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Neurology > Multiple Sclerosis > Flashcards

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?

A

AQP4

24
Q

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

A

IV steroids

Plasmapharesis for steroid-unresponsive patients

25
Q

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

A

Immunosuppressants- mainly azathioprine ± steroids.

26
Q

What criteria are required to diagnose MS?

A

Lesions disseminated in time and space

May use McDonald criteria

27
Q

What is the ddx for MS?

A

CNS sarcoid

SLE

Neuromyelitis optica (Devic’s disease)

28
Q

What is the mx of MS?

A

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
Q

What are the different disease modifying agents used in MS

A

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
Q

What is PML

A

Progressive multifocal leukoencephalopathy

Caused by JC virus

Requires frequent blood tests and MRIs

31
Q

What gait would you expect in spastic paraparesis?

A

Scissoring gait

May be high steppage gait due to foot drop.

32
Q

What is the differential for spastic paraparesis?

A
  • 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
Q

What would raise the suspicion of cord compression as a cause of spastic paraparesis?

A

Identifying a sensory level- absence of symptoms above this level

34
Q

What is the difference between spasticity and rigidity?

A
  • 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
Q

What is transverse myelitis?

A

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
Q

What are the causes of transverse myelitis?

A

Bacterial infection: e.g. lyme disease, TB, syphilis

Viral infection: e.g. HSV, VZV, HIV

Demyelination

Radiation myelopathy

Vasculitis

37
Q

What are the surgical options for treating spasticity?

A

Neurosurgery: Selective dorsal rhizotomy

Ortho: Contracture and tendon release, oseotomy

Other: Botulinum toxin injection

38
Q

What are poor prognostic signs in MS?

A

Advanced age at dx

Motor signs at onset

Multiple early relapses

Multiple MRI lesions

Gender- M

Neurology (29 decks)

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