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
What do you need annual
MRI to look for PML
26
What are symptomatic treatment
``` 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
What is PML and what causes causes
Progressive multifocal leukoencephalopathy Fatal disease of white matter JC virus reactivation
28
What are RF
HIV | Biologics
29
How do you Dx or screen
Annual MRI | JC Ab + urine 6 monthly
30
What is Devic's
Bilateral optic neuritis + spinal cord myelitis - UMN signs - Limb weakness - Sensory loss - Urinary incontinence - Bilateral visual loss / swollen optic disc Relapsing remitting
31
What causes Devic's
Autoimmune IgG Ab against aquaporin-4 Immune system attacks astrocytes Myelin sheath destroyed
32
How do you Dx Devic's
Ab in blood - aquaporin 4 | Perivascuar lesion on MRI
33
How do you treat Devics
Immunosuppression High dose steroids during attack Plasma exchange
34
How do you Dx MS
``` 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
What type of MRI
MRI with contrast
36
What are differentials
``` 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
If patient presents with signs that could be attributed to MS what is needed
Urgent discussion with neurologist and MRI
38
What other investigations
``` CT brain for DDx if think acute MRI to exclude compression of cord LP for CSF analysis Serum glucose U+E ```
39
If patient with known MS presents
FBC to look for infection Urinanalysis to exclude UTI Bladder scan
40
UTI in MS
Much more common due to incomplete voiding and retention Rx pyrexia quick as can worsen Sx Catheter to drain urine
41
What needs to be aggressively managed
Fever and all infections
42
If LL weakness + incontinence what do you think
Some form of cord compression | Obstructing cause must be excluded first
43
What are common area's affected
Optic nerve - neuritis (20%) Cerebellum - co-ordination / cerebellar syndrome Brain stem - eye movement + INO Spinal cord - paraparesis + transversemyelitis