for infection triggering more relapses

43
Q

What is the symptomatic treatment for MS?

part 2

A

Fatigue (graded exercise, medication)

Depression (CBT, medication)

Cognitive (memory aids etc)

Tremor (aids/ pharmaceutical)

Vision (carbamazepine)

Motor/ sensory impairment (MDT)

44
Q

Who would be involved in the MDT for MS?

A 
MS nurse
Physiotherapy
Occupational therapy
-Speech and language therapy
-Dietician
-Rehabilitation specialists
-Continence advisor
-Psychology/ psychiatry

N - C (35 decks)

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