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Neuro > Multiple Sclerosis > Flashcards

Multiple Sclerosis Flashcards

1
Q

What is MS

A

Demyelination of the white matter of brain and spinal cord
Causes abnormal conduction and loss of axons
UMN Signs only
Rarely affects peripheral nervous system

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2
Q

What causes MS

A

Autoimmune - HLA
Complex genetics
T cells cross BBB causing inflammation and demyelination of glial cells (oligodendrocyte) that form myelin sheath
Post inflammatory gliosis
2 axon damage lead to irreversible loss of function

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3
Q

What are the RF for MS

A 
Genetics 
F>M
Autoimmune 
Temperate climate > tropical 
Increased distance from equator  
Viral - EBV / HPV6 / chlamydia
Vitamin D deficiency
Smoking
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4
Q

What is the diagnostic criteria for MS

A

Mcdonald criteria
2 episodes of demyelination in different regions of CNS +- 2+ lesions on scan
Dissmeninated in time (2 attacks or different enhancement) and space (2 diff lesions MRI)

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5
Q

What are lesions seen as on MRI

A

White blobs of demyelination of myelin sheath

Axonal loss may account for persistent disability - seen as black holes

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6
Q

What is the most common type of MS

A

Relapsing remitting

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7
Q

What happens in relapsing remitting MS

A

Episode of demyelination which stabilises to complete or partial recovery
Will develop into secondary progressive where symptoms present all the time

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8
Q

What is secondary progressive MS

A

10-35 years after relapse
Disability increases
Gait and bladder disturbance dominate

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9
Q

What is primary progressive MS

A 
Progressive deterioration from onset 
No relapse 
5/6th decade
Poor prognosis 
Spinal and bladder symptoms common
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10
Q

What is sensory MS

What is acute fulminate MS

A

Only sensory inflammation

Very rare, rapidly detiorating from that leads to death over days

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11
Q

What suggests a positive prognosis

A 
Female 
Young age of onset 
Present with optic neuritis 
Relapsing remitting 
Long interval between relapse
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12
Q

What is signs of -ve prognosis

A 
Male 
Age
Multifocal S+S
Motor S+S at onset - pyramidal, brain stem or cerebellar 
Early relapse
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13
Q

What are the features of MS

A 
Fatigue / lethargy / poor concentration + memory 
- Due to neurone conducting more slowly 
Optic neuritis = common
Demyelinating myelitis 
Trigeminal neuralgia 
Cerebellar 
Eye movement abnormalities 
Internuclear ophthalmoplegia
Oscillipsia - visual fields oscillate
Unpleasant sensation
- Neurone discharge spontaneously 
Pain, paraesthesia, heat disturbance 
Conduction can fail with increased temperature so Sx worse in hot / after exercise
Autonomic - incontinente, retention and problems emptying
Cognition - depression + mild cognitive
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14
Q

How does optic neuritis present (15% present with this)

A 
Central scrotoma - blind spot 
Unilateral visual loss
Pain when moving eye and behind eye 
Light flashes precipitated by eye movement 
Optic disc swelling but can be normal
Afferent pupillary defect
Often get gradual return in vision
Can't see bright red
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15
Q

What are cerebellar signs

A

Vertigo
Ataxia
Tremor
DANISH P

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16
Q

What is internuclear ophthalmoplegia

  • Symptoms
  • What type of nystagmus and where
A

Lesion in MLF of pons - connects CN 3,4,6
Can be MS of vascular
Causes lateral conjugate gaze so if one eye moves other doesn’t
Failure of adduction on side of lesion
- e.g. R INO = failure adduction of R eye when looking to L

Other
Horizontal nystagmus on abduction on contralateral side e.g. L eye
Diplopia on lateral gaze

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17
Q

What is myelitis

A

Inflammation of spinal cord

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18
Q

What are signs of myelitis and what is Ddx

A

Presents like cord compression without obstruction on imaging
UMN signs
Can be partial or transverse
Hyperaesthesia / pins and needles
Weakness - LL > UL
Spastic paralysis
Hyperreflexia
Hypertonia
Babinski +Ve
Impairment in sensation - pain, temp, prorpiception
Bladder, bowel and sexual issues due to autonomic dysfunction

