Multiple Sclerosis Flashcards
What populations is MS most commonly diagnosed in?
Aged 20-40
Female:Male 3:1
What type of matter does MS affect?
White matter
How does demyelination occur in MS?
Auto immune process
Activated T cells cross blood brain barrier causing demyelination through acute inflammation of the myelin sheath
What may be present on an MRI scan in patients with MS?
Lesions/plaques indicating demyelination
How does MS progress pathologically?
Axonal loss key to progression of disease and development of persistent disability
How does axonal loss present on an MRI scan?
As black holes in the brain
What are the potential causes of MS?
Complex genetic inheritance Association with autoimmune disease Female to male 3:1 Commoner in temperate climate Age of exposure Potential link to EBV and vitamin D exposure
How does MS initially present?
80% cases present with a relapse
This onsets gradually over days and stablisies within days to weeks, before gradually resolving to a full or partial recovery
What is the name of one episode of demyelination?
Clinically isolated syndrome
What are the symptoms of a relapse of MS?
Optic neuritis Sensory symptoms Limb weakness Brainstem diplopia/vertigo/ataxia Spinal cord bilateral signs/symptoms with potential bladder problems
What are the signs and symptoms of optic or retobulbar neuritis?
Subacute visual loss Pain on moving eye Relative afferent pupillary defect Colour vision disturbed Initial swelling of optic disc, with optic atrophy seen later Usually resolves over weeks
What would be on a differential diagnosis for optic neuritis other than MS?
Neuromyelitis optica Sarcoidosis Ischaemic optic neuropathy Toxic/drugs/vitamin B12 deficiency Wegeners granulomatosis Local compression Lebers hereditary optic neuropathy Infection
What are the symptoms of a brainstem relapse?
Cranial nerve involvement Pons- internuclear opthalmoplegia Cerebellum- vertigo, nystagmus, ataxia UMN lesion signs in limbs Sensory involvement
What are the symptoms of myelitis?
Hyperaesthesia
Weakness/UMN changes below level
Bladder and bowel involvement
May be painful
What would be on a differential diagnosis for myelitis other than MS?
Inflammation due to sarcoidosis, neuromyelitis optica or SLE Paraneoplastic process Infection Tumour Stroke
When is a patient considered to be in the progressive phase of MS?
When they have multiple symptoms present at the same time
What are the symptoms that can be associate with the progressive phase of MS?
Fatigue Temperature sensitivity Sensory Stiffness or spasms Balance Slurred speech Swallowing difficulties Bladder/bowel problems Diplopia/visual loss Cognitive dementia
What signs may be present during examination of someone with progressive MS?
Afferent pupillary defect Nystagmus Cerebellar signs Sensory signs Weakness Spasticity Hyperreflexia Plantars extensor reflex
How is MS diagnosed
Evidence of demyelination separated in time and space
Evidence can be clinical or MRI (Macdonald criteria)
What other investigations may be useful in patients with MS other than an MRI?
Lumbar puncture (oliboclonal bands found in CSF but not serum is indicative of MS)
Bloods to exclude other inflammatory causes
Chest X-ray
What is the difference between relapsing remitting, primary progressive and secondary progressive MS?
Relapsing remitting- episodic attacks of symptoms/demyelination that fade away with time
Primary progressive- symptoms gradually but consistently become worse over time
Secondary progressive-symptoms start as attacks but then become constant and worsen over time
What are some indicators of a good prognosis of MS?
Female
Presents with optic neuritis
Long interval between first and second relapse
Few relapses in the first five years
What are some indicators of a bad prognosis of MS?
Male
Older age
Multifocal symptoms/signs
Motor symptoms/signs
What are the characteristics of primary progressive MS?
Often presents in 5th and 6th decade No relapses Spinal symptoms Bladder symptoms M:F 1:1
How is an acute relapse of MS managed?
Look for an underlying infection Exclude worsening of usual symptoms with intercurrent illness Give oral or IV prednisolone Rehabilitation Symptomatic treatment
What are the first line disease modifying treatments for MS?
Subcutaneous or intramuscular injections of beta-interferons and glatiramer acetate
Oral teriflunomide and dimethyl fumarate
What are the side effects of the first line treatments of MS?
Injection site reaction
Flu-like symptoms
Abnormalities of blood count and liver function
What are the second line disease modifying treatments for MS?
Natalizumab
Fingolimod
Alemtuzumub
What are the symptomatic treatments for MS?
Spasticity- muscle relaxants, antispasmodics, physiotherapy
Dysaesthesia- amitriptyline, gabapentin
Urinary- anticholinergic Rx, bladder stimulation/catheterisation
Constipation- laxatives
Sexual dysfunction- sildenafil
SALT
Depression- CBT, medication
