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Z - old neuro and stroke > Multiple Sclerosis > Flashcards

Multiple Sclerosis Flashcards

1
Q

What is multiple sclerosis (MS)?

A

A cell-mediated autoimmune condition characterised by repeated episodes of inflammation of the nervous tissue in the brain and spinal cord

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2
Q

What is the result of the inflammation of the nervous tissue seen in MS?

A

Loss of the insulating myelin sheath

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3
Q

What cells are lost in MS?

A

Oligodendrocytes

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4
Q

What are oligodendrocytes responsible for?

A

Creating and maintaining the myelin sheath

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5
Q

What is the effect of MS on the myelin sheath?

A

Causes thinning and eventually complete loss

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6
Q

When may MS affect the axons of the neurons?

A

In advanced disease

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7
Q

What is the result of the loss of myelin in MS?

A

Less effective conduction of electrical signals

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8
Q

How is loss of myelin handled in early MS?

A

Remyelination occurs

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9
Q

Why is remyelination not involved later in MS?

A

It becomes less effective after repeated attacks and eventually scar-like plaques build up around the axon

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10
Q

What are the three main characteristics of MS?

A
  • Formation of plaques in the CNS
  • Inflammation
  • Destruction of the myelin sheath
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11
Q

Does MS form plaques in the white or grey matter?

A

White matter

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12
Q

White matter in what parts of the nervous system are commonly affected in MS?

A
  • Optic nerve
  • Brain stem
  • Basal ganglia
  • Spinal cord
  • Peri-ventricular
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13
Q

What cells cause the inflammation in MS?

A

T cells

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14
Q

What happens as a result of the inflammation caused by attack of the myelin?

A

Other immune cells are signalled and factors such as cytokines are released, worsening the problem

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15
Q

What are the three different patterns of MS?

A
  • Relapsing-remitting
  • Primary progressive
  • Secondary progressive
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16
Q

What is the pattern of disease in relapsing-remitting MS?

A

The disease comes and goes with occasional irrecoverable loss of function in some relapses

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17
Q

What percentage of patients with MS have relapsing-remitting at first onset?

A

80%

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18
Q

What is secondary progressive MS?

A

Gradually worsening symptoms with fewer relapses that follows on from relapsing-remitting MS

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19
Q

What percentage of patients with relapsing-remitting MS go on to develop secondary progressive within first 10 years?

A

50%

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20
Q

What is primary progressive MS?

A

Gradually worsening symptoms from the beginning with no remission

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21
Q

What percentage of MS patients have primary progressive from onset?

A

10-15%

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22
Q

What factors can have an influence on the development of MS?

A
  • Genetic factors

- Environmental e.g. early viral infections

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23
Q

What are the risk factors for MS?

A
  • Family history
  • Smoking
  • Vitamin D deficiency
  • Autoimmune disease
  • EBV
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24
Q

What are the common initial features of MS?

A
  • Loss of vision in one eye with painful eye movements
  • Diplopia
  • Ascending sensory disturbance and/or weakness
  • Altered sensation down the back and sometimes into the limbs
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25
Q

What are the common features in the history in a patient presenting with MS?

A
  • Often <50
  • History of previous neurological symptoms
  • Symptoms evolving over more than 24 hours
  • Symptoms persisting and then improving after a few weeks
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26
Q

What neurological signs or symptoms can present in patients with MS?

A

Almost any

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27
Q

What are the more common types of neurological symptoms in MS?

A
  • Autonomic
  • Visual
  • Motor
  • Sensory
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28
Q

How can the main symptoms of MS be divided?

A
  • Central
  • Visual
  • Speech
  • Throat
  • MSK
  • Sensation
  • Bowel
  • Urinary
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29
Q

What are the central symptoms of MS?

A
  • Fatigue
  • Cognitive impairment
  • Depression
  • Anxiety
  • Unstable mood
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30
Q

What are the visual symptoms of MS?

A
  • Nystagmus
  • Optic neuritis
  • Diplopia
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31
Q

Why is optic neuritis an important symptom in MS?

A

It is often a first presenting symptom

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32
Q

Give one speech and one throat symptom of MS?

A
  • Dysarthria

- Dysphagia

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33
Q

What are the MSK symptoms of MS?

A
  • Weakness
  • Spasms
  • Ataxia
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34
Q

What are the sensation symptoms of MS?

A
  • Pain
  • Hypoesthesia
  • Paraesthesia
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35
Q

What are the bowel symptoms of MS?

A
  • Incontinence

- Diarrhoea and constipation

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36
Q

What are the urinary symptoms of MS?

A
  • Incontinence

- Frequency or retention

37
Q

What blood tests should be made in order to rule out differentials for MS before referring to a neurologist?

A
  • FBC
  • Inflammatory markers
  • U&E’s
  • LFTs
  • TFTs
  • Glucose
  • HIV serology
  • Calcium and B12 levels
38
Q

How should investigations be used in diagnosing MS?

A

To support diagnosis with clinical features

39
Q

What investigations can be used to support a diagnosis of MS?

A
  • Electrophysiology
  • MRI
  • Lumbar puncture
40
Q

What is the use of electrophysiology in MS investigation?

A

It can detect demyelination in apparently unaffected pathways

41
Q

What abnormalities can be seen on MRI in MS?

A
  • Periventricular lesions
  • Discrete white matter abnormalities
  • Plaques of the optic nerve, spinal cord and brainstem
42
Q

What percentage of patients with MS have periventricular lesions on MRI?

A

95%

43
Q

What percentage of patients with MS have discrete white matter abnormalities on MRI?

A

90%

44
Q

How can active inflammatory plaques be distinguished from inactive ones?

A

Using a contrast agent

45
Q

How does the number and size of the lesions correlate to disease activity or progress?

