Multiple Sclerosis

Question 1

Multiple Sclerosis

Answer 1

the most common immune-mediated inflammatory demyelinating disease of the central nervous system. Pathologically characterized by multifocal areas of demyelination with loss of oligodendrocytes, astroglial scarring and Axonal injury

Question 2

Test of choice in dx MS

Answer 2

MRI

Question 3

Characteristic lesions of MS

Answer 3

Cerebral or spinal plaque

Question 4

Requirement for diagnosis of MS

Answer 4

demonstration of central nervous system lesion in time and space, based on either clinical findings alone or a combination of clinical and MRI findings

Question 5

Dissemination in space

Answer 5

on MRI one or more T2 lesion in at least two of four MS typical regions (periventricular, juxtacortical, indratentorial, spinal cord) OR a different clinical attack implicating a different central nervous system site

Question 6

Dissemination in time

Answer 6

on MRI simultaneous presence of asymptomatic gandolinium enhancing and nonenhancing lesions at any time OR a new t2 and or gadolinium enhancing lesion on follow up MRI with reference of a baseline scan OR by the development of a second attack

Question 7

Patients with two or more attacks who have objective clinical evidence of one lesion need evidence of

Answer 7

dissemination in space

Question 8

Patients with one attack who have objective clinical evidence of two or more lesions need evidence of

Answer 8

dissemination in time

Question 9

Lumbar puncture findings with MS

Answer 9

Elevation of CSF immunoglobulin relative to other protein compounds, increased igG index

Question 10

Features suggestive of MS

Answer 10

Relapse and remissions. Onset between 15 and 50, optic neuritis, lhermitte sign (electric sensation that travels down your neck and back and also feels present in the arms, legs, fingers, and toes. The pain is usually strongest when you bend your neck forward), internuclear ophthalmoplegia- impairment of horizontal eye movements, fatigue, heat sensitivity (uhthoff phenomenon)

Question 11

Features atypical for MS

Answer 11

steady progression, age before 10, age after 50, cortical deficits such as aphasia, apraxia, neglect. Rigidity, sustained dystonia, convulsions, early dementia, deficit deveoping within minutes

Question 12

Clinically isolated syndrome

Answer 12

the first attack of a disease compatible with MS that exhibits characteristics of inflammatory demyelination but has yet to fulfill MS diagnostic criteria, if untreated with most likely lead to a diagnosis of MS

Question 13

Relapsing-Remitting MS

Answer 13

clearly defined relapses with full recovery or with sequelae and residual deficit upon recovery None or minimal disease progression. Most will eventually enter progressive.

Question 14

Secondary Progressive MS

Answer 14

initial RRMS followed by progession with or without occasional relapses, minor remission.

Question 15

Primary Progressive MS

Answer 15

Disease progression from the onset with occasional plateuas and temporary minor improvements. 10 percent of adult cases.

Question 16

MS is ____ mediated

Answer 16

immune

Question 17

Immune cells are made where

Answer 17

throughout the body except the brain and spinal cord. Made in the tonsils, thymus, bone marrow, spleen, lymphoid tissue

Question 18

Diagnose MS

Answer 18

clinically

Question 19

Nerve damage and myelin loss

Answer 19

Axons have a protective myelin coating that is necessary for normal conduction of electrical impulses. In MS the immune system destroys the myelin resulting in slowed (not absent)* conduction and exposure of axons. Exposed axons can then be severed causing them to lose nerve function once degraded causing permanent loss of the axon. Results in permanent loss.

Question 20

Patho of blood brain barrier breakdown

Answer 20

BBB prevents the entrance of T cells into the nervous system. infections or virsuses can alter this barrier and make it permeable to T cells. Once it regains integrity after the infection has cleared the T cells are still trapped inside the brain

Question 21

Autoimmunology pathio

Answer 21

Immune system T cells are attacking the nervous system myelin leading to plaques and lesions within the white matter. This destroys oligodendrocytes leading to demyelination, can remyelinate early but not completely and with each attack will lead to further remylination

Question 22

Inflammation

Answer 22

T cells attacking myelin leads to cytokines and antibodies to come and cause inflammation. BBB leaks lead to swelling and activation of macrophages

Question 23

Most common initial symptoms of MS

Answer 23

changes in sensation of arms, legs, face, optic neuritis, weakness, internuclear opyhalmoplegia – nystagmus, eye cannot look inward., unsteady when walking, balance problems

Question 24

Lhermitte sign

Answer 24

Electric sensation run down the back into the limbs by bending the neck forward. Means lesion in the dorsal column of the cervical cord or caudal medulla

Question 25

Uhthoff phenomenon

Answer 25

worsening of neurological symptoms in MS where the body gets overheated from weather, exercise, fever, saunas, hot tubs

