MULTIPLE SCLEROSIS

Question 1

What is multiple sclerosis?

Answer 1

An inflammatory disease in which the insulating covers of nerve cells in the brain and spinal cord are damaged.

Question 2

Which age group are most affected by MS?

Answer 2

20-30 year olds

Question 3

Where in the world is MS most prevalent?

Answer 3

The further from the equator you, the higher the prevalence of MS.

Question 4

What are the theories regarding underlying cause of MS?

Answer 4

Immunological mechanisms - cytokines

Genetic factors - HLA-A3, B7, B18, DR2 and DW2

Infection - evidence of viral aetiology

Question 5

What do we call the areas of demyelination in MS?

Answer 5

Plaques

Question 6

What structure do the lesions in MS lie in close relationship with?

Answer 6

Lesions lie in close relationship with the post-capillary venules (perivenular).

Question 7

Which sites of the brain are most commonly affected by MS?

Answer 7

Periventricular region of cerebral hemisphere
Corpus callosum
Brainstem
Cerebellum and cerebellar peduncles
Cervical cord
Optic nerves

Question 8

What is the underlying pathology in MS?

Answer 8

Myelin destruction with relative preservation of axons. An inflammatory infiltrate containing mono-nuclear cells and lymphocytes is found. Interstitial oedema occurs in acute lesions. It is postulated that chronic demyelination may account for loss of axons and subsequently the cell bodies.

Question 9

What are the three main patterns of disease progression in MS?

Answer 9

Relapsing and remitting with lesions occuring at different times in different parts of the CNS - 90% of cases initially

Secondary progressive - Disease starts with relapsing and remitting picture but then progresses to a point where each recovery because less complete. 50% of cases with relapsing and remitting disease

Primary progressive - little or no recovery from relapses - 10% of cases.

Question 10

What is acute demyelinating optic neuritis and how does it present?

Answer 10

Inflammation of the optic nerve as a result of MS.

Presents as: 
Subacute visual loss
Usually unilateral
Central scotoma
Pain on ocular movement

Question 11

What will the ophthalmological findings be in someone with optic neuritis as a result of lesions in the optic nerve head (also called papilitis)?

Answer 11

Pink swollen disc

Question 12

What will the ophthalmological findings be in someone with optic neuritis as a result of lesions in the optic nerve behind the eye (also called retrobulbar neuritis)?

Answer 12

Disc will look normal

Question 13

At what point in MS does optic neuritis normally become an issue?

Answer 13

Early on in disease. In 70% of cases optic neuritis is a forerunner for further episodes of CNS demyelination.

Question 14

What symptoms might be associated with MS affecting the brainstem or cerebellum?

Answer 14

Diplopia (commonly bilateral)
Nystagmus
Vertigo
Dysarthria
Facial numbness
Trigeminal neuralgia
Dysphagia
Ataxia
Pyramidal signs (with involvement of the corticospinal tracts)
Patchy sensory changes

Question 15

What is the most common reason for presentation of MS?

Answer 15

Spinal cord lesion leading to a spastic paraparesis or tetraparesis. This leads to difficulty walking and sensory loss. Bladder symptoms are also very common.

Question 16

What is Lhermitte’s symptom, with regard to multiple sclerosis?

Answer 16

A brief, electric shock like sensation down the limbs on flexion of the neck.

Question 17

Can seizures occur in MS?

Answer 17

Yes seizures are actually fairly common in MS.

Question 18

What does the differential diagnosis of someone with signs and symptoms consistent with MS include?

Answer 18

SLE
Behcet's disease
Neurosyphilis
Lyme disease
Vitamin B12 deficiency

Question 19

What is neuromyelitis optica?

Answer 19

A relapsing autoimmune condition in which patients present with a demyelinating optic neuritis and transverse myelitis.

Question 20

How might you differentiate between neuromyelitis optica and MS?

Answer 20

NMO patients are typically positive for antibodies to aquaporin 4.

Question 21

Do neuromyelitis optica patients have a worse or better prognosis than MS patients?

Answer 21

Typically worse.

Question 22

What investigations would you order for someone presenting with signs and symptoms consistent with MS?

Answer 22

MRI T2 weighted (CT is not accurate)
Lumbar puncture
Evoked potentials

Question 23

What might be seen on the MRI of someone with MS?

Answer 23

Lesions are typically found in the periventricular areas, the corpus callosum and juxtacortical white matter.

Question 24

What might be found in the CSF of a patient with MS?

Answer 24

A mild lymphocyte pleocytosis. Slightly elevated protein.

Oligoclonal bands is highly suggestive of MS (IgG in CSF but not serum)

Question 25

What is the criteria used in the diagnosis of MS?

Answer 25

The McDonald criteria - states that lesions should occur in different places at separate times.

Question 26

What is the model answer to the question how do we treat MS?

Answer 26

MDT

Question 27

What do we use to treat an acute relapse of MS? Give doses if possible.

Answer 27

Steroids - IV methylprednisolone 1gram a day for 3 days

500mg a day for 5 days PO

Question 28

What are the main two disease modifying drugs used in the treatment of MS?

Answer 28

Beta-interferon 1a and 1b

Glatiramer acetate

Question 29

When should disease modifying drugs be used in MS patients?

Answer 29

When they have had at least two relapse in the preceeding 24 months and in whom there is no progression between relapses.

Question 30

What are the guidelines for female patients with MS currently taking beta-interferon who are looking to become pregnant?

Answer 30

They must stop their medication for 12 months before conceiving.

Question 31

Upon being diagnosed with MS, what must patients do by law?

Answer 31

Inform the DVLA

Question 32

What are the second line disease modifying drugs used in the management of MS?

Answer 32

Natalizumab

Mitoxantrone