A

Poorly

46
Q

What can an LP show in MS?

A

Rise in total CSF protein with increased immunoglobulin concentration and oligoclonal bands

47
Q

What are the differentials for MS?

A
  • Hereditary spastic paraplegia
  • Cerebral variant of SLE
  • Sarcoidosis
  • Myelopathy
  • Fibromyalgia
48
Q

How can the management of MS be divided?

A
  • Treatment of relapses
  • Disease modifying therapy
  • Treatment of symptoms
49
Q

What is the main drug type used to manage relapses in MS?

A

Corticosteroids

50
Q

What is the standard steroid therapy for relapses of MS affecting functioning?

A

IV methylprednisolone

51
Q

If patients cannot take methylprednisolone IV what alternative is available?

A

High dose oral methylprednisolone

52
Q

Who should be consulted for starting high dose oral methylprednisolone in MS?

A

Specialists

53
Q

How long is typical methylprednisolone for MS relapses?

A

3-5 days

54
Q

What care must be taken when using high dose methylprednisolone for MS?

A
  • Look for signs of infection

- Check blood sugars in diabetics

55
Q

What may benefit MS patients with severe or rapidly progressing disability?

A

Plasma exchange with or without IV steroids

56
Q

Which type of MS are DMARDs useful for?

A

Relapsing-remitting MS (sometimes secondary progressive)

57
Q

What are the first-line option DMARD’s for MS?

A
  • Interferon beta
  • Glatiramer
  • Dimethyl fumurate
  • Teriflunomide
  • Alemutuzab
58
Q

When should DMARD’s be used in relapsing-remitting MS?

A

During active disease

59
Q

What is considered active relapsing-remitting MS?

A

At least 2 attacks of neurological dysfunction over the previous 2 years, followed by complete or incomplete recovery

60
Q

Who can interferon beta be used in to treat MS?

A
  • Those with active relapsing-remitting who can walk 100m unaided
  • Those with secondary progressive MS
61
Q

How is interferon beta administered for MS?

A

SC or IM injection on alternate days, 3 times/week, or weekly

62
Q

What are the most common side-effects of interferon beta?

A
  • Flu-like ague

- Injection site reactions

63
Q

What is ague?

A

A fever, or shivering fit

64
Q

Who can glatiramer be used in to treat MS?

A

Those with active relapsing-remitting disease

65
Q

How is glatiramer administered to treat MS?

A

Daily SC injections

66
Q

What are the common side-effects of glatiramer?

A
  • Flu-like symptoms

- Injection site reactions

67
Q

Who can dimethyl fumarate be used in to treat MS?

A

Those with active relapsing-remitting MS but only if they don’t have rapidly evolving disease

68
Q

How is dimethyl fumarate administered to treat MS?

A

Orally, BD

69
Q

Who can teriflunomide be used in to treat MS?

A

Those with active relapsing-remitting MS but only if they don’t have rapidly evolving disease

70
Q

Who can alemtuzumab be used in to treat MS?

A

Those with active relapsing-remitting disease

71
Q

What symptoms of MS should be managed?

A
  • Fatigue
  • Pain
  • Visual problems
  • Speech difficulties
  • Weakness and cardiorespiratory fitness
  • Spasticity and spasms
  • Ataxia and tremor
  • Pressure ulcers
  • Urgency or urge incontinence
  • Constipation
72
Q

What can be the underlying causes of fatigue in patients with MS?

A
  • Depression
  • Pain
  • Medication
73
Q

How can fatigue be managed in MS?

A
  • Amantadine
  • Mindfulness
  • CBT
74
Q

What can cause pain in MS?

A
  • Neuropathic pain

- MSK pain secondary to immobility

75
Q

How should neuropathic pain be managed in MS?

A
  • Anticonvulsants e.g. gabapentin

- Antidepressants e.g. amitryptilline

76
Q

How can MSK pain be managed in MS?

A
  • Standard analgesic pain ladder
  • TENS
  • Anti-depressants e.g. amitryptilline
77
Q

What is the usual cause of visual problems in MS?

A

Poor control over eye movements

78
Q

What else should patients with poor vision in MS be assessed for?

A

Need for glasses

79
Q

What can be offered to MS patients with nystagmus causing reduced visual acuity?

A

Trial of oral gabapentin

80
Q

What non-medical management strategies bay me needed for MS patients with visual problems?

A
  • Low-vision equipment
  • Adaptive technology
  • Registered as sight impaired
81
Q

How can speech problems be managed in MS?

A

Referral to SALT

82
Q

How can weakness be managed and cardiorespiratory fitness maintained in MS?

A
  • Exercises and techniques to maintain strength
  • Equipment
  • Physiotherapy
83
Q

What can aggravate spasticity and spams in MS?

A
  • Pain

- Infection

84
Q

What can help spasticity in MS?

A
  • Passive stretching
  • Baclofen
  • Gabapentin
85
Q

How should ataxia and tremor be managed in MS?

A

Specialist referral

86
Q

Why are MS patients at high risk of pressure ulcers?

A
  • Limited mobility
  • Impaired sensory function
  • Impaired cognition
87
Q

How can urge incontinence be managed in MS patients?

A
  • Conveen for men
  • Pads for women
  • Anticholinergics e.g. oxybutynin
  • Intermittent self-catheterisation can be considered
88
Q

What can be used to manage constipation in MS?

A

Routine suppositories and enemas

89
Q

What are the potential complications of MS?

A
  • Muscle stiffness and spasms
  • Paralysis
  • Bowel, bladder or sexual dysfunction
  • Changes in mental status
  • Epilepsy
  • Osteoporosis
  • Pressure sores
  • Inflammation of lungs
  • Severe UTIs

Z - old neuro and stroke (52 decks)

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