Multiple Sclerosis Flashcards
What is multiple sclerosis (MS) defined as?
inflammatory demyelinating disorder the central nervous system (brain and spinal cord)
What name is given to the specific areas of inflammation in MS ?
Plaques
Plaques are disseminated in time and space. What does this mean?
Plaques appear in different places at different times
Describe the Female:Male ratio of MS
3:1
When are most initial presentations of MS?
30s-40s
How is MS thought to be distributed geographically?
Further from equator = higher risk of MS
Also countries with low Vitamin D levels shower higher rates of MS
What type of course can a patient’s MS take after their diagnosis?
1) Relapsing and Remitting Course
2) Secondary progressive (starts like number 1 but can progress)
3) Progressive Relapse (No. 1 but always progressing)
4) Primary progressive
What are the main clinical features of MS?
- Pyramidal dysfunction
- Optic neuritis
- Sensory symptoms
- Lower urinary tract dysfunction
- Cerebellar and brain stem features
What is meant by pyramidal dysfunction?
- Increased tone => increased reflexes also
- Spasticity
Weakness in: - Extensors of upper limbs
- Flexors of lower limbs
What is an optic neuritis and how many MS patients have this as their initial presentation?
- Painful visual loss lasting 1-2 weeks (due to inflammation of nerves around eye)
- Most of these improve
- around 1/2 of MS patients initially present with ON
What sensory symptoms may a patient with MS experience?
- pain
- Paraesthesia “burning” or “water running down leg”
- Loss of Proprioception and vibration
- Numbness
- trigeminal neuralgia
What symptoms may indicate a patient has cerebellar dysfunction due to MS?
Ataxia Intention Tremor Nystagmus Dysdiadokinesis (cant perform rapid alternating movements) Dysarthria
What symptoms can indicate brainstem dysfunction in MS patients?
Diplopia (CN VI palsy) Facial weakness (CN VII palsy)
What is internuclear ophthalmoplegia?
Inability to coordinate both eyes moving at same time
Failure of adduction in affected eye
=> it lags behind and causes a diplopia
Nystagmus is seen in abducting eye whilst lagging eye is catcing up
What symptoms indicate lower urinary tract dysfunction?
- frequency
- nocturia
- urgency
- urge incontinence
- retention
Why do patients with MS often have lower urinary tract dysfunction?
Increased muscle tone at the bladder neck
Increased irritability of the detrusor muscle
How is the symptom of fatigue tackled in patients with MS?
- Amantadine (BEWARE can cause heart failure)
- Modafinil if sleepy (used less often now)
- Hyperbaric oxygen therapy
=> air pressure increased to 3x normal air pressure
=> lungs can gather more O2 to transport in blood
How is MS usually diagnosed?
- At least 2 episodes suggestive of demyelination
- Dissemination in time and place on MRI
- McDonald criteria - 1 yr disability \+ 2 of: - hyperintense brain lesions - hyperintense spinal lesions - oligoclonal bands in CSF
What other differentials diagnoses may mimic MS?
Vasculitis Granulomatous disorder (e.g. sarcoidosis) Vascular disease Tumour Infection Metabolic disorder
AKA any disorders causing inflammation!
What investigations can be used for MS diagnosis and what are you looking for?
MRI - hyperintensities
CSF - oligoclonal bands
Blood tests - raised inflammatory markers
Neurophysiology - specific pattern for demyelination injury
What are the 3 stages at which MS is managed?
- Acute exacerbation (relapse)
- Symptomatic treatment
- Disease modifying therapy
How are acute relapses of MS usually treated?
Mild Relapse - symptomatic treatment
Moderate Relapse - Oral steroids (500mg methylprednisolone daily)
Severe Relapse - Admit / IV steroids
How are pyramidal symptoms treated in MS?
- physiotherapy
- occupational therapy
- anti spasmodic agent (baclofen, tizanidine)
Other than oral medication, what anti-spasmodic treatments are available?
Botulinum toxin
Intrathecal baclofen / phenol (for bed bound patients)
How are sensory symptoms such as pain and parasthesia treated?
- anti convulsant eg. gabapentin
- anti depressant eg. amitriptyline
- tens machine
- Acupuncture clinic
- Lignocaine infusion (to reset baseline pain threshold)
What symptomatic management is available for lower urinary tract dysfunction?
- bladder training
- anti cholinergics eg., oxybutynin (USE WITH CAUTION)
- Desmopressin (used less now)
- catheterisation
When is the best time to intervene for an MS patient?
During a relapse
What disease modifying drugs are used to manage MS relapses?
1st Line:
- Interferon Beta (INJ.)
- Glitiramer Acetate (INJ.)
- Tecfedira (ORAL)
2nd line - worsening relapses:
- Monoclonal antibody – Tysabri, Lemtrada
- Fingolimod
3rd Line - end stage:
- Mitoxantrone (chemo drug)
How are interferon beta and glitiramer acetate delivered into the body, and how effective are they at reducing relapse?
Subcutaneous injections
reduce relapse by 1/3
How does the oral first line agent, Tecfidera, compare to the s/c injections?
It reduces relapse rate by 44%
BUT it is newer and therefore long term data is not available
What are the advantages and disadvantages of placing MS patients on 2nd or 3rd line drugs?
Advantages: larger reduction in relapse rates
Disadvantages: more toxic
When is the monoclonal antibody Ocrelizumab used?
Early primary progressive MS
What do monoclonal antibodies such as ocrelizumab do to reduce progression of inflammation in MS?
- Attach to integrins on leukocytes and prevent them from crossing BBB to cause more inflammation.
- also enhance apoptosis of leukocytes already across in CNS
