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Neurology > Multiple Sclerosis > Flashcards

Multiple Sclerosis Flashcards

1
Q

What is MS?

A

Idiopathic inflammatory demyelinating disease of the CNS
Acute episodes of inflammation are associated with focal neurological deficits
If left untreated, patients become progressively more disabled

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2
Q

Name the five subtypes of MS.

A 
Relapsing remitting MS 
Primary progressive MS 
Secondary progressive MS 
Progressive-relapsing MS
Benign MS
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3
Q

What is meant by relapsing remitting MS?

A

Unpredictable attacks which may or may not leave permanent deficits, followed by periods of remission

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4
Q

What is meant by progressive relapsing MS?

A

Steady decline since the onset, with super-imposed attacks

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5
Q

What is meant by primary progressive MS?

A

Steady increase in disability from onset, without any attacks

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6
Q

What is meant by secondary progressive MS?

A

Initial relapsing remitting MS that suddenly begins to decline without periods of remission

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7
Q

Which symptoms commonly develop into MS?

A

Optic neuritis
Clinically isolated syndromes
Transverse myelitis
Radiologically isolated syndromes

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8
Q

What is optic neuritis and what is the risk of developing MS after an attack?

A

Painful vision loss that comes on over a few days
- demyelination of the optic nerve
- may resolve after a few weeks
30% develop MS after 5 years
50% develop MS after 15 years
Risk depends on MRI scan and oligoclonal bands in the CSF

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9
Q

What are the symptoms of optic neuritis?

A

Blurry vision
Loss of colour vision
Pain
Vision loss

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10
Q

What is transverse myelitis?

A

Inflammation of the spinal cord

Causes weakness, sensory loss and incontinence

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11
Q

What is a clinically isolated syndrome?

A

Single episode of neurological disability due to focal CNS inflammation
- e.g. optic neuritis or transverse myelitis

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12
Q

When is MS diagnosed?

A

When on MRI, there is evidence of 2 OR MORE EPISODES of DEMYELINATION, DISSEMINATION in SPACE AND TIME.

  • inflammation of two different parts of the CNS - disseminated in space
  • evidence of active and past inflammation - disseminated in time
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13
Q

What causes MS?

A

Genetic factors - low in China
Sunlight/Vit D
Viral triger (EBV)
Smoking (increases rate of disability progression)

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14
Q

When should you suspect MS in a patient?

A

Neurological symptoms that develop over a few days
A history of transient neurological symptoms that lasted 24 hours and spontaneously resolved
Hidden relapses
- optic neuritis
- Bell’s palsy
- labyrinthitis
- sensory symptoms
- bladder symptoms in young men and women without children

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15
Q

List some of the main symptoms of MS.

A

Depends on the area of demyelination

  • fatigue
  • depression
  • optic neuritis
  • dysarthria
  • dysphagia
  • weakness of limbs
  • pain
  • incontinence
  • diarrhoea
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16
Q

What signs and symptoms indicate MS might not be the cause?

A 
Sudden onset
Peripheral signs - areflexia, glove and stocking distribution, muscle wasting and fascicualtions
Major cognitive involvement 
Prominent seizures 
Pyrexia
Normal MRI
17
Q

What is radiologically isolated syndrome?

A

MRI scan performed on patient who doesnt have signs or symptoms of MS
- incidental finding that looks like MS
May develop into MS, but might not
Unnecessary distress for patient (VOMIT)

18
Q

How do you investigate suspected MS with an MRI?

A

MRI of the brain and cervical spine with gadolinium contrast

  • evidence of demyelination in 2 regions to indicate dissemination in space
  • enhancing and non-enhancing areas of demyelination indicate dissemination in time
19
Q

Name a T2 hyperintensity.

A

Dawson’s fingers

  • demyelinating plaques through the corpus collosum
  • specific for MS
20
Q

What investigations can you do to test someone for MS?

A 
Lumbar puncture
MRI
Blood - exclude other conditions 
Visual evoked potentials
Chest X-Ray - exclude sarcoidosis
21
Q

What are you looking for in the CSF after a lumbar puncture?

