Multiple Sclerosis Flashcards
what part of the nervous system is affected in ms?
central nervous system
white matter disease
demyelination
what is demyelination?
Auto immune process
Activated T cells cross blood brain barrier causing demyelination
Acute inflammation of myelin sheath
Loss of function
how does the repair of demyelination affect the functional recovery?
Repair-Recovery of function
Post inflammatory gliosis- may have functional deficit
what investigation shows ms?
Lesions or plaques on MRI scan
Later seen as cerebral atrophy
who more commonly gets ms?
Female:male 2-3:1
Complex genetic inheritance
Association with autoimmune disease
Commoner in temperate climate
how often do cases MS present with a relapse?
80%
“attack of demyelination” or “inflammation”
how long does the initial relapse last?
Gradual onset over days
Stabilises days to weeks
Gradual resolution to complete or partial recovery
what is affected in the first ms relapse?
Optic neuritis
Sensory symptoms
Limb weakness
Brainstem Diplopia/Vertigo/Ataxia-
Spinal cord-bilateral symptoms and signs +/- bladder
what are the symptoms of optic/retrobulbar neuritis?
Subacute visual loss Pain on moving eye Colour vision disturbed Usually resolves over weeks Initial swelling optic disc Optic atrophy seen later Relative afferent pupillary defect
describe a brainstem relapse?
Cranial nerve involvement
Pons- internuclear ophthalmoplegia
E.g. Vertigo, nystagmus, ataxia
Upper motor neurone changes limbs
what is myelitis?
infection or inflammation of spinal cord Partial or Transverse (complete) Sensory level Weakness/ upper motor neurone changes below level Bladder and bowel involvement
is an isolated episode of demyelination ms?
no, MS=episodes of demyelination disseminated in space and time
when do further relapses occur?
within months or years of first relapse
what is affected in further ms relapses?
Variable site and severity
Optic nerve Sensory Limb weakness Diplopia Vertigo Ataxia Sphincter disturbance etc etc
what can be found on examination of ms?
Afferent pupillary defect Nystagmus or abnormal eye movements Cerebellar signs Sensory signs Weakness Spasticity Hyperreflexia Plantars extensor
how can ms be diagnosed when areas of demyelination are found on MRI scan?
For 10 lesions (approximately) patient experiences 1 relapse
Scan and patient symptoms and signs often do not correlate-patient can be clinically well
Allowed a couple of lesions in a decade so someone in 60s has quite a few
patients who smoke/have diabetes will have more
how do you confirm if a lesion of inflammation is active?
old lesion of inflammation is seen in T2 but not shown in T1 (with Gadolinium)-inactive
active lesion seen in both
apart from mri what other investigations can diagnose ms?
Lumbar puncture-oligoclonal bands present in CSF but not serum
Visual/ somatosensory evoked response
Bloods-exclude other inflammatory conditions
Chest X Ray
what are the different types of ms?
Relapsing remitting-85% at outset (RRMS) Secondary progressive (SPMS) Primary progressive – 10-15% (PPMS) Sensory – 5% Malignant
what percentage of patients who present with RRMS go on to develop secondary progressive disease?
25% 10 years from onset
50% 20 years
75% after 35 years.
how does the progression of ms vary?
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
what are good prognostic indicators?
female
Present with optic neuritis
Long interval between 1st and 2nd relapse
Few relapses in 1st 5 years
what are bad prognostic indicators?
male
Older age
Multifocal symptoms and signs
Motor symptoms and signs
describe Primary progressive ms
Often presents in 5th and 6th decade No relapses Spinal symptoms Bladder symptoms Prognosis poor M:F = 1:1
what is Devic’s Disease?
Optic neuritis Myelitis Aquaporin-4 antibodies Antibody negative in some cases Treat slightly different and manage a bit better
what are the 1st line disease modifying treatments?
Beta-interferons/ glatiramer acetate Reduce relapse rate ~1/3 No effect on progression of disability Not a cure Daily-weekly im/ sc injection
Oral treatments
Teriflunomide
Dimethyl Fumarate
what are side effects of 1st line disease modifying treatments?
Flu-like symptoms
Injection site reaction
Abnormalities of blood count and liver function
what are the 2nd line disease modifying treatments?
Natalizumab Reduce relapse rate ~2/3 Monthly infusion Fingolimod- tablets Alemtuzumub
what does the treatment of ms make patients more vulnerable to?
JC-virus Immunosuppression (AIDS) Natalizumab Dimethyl fumarate Fingolimod
what is the treatment for acute relapse of ms?
look for underlying infection exclude worsening of usual symptoms with intercurrent illness oral prednisolone (intravenous) rehabilitation symptomatic treatment
what is the treatment for further relapses of ms?
Underlying viral infection-25-30%
Vaccination usually advised
how does pregnancy affect the risk of relapses?
Fewer relapses during pregnancy
Increased risk in first 3 months post partum
what is the symptomatic treatment of ms?
Spasiticity-muscle relaxants/ antispasmodics/ physiotherapy Dysaesthesia-amitriptyline Urinary-anticholinergic Rx Constipation-laxatives Sexual dysfunction Fatigue-graded exercise, medication Depression-CBT, medication Cognitive-memory aids etc Tremor-aids/ pharmaceutical Vision/ oscillopsia-carbamazepine Speech/ swallowing-SALT Motor/ sensory impairment- multi-disciplinary team