DDX
- Spinal cord compression
- Cauda equina
Will require urgent MRI to see if benefit from surgical decompression

19
Q

What do you do for relapse

A 
Look for infection + treat
Oral prednisone or IV for any acute 
PPI protection 
Explain risk vs benefit
Not >3 weeks and not >3x a year 
Symptomatic Rx
20
Q

When do you start disease modifying drugs

A

If 2 relapses in 2 years

21
Q

What is 1st line disease modifying drugs

A 
Beta-interferon
- Adminstered weekly IM 
- Improve integrity of BBB
Dimethyl fumarate
Immunosuppression
22
Q

What are SE

A

Flu-like symptoms
Abnormal blood count + LFT
CI if severe depression / psychosis

23
Q

What is 2nd line if regularly relapses

A

Biologic infusion - Almetizumab

24
Q

SE of 2nd line

A 
Pain so admit for 5 days
Reactivation TB
Infusion reaction
Immunosuppression  
High risk of autoimmune thyroid or kidney
ITP
PML
Malignancy - skin / lymphoma
25
Q

What do you need annual

A

MRI to look for PML

26
Q

What are symptomatic treatment

A 
Analgesia 
Muscle relaxant for spasticity 
- Gabapentin / baclofen = 1st line for spasticit
- Diazepam if fails 
- Physio 
Anti-convulsant for dysasthesia 
Anti-cholinergic / catheter for urinary incontience 
Oscillipsia - Gabapentin 
Laxatives
Graded exercise for fatigue or amantadine
CBT 
OT / PT 
Aids for walking
Botilum toxin for tremor
27
Q

What is PML and what causes causes

A

Progressive multifocal leukoencephalopathy
Fatal disease of white matter
JC virus reactivation

28
Q

What are RF

A

HIV

Biologics

29
Q

How do you Dx or screen

A

Annual MRI

JC Ab + urine 6 monthly

30
Q

What is Devic’s

A

Bilateral optic neuritis + spinal cord myelitis
- UMN signs
- Limb weakness
- Sensory loss
- Urinary incontinence
- Bilateral visual loss / swollen optic disc
Relapsing remitting

31
Q

What causes Devic’s

A

Autoimmune IgG Ab against aquaporin-4
Immune system attacks astrocytes
Myelin sheath destroyed

32
Q

How do you Dx Devic’s

A

Ab in blood - aquaporin 4

Perivascuar lesion on MRI

33
Q

How do you treat Devics

A

Immunosuppression
High dose steroids during attack
Plasma exchange

34
Q

How do you Dx MS

A 
Primary clinical 
Can do urgent CT head
MRI = main diagnostic - plaque
CSF - oligoclonal bands not present in serum if unsure of Dx 
Delayed VEP if spinal lesion
- Litle help if optic neuritis
35
Q

What type of MRI

A

MRI with contrast

36
Q

What are differentials

A 
Motor neurone
Bells palsy
Brain abscess
Devics
GBS - peripheral 
HIV
Trauma
Sarcoid
Lumbar disc herniation
Spinal cord infection
Stroke - look at patient presenting but CT if concern 
Subdural
Syphillis
SLE 
TIA 
Trigeminal neuralgia
37
Q

If patient presents with signs that could be attributed to MS what is needed

A

Urgent discussion with neurologist and MRI

38
Q

What other investigations

A 
CT brain for DDx if think acute
MRI to exclude compression of cord
LP for CSF analysis
Serum glucose 
U+E
39
Q

If patient with known MS presents

A

FBC to look for infection
Urinanalysis to exclude UTI
Bladder scan

40
Q

UTI in MS

A

Much more common due to incomplete voiding and retention
Rx pyrexia quick as can worsen Sx
Catheter to drain urine

41
Q

What needs to be aggressively managed

A

Fever and all infections

42
Q

If LL weakness + incontinence what do you think

A

Some form of cord compression

Obstructing cause must be excluded first

43
Q

What are common area’s affected

A

Optic nerve - neuritis (20%)
Cerebellum - co-ordination / cerebellar syndrome
Brain stem - eye movement + INO
Spinal cord - paraparesis + transversemyelitis

Neuro (19 decks)

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