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Systems: Neurology AB > Multiple Sclerosis > Flashcards

Multiple Sclerosis Flashcards

1
Q

Who is usually affected by MS?

A
  • It is a disease of young people

- F:M 2-3:1

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2
Q

What is MS?

A

It is a white matter disease of the centre nervous system with focal disturbance of function

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3
Q

What do most MS patients develop?

A

Progressive disability

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4
Q

What type of course does MS have?

A

Relapsing remitting course

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5
Q

What is demyelination?

A

An auto immune process where there is acute inflammation of myelin sheath which leads to loss of function

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6
Q

What is the cause of demyelination?

A

Activated T cells cross blood brain barrier causing demyelination

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7
Q

What signs of demyelination may be seen on MRI?

A

Lesions or plaques

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8
Q

What may post inflammatory gliosis produce?

A

May have functional deficits

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9
Q

What process may be important in disease progression?

A

Axonal loss may be important in disease progression and development of persistent disability

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10
Q

What suggest cerebral atrophy on MRI?

A

Black holes on MRI

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11
Q

What is the prevalence of MS?

A

Prevalence ~190 per 100 000 in Scotland

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12
Q

What is MS associated with?

A

It has complex genetic inheritance and is associated with autoimmune disease

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13
Q

Where is MS commoner?

A

Temperate climate

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14
Q

What do 80% of MS cases present with?

A

A relapse

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15
Q

What is the usual timeline of initial presentation of MS?

A
  • Gradual onset over days
  • Stabilises days to weeks
  • Gradual resolution to complete or partial recovery-
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16
Q

How may MS relapse present?

A
  • Optic neuritis -Sensory symptoms
  • Limb weakness
  • Brainstem Diplopia/Vertigo/Ataxia
  • Spinal cord-bilateral symptoms and signs +/- bladder
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17
Q

Describe optic/retrobulbar neuritis which can occur in MS.

A
  • 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
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18
Q

What is the differential diagnosis for optic neuritis?

A
  • Neuromyelitis optica
  • Sarcoidosis
  • (Ischaemic optic neuropathy)
  • Toxic/ drugs/ B12 deficiency
  • Wegeners granulomatosis
  • (Local compression)
  • Lebers hereditary optic neuropathy
  • Infection-borrelia
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19
Q

What signs/symptoms can occur with a brainstem relapse?

A
  • Cranial nerve involvement
  • Pons- internuclear ophthalmoplegia
  • Cerebellum -vertigo, nystagmus, ataxia
  • Upper motor neurone changes limbs
  • Sensory involvement
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20
Q

How does myelitis present?

A
  • Partial or Transverse (complete)
  • Sensory level often with band of hyperaesthesia
  • Weakness/ upper motor neurone changes below level
  • Bladder and bowel involvement
  • May be painful
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21
Q

What is the differential for myelitis?

A
  • Inflammation: Devics, SLE, sarcoidosis
  • Infection/Post infection: HIV, HTLV, HSV, TB, Borrelia, Mycoplasma
  • Tumour
  • Paraneoplastic process
  • Stroke
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22
Q

What must occur for a diagnosis of MS?

A

Separate episodes of demyelination disseminated in space and time

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23
Q

When may further relapses occur?

A

May occur within months or years of first relapse

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24
Q

How can further relapses present?

A

Vary in site and severity

  • Optic nerve
  • Sensory
  • Limb weakness
  • Diplopia
  • Vertigo
  • Ataxia
  • Sphincter disturbance
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25
Q

What can occur in the progressive phase of MS?

A

Accumulation of symptoms and signs

  • Fatigue, temperature sensitivity
  • Sensory
  • Stiffness or spasms
  • Balance, slurred speech
  • Swallowing
  • Bladder & bowel
  • Diplopia/ oscillopsia/ visual loss
  • Cognitive-dementia/ emotional lability
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26
Q

What may be found on examination of MS?

A

Depends on where demyelination has occurred and stage of disease:

  • Afferent pupillary defect
  • Nystagmus or abnormal eye movements
  • Cerebellar signs
  • Sensory signs
  • Weakness
  • Spasticity
  • Hyperreflexia
  • Plantars extensor
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27
Q

How can MS be diagnosed?

A

May be clinical or MRI based diagnosis

  • Posers criteria (requires 2 clinical episodes)
  • Macdonald Criteria (MRI)
28
Q

What is a lesion/plaque?

A

Area of demyelination on MRI scan

29
Q

How do lesions correspond to relapses?

A

For 10 lesions (approximately) patient experiences 1 relapse

30
Q

How should MRIs be interpreted?

A
  • White areas do not necessarily mean MS

- Active lesions will appear white whereas old lesions cannot be seen without contrast

31
Q

How should MS be investigated?

A

Depends on clinical picture……

  • Lumbar puncture-oligoclonal bands present in CSF but not serum
  • Visual/ somatosensory evoked response
  • Bloods-exclude other inflammatory conditions
  • Chest X Ray
32
Q

What does the differential diagnosis for MS depend on?