A

Oligoclonal bands - bands of immunoglobulin
Cell count - to exclude mimics
Glucose - matches blood sample
Protein

22
Q

What are oligoclonal bands?

A

Immunoglobulin bands seen in blood and spinal fluid after protein electrophoresis
(suggests inflammation)
- suggestive of MS when bands aren’t also present in the blood (means inflammation is in the CNS)
- can be seen in other conditions or after brain surgery

23
Q

What blood tests do you do if you suspect MS?

A

Mainly to exclude other possible causes

  • B12/folate
  • serum ACE
  • lyme serology
  • ESR/CRP (should be normal)
  • ANA/ANCA/RA
  • aquaporin-4 antibodies (show up in transverse myelitis and optic neuritis)
24
Q

What are visual evoked potentials?

A

Measure of conduction of nerve signals in optic nerves to look for subclinical neuritis

  • conduction is slower if patient has had optic neuritis in the past
  • conduction should be the same on both sides
25
Q

What is the difference between a relapse or a pseudo-relapse in MS?

A

Relapse
- new neurological symptoms they have never had before
- lasts more than 24 hours in the absence of temperature or infection
Pseudo-relapse
- flaring of an old area of demyelination causing re-emergance of pervious neurological symptoms (usually caused by heat or infection)

26
Q

How are MS relapses managed?

A

Treatment isn’t always needed
High dose steroids can be used to suppress the inflammation
- not given if any evidence of inflammation
Physiotherapy
Occupational therapy
RRMS
- MRI to check for active disease and see if they need new treatment

27
Q

Describe the steroid regime for relapse?

A 
1g of IV methylprednisolone for 3 days
OR
500mg oral methylprednisolone for 5 days
AND
PPI for gastroprotection
28
Q

What are the two different methods of giving disease modifying therapies in RRMS.

A

Induction therapy
- therapy started with more effective drugs, but they are hard on the body
Escalation therapy
- start with less effective, but more safe drugs

29
Q

Name some disease modifying drugs for RRMS.

A 
Powerful drugs
- Alemtuzumab
- Natalizumab 
Oral treatments
- Fingolimod 
- Dimethyl Fumerate
30
Q

What are the pros and cons of Alemtuzumab?

A 
Pros
- two short courses over a year
- stops relapse in 40% of patients
- may improve disability
Cons
- high risk of secondary autoimmune problems (thyroid, ITP)
31
Q

What are the pros and cons of Natalizumab?

A 
Pros
- monthly infusions
- very effective
Cons
- serious risk of fatal PML is infected with JC virus
32
Q

What are the pros and cons of Fingolimod?

A

Pros
- less side effects compared to the more powerful drugs
Cons
- daily tablet
- less effective than natalizumab or alemtuzumab
- risk of infection
- slows heart rate

33
Q

What are the pros and cons of dimethyl fumerate?

A 
Pros
- less side effects compared to the more powerful drugs
Cons
- twice daily tablet
- less effective than Fingolimod
- low WCCs
- risk of infections
34
Q

Name some of the older treatments for MS.

A

Beta interferon and Copaxone

- less effective than Fingolimod or monoclonal antibodies

35
Q

What is the cause of primary progressive MS?

A

JC virus

  • can lead to PML in the immunocompromised
  • progressive destruction of white matter in the brain
36
Q

How is primary progressive MS diagnosed?

A

At least one year of disease progression
MRI scan supports diagnosis of MS
Oligoclonal bands support diagnosis of MS

37
Q

How is secondary progressive MS diagnosed?

A

When they have had RRMS in the past, but have no started exhibiting signs of progressive disease without relapses on scan

38
Q

What is the treatment for progressive MS?

A

Treating symptoms
Effective treatment for RRMS reduces progression to secondary progressive MS.
Potential treatment for PPMS - ocrelizumab
Potential treatment for SPMS - siponimod

39
Q

Describe the symptom management for secondary progressive MS

A

Rehabilitation

Control symptoms of the bladder, fatigue, mood, spacicity and mobility

Neurology (13 decks)

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