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Neuro Pathology > Multiple Sclerosis > Flashcards

Multiple Sclerosis Flashcards

1
Q

What part of the nervous system does MS affect?

A

CNS

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2
Q

What is MS a disease of?

A

White matter

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3
Q

Pathology of MS

A

Demyelination / inflammation

Myelin sheath around the nerves become inflamed during an attack or relapse

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4
Q

What do symptoms of MS depend on?

A

Where the inflammation has occurred in the brain or spinal cord

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5
Q

Pathology of demyelination

A

Autoimmune process
Activated T cells cross BBB causing demyelination
Acute inflammation of myelin sheath

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6
Q

How can lesions of plaques be seen in MS?

A

MRI scan = white areas

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7
Q

What can be looked at on an MRI to determine progression of MS?

A

Black holes - axonal loss

Later seen as cerebral atrophy

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8
Q

Which gender gets MS more?

A

F > M

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9
Q

How do 80% of cases of MS present?

A

With a relapse

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10
Q

Features of initial presentation of MS

A

Gradual onset over a few days
Stabilises days to weeks
Gradual resolution to complete or partial recovery

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11
Q

Where in the CNS can relapses occur?

A

Anywhere

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12
Q

Examples of possible symptoms of a relapse

A

Visual

  • Optic Neuritis
  • Optic atrophy
  • Uhthoff’s phenomenon (worsening of vision following rise in body temp)
  • internuclear ophthalmoplegia

Sensory symptoms

  • pins and needles
  • numbness
  • trigeminal neuralgia
  • Lhermittes syndrome; paraesthesia in limbs on neck flexion

Motor
- spastic weakness (especially in legs)

Cerebellar

  • ataxia (more often seen in acute relapse as opposed to a presenting symptom)
  • tremor

Urinary incontinence
Sexual dysfunction
Intellectual deterioration

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13
Q

Presentation of optic/retrobulbar neuritis

A 
Subacute visual loss
Pain on moving eye
Colour vision disturbed 
Initial swelling optic disc
Optic atrophy seen later
Relative afferent pupillary defect 
- pupil dilates when shining a light on it
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14
Q

Causes of optic neuritis

A 
MS
Neuromyelitis optica
Sarcoidosis
Ischaemic optic neuropathy 
Toxic / drugs 
B12 deficiency 
Wegeners granulomatosis
Local compression 
Lebers hereditary optic neuropathy
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15
Q

If there was a brainstem relapse, what possible symptoms might be seen?

A 
Cranial nerve involvement
Pons - internuclear opthalmoplegia
Cerebellum e.g. ataxia, vertigo, nystagmus
UMN changes in limbs 
Sensory involvement e.g. weakness
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16
Q

What is myelitis?

A

Inflammation of the spinal cord

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17
Q

Presentation of myelitis

A

Ascending pins and needles in feet / arms to torso over a few days / a week or two
Partial or transverse (complete)
Sensory level
Weakness/UMN changes below level
May be unable to weight bound at all
Bladder and bowel involvement (constipation)

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18
Q

Differential diagnosis for myelitis

A

Infection
Tumour
Inflammation

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19
Q

Is it possible to have an isolated episode of demyelination?

A

Yes

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20
Q

Criteria of demyelination episodes to have MS

A

Episodes of demyelination disseminated in space and time

Has to occur in different parts of the nervous system

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21
Q

Features of the progressive phase of MS

A 
Accumulation of symptoms and signs
- fatigue, temp sensitivity
- sensory 
- stiffness or spasms
- balance, slurred speech 
- swallowing
- bladder and bowel 
- diplopia / oscillopsia / visual loss
- cognitive - dementia/emotional lability
Not able to walk far
Have to use a stick 
Need help for the toilet
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22
Q

What antibodies are seen in devics disease (neuromyelitis optica spectrum disorder)?

A

Aquaporin 4 antibodies

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23
Q

Features of devics disease

A

Particularly affects

  • Optic neuritis
  • Myelitis
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24
Q

Treatment of devics disease

A

Immunosuppression

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25
Q

Associations to causes of MS

A

Complex genetic inheritance
Autoimmune assosiations
Commoner in temperature climate
Age

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26
Q

How many people with MS never have their ADL affected?

A

1/4

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27
Q

How many people with MS become severely disabled quickly?

A

15%

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28
Q

Good prognostic indicators for MS

A

Female
Present with optic neuritis
Long interval between 1st and 2nd relapse
Few relapses in 1st 5 years

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29
Q

Bad prognostic indicators for MS

A

Male
Older age
Multifocal symptoms and signs
Motor symptoms and signs

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30
Q

Things in life MS can affect

A 
Work 
Family
Pregnancy 
Sexual function 
Bladder and bowel function
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31
Q

Is there a cure for MS?

A

No

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32
Q

What are the two criterias that can diagnose MS?

A 
Posers criteria (clinical)
Macdonald criteria (MRI)
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33
Q

What is posers criteria?

A

Two clinical episodes/relapses to make a diagnosis

34
Q

What is macdonalds criteria?

A

MRI diagnosis

May not even have had any symptoms to go long with it

35
Q

How many lesions on an MRI would it take approx. for a patient to experience 1 relapse?

A

10

36
Q

What can cause the white blobs on the MRI?