A

Depends on symptoms and signs and on whether a first relapse or progressive disease

33
Q

What types of MS are there?

A
  • Relapsing remitting-85% at outset (RRMS)
  • Secondary progressive (SPMS)
  • Primary progressive – 10-15% (PPMS)
  • Sensory – 5%
  • Malignant
34
Q

Describe relapsing remitting MS.

A
  • Episodes vary in severity

- Vary in duration

35
Q

Describe secondary progressive MS.

A
  • Relapses with recovery

- Followed by progressive relapse with no recovery

36
Q

Describe sensory MS

A

-Relapsing with low severity

37
Q

How can MS progress?

A
  • 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
38
Q

What are good prognostic indicators for MS?

A
  • Female
  • Present with optic neuritis
  • Long interval between 1st and 2nd relapse
  • Few relapses in 1st 5 years
39
Q

What are bad prognostic indicators for MS?

A
  • Male
  • Older age
  • Multifocal symptoms and signs
  • Motor symptoms and signs
40
Q

Describe primary progressive MS.

A

First episode does not resolve but progresses a continuous episode

41
Q

When does primary progressive MS usually present?

A

Often presents in 5th and 6th decade

42
Q

What types of symptoms are present in primary progressive MS?

A
  • Spinal symptoms

- Bladder symptoms

43
Q

Who is affected by primary progressive MS?

A

M:F 1:1

44
Q

What is the prognosis of primary progressive MS?

A

Poor

45
Q

What is another name for neuromyelitis optica spectrum disorder?

A

Devic’s disease

46
Q

How does NOSD (Devic’s disease) present?

A
  • Optic neuritis
  • Myelitis
  • Aquaporin-4 antibodies
  • Antibody negative in some cases
47
Q

How is MS treated?

A
  • General health and diet
  • Treatment of relapse
  • Symptomatic treatment
  • Multi-disciplinary approach
  • Disease modifying treatment
48
Q

What should you look for with an acute relapse?

A
  • Look for underlying infection

- Exclude worsening of usual symptoms with intercurrent illness

49
Q

How should acute relapses be treated?

A
  • Oral prednisolone (Intravenous)
  • Rehabilitation
  • Symptomatic treatment
50
Q

What accounts for 25-30% of further relapses?

A

Underling viral infection therefore vaccination is usually advised

51
Q

When may a women have fewer relapses?

A

Pregnancy

52
Q

When may a women have an increased risk of relapse?

A

First 3 months post partum

53
Q

What disease modifying treatments are 1st line?

A

s/c or i/m injections

  • Beta-interferons
  • Glatiramer acetate

Oral treatments

  • Teriflunomide
  • Dimethyl Fumarate
54
Q

What are the side effects of 1st line disease modifying treatments?

A

Flu-like symptoms
Injection site reaction
Abnormalities of blood count and liver function

55
Q

How effective are 1st line disease modifying treatments?

A
  • Reduce relapse rate ~1/3
  • No effect on progression of disability
  • Not a cure
56
Q

What are the 2nd line agents?

A
  • Natalizumab monthly infusion
  • Fingolimod tablets
  • Alemtuzumub annual infusion
57
Q

How effective is natalizumab?

A

Reduce relapse rate ~2/3

58
Q

What is there a risk of with fingolimod?

A

Risk of developing Cardiac: bradyarrythmias

59
Q

What is there risk of with alemtuzumub?

A

Risk of developing Autoimmune thyroid disease/ Goodpastures/ immune thrombocytopenic purpura

60
Q

What causes multifocal leukencephalopathy?

A

JC virus

61
Q

How is PML screened for?

A
  • MRI annual

- Check for JC antibody blood and urine 6 monthly

62
Q

Who is usually affected by PML?

A

Immunosuppression (AIDS)

  • Natalizumab
  • Dimethyl fumarate
  • Fingolimod
63
Q

What symptomatic treatment is there?

A
  • Spasiticity-muscle relaxants/ antispasmodics/ physiotherapy
  • Dysaesthesia-amitriptyline, gabapentin etc.
  • Urinary-anticholinergic Rx, bladder stimulator/ catheterisation
  • Constipation-laxatives
  • Sexual dysfunction-sildenafil
  • 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
64
Q

Who is involved in the MDT?

A
  • MS nurse
  • Physiotherapy
  • Occupational therapy
  • Speech and language therapy
  • Dietician
  • Rehabilitation specialists
  • Continence advisor
  • Psychology/psychiatry
65
Q

What can the differential diagnosis of MS include?

A
  • Acute Disseminated -Encephalomyelitis (ADEM)
  • Other Auto-immune conditions eg SLE
  • Sarcoidosis
  • Vasculitis
  • Infection eg Lyme disease, HTLV-1
  • Adrenoleucodystrophy etc etc

Systems: Neurology AB (51 decks)

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