Multiple Sclerosis

Question 1

Where in the NS does MS affect?

Answer 1

CNS

White matter tracts

Question 2

What is the pathology associated with MS?

Answer 2

Demyelination of nerve axons due to autoimmune process causing inflammation of myelin sheath

Question 3

What scan allows the visualisation of plaques of demyelination?

Answer 3

MRI

Question 4

What is seen on MRI with axonal loss?

Answer 4

Black holes

Cerebral atrophy

Question 5

What is the aetiology of MS?

Answer 5

Complex genetic inheritance
Associated with other autoimmune conditions 
F>M
Commoner in temperate climates 
VitD
EBV virus

Question 6

What is the typical age of onset?

Answer 6

20-30s

Question 7

How will MS usually present?

Answer 7

With a relapse = “Attack of demyelination”

Question 8

What symptoms are observed in relapse of MS?

Answer 8

Optic neuritis
Sensory symptoms
Limb weakness
Brainstem diplopia, vertigo, ataxia

Question 9

What is SYMPTOMS are observed with optic neuritis?

Answer 9

Subacute visual loss in one eye
Pain on eye movement
Loss of visual acuity
Swelling of optic disc

Question 10

What are the differentials for optic neuritis?

Answer 10

Vit B12 deficiency
Wegeners granulomatosis
Local compression
Infection

Question 11

If the cerebellum is involved in relapse, what likely symptoms will be observed?

Answer 11

Ataxia
Vertigo
Nystagmus

Question 12

When can myelitis occur in MS?

Answer 12

Demyelination of the spinal cord

Question 13

What symptoms will be observed with myelitis?

Answer 13

Sensory level (hyperasthesia)
Wekness/ upper neuron changes below level 
Bladder & bowel problems

Question 14

What are differentials for myelitis?

Answer 14

Tumour
Stroke
Infection

Question 15

What is clinically isolated syndrome?

Answer 15

No further episodes after initial relapse

Question 16

What is required for MS diagnosis?

Answer 16

Episodes of demyelination separated in space & time

Question 17

What symptoms may be observed in relapses of MS?

Answer 17

Sensory loss
Optic nerve symptoms 
Limb weakness
Diplopia 
Vertigo 
Ataxia 
Sphincter disturbance

Question 18

What signs may be observed on examination?

Answer 18

Hyperreflexia
Extensor plantars
Spasticity 
Weakness
Sensory loss
Abnormal eye movements 
Afferent pupillary defect

Question 19

How many areas of demyelination equate to 1 relapse?

Answer 19

10 Areas

Question 20

What other investigations may be done in addition to MRI?

Answer 20

Lumbar puncture - asses for oligoclonal bands in CSF

Bloods - look for inflammatory markers

Question 21

What are some of the differentials for MS?

Answer 21

Sarcoidosis
Vascultitis
Infection (Lyme Disease)

Question 22

What are the different types of MS?

Answer 22

Relapsing - remitting (RRMS) -85%
Primary progressive (PPMS)
Secondary progressive (SPMS)

Question 23

What are some good prognostic indicators for MS?

Answer 23

Female
Presenting with optic neuritis
Long interval btw 1st & 2nd episodes
Few relapse in first 5 yrs

Question 24

What are some bad prognostic indicators for MS?

Answer 24

Male
Presenting in older age
Multifocal S & Ss
Motor symptoms

Question 25

What are the characteristics of PPMS?

Answer 25

``` Presents in 50s/60s No relapses Spinal symptoms Bladder symptoms Prognosis poor M:F ```

Question 26

What diseases are associated with neuromyelitis optic spectrum disorders?

Answer 26

Devics Disease = Optic neuritis Myelitis Aquaporin-4 antibodies

Question 27

How can you treat acute relapse?

Answer 27

Look for underlying infection | Oral or IV prednisolone

Question 28

How do you treat further relapses?

Answer 28

Look for underlying viral infection | Vaccine is advised

Question 29

What is the 1st line therapies for disease modifying meds?

Answer 29

Beta-interferons Glatiramer - these are all injectable Teriflunomide Dimethyl fumarate

Question 30

What do 1st line therapies prevent?

Answer 30

Reduce relapses by 1/3 | No effect on disease progression

Question 31

What is a 2nd line disease modifying treatment?

Answer 31

Natalizumab | Fingolimod

Question 32

What are some of the risk factors associated with immunosuppression in MS?

Answer 32

Progressive Multifocal Leukencephalopathy (PML) | Activation of JC virus

Question 33

What other symptomatic meds bay be given?

Answer 33

``` Antispasmodics (spasticity) Anticholinergics (urinary) Laxative (constipation) Gabapentin (dysaesthesia) Depression - CBT Cognition - memory aid Speech & swallowing - SALT ```