Multiple Sclerosis Flashcards

1
Q

What areas are most likely to be affected in MS?

A

Optic nerve

Brainstem

Cerebellum

Spinal cord- corticospinal tracts

Spinal cord- dorsal columns

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2
Q

How is multiple sclerosis defined?

A

A chronic demyelinating disorder of the central nervous system characterised by multiple lesions separated in space and time

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3
Q

What eye signs would be especially suggestive of MS?

A

Internuclear ophthalmoplegia

Cerebellar eye signs

Optic atrophy (secondary to optic neuritis)

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4
Q

What is pseudoasthetosis and what is it a sign of?

A

Unconscious writhing movements of the fingers with the eyes closed

Indicates dorsal column involvement

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5
Q

Which gender is more commonly affected by MS?

A

F

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6
Q

What is the pathophysiology of MS?

A

Considered an autoimmune disease, though no one antibody identified

CD4-mediated destruction of oligodendrocytes –> demyelination –> loss of saltatory conduction and eventually neuronal death

Inflammatory demyelinating plaques are hallmark

Thought an initial viral inflammation may trigger disease.

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7
Q

What are the types of MS?

A

Relapsing-remitting: Most common

Secondary progressive: R-R form often reaches this stage

Primary progressive: 10-15% Progressive-relapsing

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8
Q

What symptoms might a patient with MS present with?

A

TEAM

Tingling

Eye signs: Optic neuritis –> reduced central vision and eye movement pain

Ataxia

Motor: Usually spastic paraparesis

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9
Q

What is Lhermitte’s sign?

A

Neck flexion –> rapid tingling/electric shocks down to arms and legs.

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10
Q

What does Lhermitte;s sign suggest?

A

Dorsal column damage

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11
Q

What are causes of Lhermitte’s sign?

A

MS

Cervical myelopathy

Cervical cord tumour

SACD of the cord

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12
Q

What is Uhtoff’s phenomenon?

A

Raised body temperature –> exacerbation of symptoms

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13
Q

What symptoms would a patient with optic neuritis complain of?

A

Pain on eye movement

Rapidly reduced central vision

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14
Q

What would you expect to find on examination of a patient with optic neuritis?

A

Reduced acuity

Reduced colour vision

White disc (optic atrophy)

Central scotoma

RAPD

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15
Q

What is the most useful investigation for confirming MS as a diagnosis?

A

MRI scan T2 weighted- hyperintense lesions of the periventricular white matter in brain and sc.

Gadolinium enhanced scan: shows active lesions

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16
Q

When is CSF analysis indicated in MS investigation?

A

If diagnosis uncertain and imaging and presentation raises suspicion of CNS infection

17
Q

What is finding on CSF analysis would be indicative of MS?

A

IgG oligoclonal bands- not in all patients! Not present in serum

18
Q

What are the differentials for IgG oligoclonal bands in the CSF?

A

MS

Neurosyphilis

SLE

GBS

19
Q

What antibodies can be looked for in MS?

A

Anti-myelin basic protein

Neuromyelitis optica IgG- Devic’s syndrome (very specific)

20
Q

What other investigation can be done to diagnose MS?

A

Evoked potentials- delayed auditory, visual and sensory

21
Q

What is neuromyelitis optica (Devic’s disease)?

A

Inflammatory demyelinating condition of the CNS that mainly affects the optic nerves and spinal cord

Relapses more severe than MS, around sc

22
Q

What antibody is highly suggestive of neuromyelitis optica (Devic’s disease)?

A

Neuromyelitis optica IgG (NMO IgG)

23
Q

What does the NMO-IgG antibody target?

24
Q

What is the management of acute attacks of neuromyelitis optica (Devic’s disease)?

A

IV steroids

Plasmapharesis for steroid-unresponsive patients

25
What is the chronic management of neuromyelitis optica (Devic's disease)?
Immunosuppressants- mainly azathioprine ± steroids.
26
What criteria are required to diagnose MS?
Lesions disseminated in time and space May use McDonald criteria
27
What is the ddx for MS?
CNS sarcoid SLE Neuromyelitis optica (Devic's disease)
28
What is the mx of MS?
Conservative: Physio, OTs, walking aids, visual aids Medical: * Disease-modifying treatments include * IFN-B: Requires specific criteria to be met (RR-MS, multiple relapses) * Glatirimer acetate * Natalizumab: Reduces relapses by 67% * Symptomatic: * Anti-spasticity meds e.g. baclofen * Depression: SSRIs * Pain * Bladder dysfunction: Self intermittent catheterisation, anti-ACh * Sexual dysfunction: counselling, sildafenil
29
What are the different disease modifying agents used in MS
Injectables - 30% effective at reducing relapses * IFN-beta * Glatiramer acetate Oral tablets - 50% effective * Dimethyl fumarate * Fingolimod Infusions - 70% effective * Alemtuzumab * Natalizumab \*The more effective drugs have a higher risk of PML
30
What is PML
Progressive multifocal leukoencephalopathy Caused by JC virus Requires frequent blood tests and MRIs
31
What gait would you expect in spastic paraparesis?
Scissoring gait May be high steppage gait due to foot drop.
32
What is the differential for spastic paraparesis?
* MS * Cord compression * Transverse myelitis * MND * SACD of the cord * Taboparesis * Friedrich's ataxia * Hereditary spastic paraparesis Differentiate based on presence of other signs- sensory/cerebellar/LMN signs.
33
What would raise the suspicion of cord compression as a cause of spastic paraparesis?
Identifying a sensory level- absence of symptoms above this level
34
What is the difference between spasticity and rigidity?
* Rigidity: Constant increase in tone throughout ROM. Independent of velocity * Spasticity: Velocity-dependent increased tone showing clasp-knife phenomenon (increased at start of movement, decreasing suddenly as passive movement continues)
35
What is transverse myelitis?
A broad term describing acute inflammation of the cord. Tends to involve more than one level and all sc function --\> bilateral sesnory, motor and sphincter deficit below the level of the lesion
36
What are the causes of transverse myelitis?
Bacterial infection: e.g. lyme disease, TB, syphilis Viral infection: e.g. HSV, VZV, HIV Demyelination Radiation myelopathy Vasculitis
37
What are the surgical options for treating spasticity?
Neurosurgery: Selective dorsal rhizotomy Ortho: Contracture and tendon release, oseotomy Other: Botulinum toxin injection
38
What are poor prognostic signs in MS?
Advanced age at dx Motor signs at onset Multiple early relapses Multiple MRI lesions Gender- M