A

Demyelination - MS
Hypertension
Smoking

37
Q

Investigations of MS

A 
MRI (with contrast)
LP 
Visual/somatosensory evoked response
Bloods
Chest XR
38
Q

How may a LP support the diagnosis of MS?

A

Oligoclonal bands present in CSF but no matched band in serum or blood
If matches - then just shows widespread inflammation going on.
If isolated to CSF - supports diagnosis of MS

39
Q

Why would you do bloods in investigations for MS?

A

To exclude other inflammatory conditions

40
Q

Differentials for MS

A 
Acute disseminated encephalomyelitis 
Other autoimmune causes e.g. SLE
Sarcoidosis
Vasculitis
Infection e.g. Lyme disease
Adrenoleukodystrophy
41
Q

Types of MS

A 
Relapsing remitting (RRMS)
Secondary progressive (SPMS)
Primary progressive (PPMS)
Sensory 
Malignant
42
Q

What % of people with MS have RRMS?

A

85%

43
Q

What % of people with MS have PPMS?

A

10-15%

44
Q

What % of people with MS have sensory MS?

A

5%

45
Q

What is sensory MS?

A

People who only have mild sensory inflammation so do not have much disability problems as others

46
Q

What can happen in malignant MS?

A

Can get very extensive disability

47
Q

When does PPMS often present?

A

5th/6th decade

48
Q

Features of PPMS

A

No relapses
Spinal symptoms
Bladder symptoms

49
Q

Prognosis of PPMS

A

Poor

50
Q

Which gender gets PPMS more?

A

F = M

51
Q

First line treatments for disease modifying treatments of MS

A

Beta-interferons/glatiramer acetate
Teriflunomide
Dimethyl fumarate

52
Q

How are beta-interferons given?

A

IM/SC Injection daily - weekly

53
Q

Side effects of first line disease modifying treatments of MS

A

Flu like symptoms
Injection site reaction
Abnormalities of blood count and liver function

54
Q

2nd line agents of disease modifying treatments of MS

A

Natalizumab
Fingolimod
Alemuzumub

55
Q

Overall treatment plan of MS

A

Disease modifying treatment
General health and diet
Treatment of relapse
Symptomatic treatment

56
Q

What is progressive multifocal leukencephlopathy (PML)?

A

Aggressive brain disease

57
Q

Pathology of PML

A

Can come on when a virus reactivates in your blood when you are immunosuppressed
JC virus antibodies can be carried and gives you risk to develop PML

58
Q

Treatment of an acute relapse of MS

A

Look for underlying infection and treat
Oral methylprednisolone (IV if need)
Rehab
Symptomatic treatment

59
Q

25-30% of the time what causes further relapses?

A

Underlying viral infection

60
Q

What is usually advised in MS?

A

Vaccination

61
Q

Relapses in pregnancy

A

Fewer relapses during pregnancy

Increased risk in the first 3 months post partum

62
Q

Symptomatic treatment for spasticity

A

Baclofen and gabapentin - 1st line
Diazepam
Dantrolene
Physio

63
Q

Symptomatic treatment for dysesthesia

A

Amitriptyline

Gabapentin

64
Q

What is dysaesthesia?

A

An abnormal unpleasant sensation felt when touched due to damage to peripheral nerves

65
Q

Symptomatic treatment for urinary symptoms

A

Anticholinergic
Bladder stimulation
Catheterisation

66
Q

Symptomatic treatment for constipation

A

Laxatives

67
Q

Symptomatic treatment for fatigue

A

Graded exercise
Medication
Trial of amantadine

68
Q

Symptomatic treatment for depression

A

CBT

Medication

69
Q

Symptomatic treatment for cognitive problems

A

Memory aids etc

70
Q

Symptomatic treatment for tremor

A

Aids

Pharmaceutical

71
Q

Symptomatic treatment for oscillopsia

A

Gabapentin 1st line

Carbamazepine

72
Q

What is oscillopsia?

A

Objects in the visual fields appear to oscillate

73
Q

Features of relapsing remitting disease

A

Acute attacks (e.g. 1 - 2 months) followed by periods of remission

74
Q

Features of secondary progressive disease

A

Relapsing remitting patients who develop neurological signs and symptoms in between relapses
Gait and bladder problems usually seen

75
Q

What % of relapsing remitting patients go onto develop secondary progressive disease within 15 years of diagnosis?

A

65%

76
Q

Who is primary progressive MS more common in?

A

Elderly

77
Q

What can you see on MRI in MS?

A 
High signal T2 lesions
Periventricular plaques
Dawson fingers (hyperintense lesions penpendicular to corupus callosum)
Brain atrophy 
Axonal loss (black areas)
Demyelination (white areas)
78
Q

What is looked at in the CSF for MS?

A 
Oligoclonal bands (not in serum)
Increased intrathecal synthesis of IgG
79
Q

What is seen on visual evoked potentials in MS?

A

Delayed, but well preserved waveform

80
Q

Criteria to be able to use beta interferon in MS

A
  1. RRMS + 2 relapses in last 2 years + able to walk 100m unaided
  2. Secondary progressive disease + 2 relapses in last 2 years + able to walk 10m (aided or unaided)
81
Q

Risk factors for MS

A

Smoking
Previous infectious mononucleosis
Genetics
Hypovitaminosis D

Neuro Pathology (21 decks)

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