Question 26

Main symptoms of MS

Answer 26

fatigue, cognitive impairment, mood swings, depression, optic neuritis, nystagmus, diplopia, dysphagia, muscle weakness, muscle spasms, pain sensation, parasethesias, bowel incontinence, diarrhea or constipation, urinary incontinence or frequency

Question 27

Who gets MS

Answer 27

Diagnosed between 15 and 50, more common in women, caucasians

Question 28

Name for early MS lesions showing thinly remylinated axons

Answer 28

Shadow plaques

Question 29

3 tests that help diagnose MS

Answer 29

MRI, LP spinal fluid, evoked potential

Question 30

Diagnostic criteria for MS

Answer 30

Time and space – damage has occured in at least two separate areas at two different points in time. Can take months to years to properly diagnose

Question 31

What do you need if… 1 clinical attack and evidence of 1 lesion

Answer 31

DIS – another lesion or another attack proving it is from a different location and a new time (DIT), DIT need another attack

Question 32

1 attack and 2 lesions need

Answer 32

DIT need another attack

Question 33

2 attacks, 1 lesion

Answer 33

DIS a lesion that is new or an attack showing a new lesion in a new location

Question 34

2 attacks, 2 lesions or 1 lesion with a history of a prior attack

Answer 34

None – has 2 attacks (DIT) and 2 lesions/hx of lesion in a different place (DIS)

Question 35

Dissemination in space

Answer 35

demonstrated with MRI by one or more t2 lesions in at least two of four places: periventricular, juxtacortical, infratorial or spinal cord — OR! – by the development of a further attack implicating a different central nervous system site.

Question 36

Dissemination in time

Answer 36

MRI by the simulataneous presence of asmpyomatic gadolinium-enhancing and nonenhancing lesions at any time – OR – a new T2 and/or gandolinium enhancing lesion on a follow up MRI (needed to have a baseline scan) – OR – by the development of a second clinical attack

Question 37

Positive CSF in MS

Answer 37

Oligoclonal IgG bands in the CSF or elevated IgG

Question 38

Test of choice for MS

Answer 38

MRI*

Question 39

Evoked potential testing

Answer 39

Electrical events generated in the central nervous system by peripheral stimulation of a sensory organ, tests abnormal nervous system function, detects subclinical lesion in a site remote from a region of clinical diagnosis of multifocal MS and those not easily seen on imagin (optic nerves, dorsal columns)

Question 40

LP in MS

Answer 40

Oligoclonocal banding MAY be seen and can help with the diagnosis as the proteins separate and forms bands. LP is not a requirement in the dx. Can help to rule out other conditions. Elevation of CSF IFF relative to other protein components. igA and igM may also be increased. + test is OCB or increased igG

Question 41

RRMS

Answer 41

85 percent have this –> secondary progressive. Unpredictable attacks which may or may not leave permanent deficits followed by periods of remission

Question 42

Clinically Isolated Syndrome

Answer 42

a first neurological event suggestive of demylination, at high risk for developing definite MS if it is accompanied by multiple, clinically silent asymptomatic lesions on MRI typical of MS

Question 43

Primary progressive MS

Answer 43

Gradual progression of the disease from he onset with no relapses or remissions

Question 44

Secondary progressive MS

Answer 44

Initial RRMS that suddenly begins to decline without periods of remission or replaces, just have the symptoms and get worse

Question 45

Progressive relapsing MS

Answer 45

Steady decline since onset with superimposed attacks

Question 46

Some examples of disease modifying drugs

Answer 46

Fingolimod, Teriflunomide, Alemtuzamab, Mitoxantrone, Natulizaumab

Question 47

Relapse management

Answer 47

Relapse is a new symptom or a sudden worsening of old symptom lasting at least 24 hours and usually accompanied by an objective change in neuro findings. Treat w corticosteroids if it interferes w functioning, a 3-5 day course of methylprednisolone w or w out taper and rehab to restore function following a relapse

Question 48

Spasicity mgmt

Answer 48

Eliminate sources of pain, stretch, ROM, weight bering, cryotherapy, aerobics, EMG feedback, electric stimlation, pool therapy. Meds baclogen intrathecal, Zanaflex, Klonopin, Neurontin

Question 49

Procedures with spasicity

Answer 49

botox, baclofen pump, cryotherapy cool and stretching, tendonontomy, rhizotomy, myelotomy, motor point blocks

Question 50

Heat sensitivity

Answer 50

common in MS. Cold can also occur. Sligh temp elevation can cause worsened symptoms – pseudoexaccerbation. Cool strategies beneficial during hot weather, exercise, cooking