Multiple Sclerosis Flashcards
What is multiple sclerosis?
affects CNS; a white matter; demyelinating disease in which the insulating covers of nerve cells in the brain and spinal cord are damaged
Describe demyelination in MS
auto-immune process leading to loss of function; activated T cells cross the blood brain barrier causing demyelination; acute inflammation of myelin sheath
What would you expect to see on an MRI scan of someone with MS?
Lesions or plaques; black holes
What are ‘black holes’?
Area on an MRI where brain tissue has been lost as a result of inflammation in an MS plaque; later seen as cerebral atrophy
What is axonal loss important in?
Disease progression and development of persistent disability
Describe the pathogenesis of MS
Complex genetic inheritance Association with autoimmune disease Female:Male 2-3:1 Commoner in temperate climate Age of exposure - EB virus; vitamin D
Describe the typical presentation of a patient with MS
80% present with a relapse - ‘attack of demyelination’ or ‘inflammation’
Describe the onset of MS
Gradual onset over days which stabilises days to weeks (gradual resolution to complete or partial recovery)
What are the symptoms of a relapse?
optic neuritis sensory symptoms limb weakness brainstem - diplopia/vertigo/ataxia spinal cord - bilateral symptoms and signs +/- bladder
What are some features 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)
What is Clinically Isolated Syndrome?
First episode of neurological symptoms lasting at least 24 hrs - can be an indicator of what turns into MS; same symptoms as MS - treat with disease modifying drugs/investigate with MRI; sometimes no further episodes
When would further relapses occur?
May occur within months or years of first relapse; variable site and severity
Describe the progressive phase of MS
Accumulation of symptoms & signs:
- Fatigue, temp sensitivity
- Sensory symptoms
- Stiffness/spasms
- Balance/slurred speech
- Swallowing difficulties
- Bladder & bowel problems
- Diplopia/oscillopsia/visual loss
- Cognitive - dementia/emotional liability
What are the criteria used to diagnose MS?
- Posers criteria = clinical
- Macdonald criteria = MRI
Scan and patient symptoms & signs often do not correlate - scan must be interpreted in context of clinical picture
Rule of thumb for number of lesions on MRI and relapses?
For approx every 10 lesions on MRI the patient experiences a relapse
What are the investigations for MS?
- MRI
- Lumbar puncture - oligoclonal bands present in CSF but not serum
- Visual/somatosensory evoked response
- Bloods - exclude other inflammatory conditions
- CXR
What are some differential diagnoses of MS?
ADEM Other auto-immune disease e.g. SLE Sarcoidosis Vasculitis Infection e.g. Lyme disease, HTLV-1, borrelia
What are the types of MS?
- Relapsing remitting - 85% at outset (RRMS)
- Primary progressive - 10-15% (PPMS)
- Secondary progressive (SPMS)
What are the good prognostic indicators for MS?
female
present with ON
long interval between 1st & 2nd relapse
few relapses in first 5 years
What are the bad prognostic indicators for MS?
male
older age
multifocal symptoms & signs
motor symptoms & signs
Describe primary progressive MS
often presents in 5th/6th decade no relapses spinal symptoms bladder symptoms prognosis poor M:F 1:1
Describe treatment of MS
- general health & diet
- treatment of relapse
- symptomatic treatment
- multi-disciplinary approach
- disease modifying treatment
What is the treatment for an acute relapse?
LOOK FOR UNDERLYING INFECTION Exclude worsening of usual symptoms with intercurrent illness - oral prednisolone (IV) - rehab - symptomatic treatment
Neuromyeltis Optica Spectrum Disorder is also known as Devic’s Disease, and is a differential diagnosis for MS, what are the symptoms?
optic neuritis myelitis aquaporin-4 antibodies antibody negative in some cases (treatment - immunosuppression)
what are some 1st line MS treatments (daily-weekly s/c or i/m injections)?
beta-interferons
glatirmer acetate
(oral treatments; teriflunomide; dimethyl fumarate)
what are side effects of 1st line MS treatments?
flu-like symptoms
injection site reaction
abnormalities of blood count and liver function
what are some 2nd line MS treatments?
natalizumab (monthly infusion)
fingolimod (tablets)
alemtuzumub
what is progressive mutlifocal leukencepalopathy (differential for MS) caused by?
JC-virus
immunosuppression (AIDS) from meds such as natalizumab, dimethyl fumarate or fingolimod
how do we screen for PML?
MRI annual
JC antibody status
symptomatic treatment for muscle spasticity in MS?
muscle relaxants
antispasmodics
physiotherapy
symptomatic treatment for dyaesthesia in MS?
amitriptyline
gabapentin
etc
symptomatic treatment for urinary problems in MS?
anticholinergic Rx
bladder stimulator
catheterisation
symptomatic treatment for constipation in MS?
laxatives
symptomatic treatment for sexual dysfunction in MS?
sildenafil
symptomatic treatment for fatigue in MS?
graded exercise
medication
symptomatic treatment for depression in MS?
CBT
medication
symptomatic treatment for cognitive problems in MS?
memory aids etc
symptomatic treatment for tremor in MS?
aids/pharmaceutical
symptomatic treatment for vision problems/oscillopsia in MS?
carbamazepine
symptomatic treatment for speech/swallowing problems in MS?
SALT (speech & language therapy)
symptomatic treatment for motor/sensory impairment in MS?
multi-disciplinary team
list the members of the MDT involved in MS?
- MS nurse
- physiotherapy
- OT
- SALT
- Dietitian
- Rehab specialists
- Continence advisor
- Psychology/psychiatry
