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Neurology > Multiple Sclerosis > Flashcards

Multiple Sclerosis Flashcards

1
Q

What is multiple sclerosis

A

Inflammatory demyelinating disorder the central nervous system
Autoimmune reaction against myelin
Characterised by distinct episodes of neurological deficits, separated in time

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2
Q

Is MS more common in men or women

A

Women

3:1 ratio

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3
Q

At what age does MS usually present

A

20s - 40s

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4
Q

What are the risk factors for MS

A

Link with the EBV
Vit D deficiency may be associated
Gets more common the further from the equator you go - for both northern and southern hemispheres
Genetic predisposition and environmental trigger

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5
Q

What is the most common clinical course for MS

A

Relapsing and remitting - periods of illness followed by a good period

Some go onto be secondary progressive – relapse pattern which then starts getting slowly worse

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6
Q

What is a progressive relapsing (secondary progressive) illness pattern

A

Periods of illness/symptoms that do get better but you never get back to baseline
Get progressively worse each time

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7
Q

What is a primary progressive disease pattern

A

Just gets gradually worse over time

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8
Q

What are the common clinical features of MS

A 
Pyramidal dysfunction
Optic neuritis
Sensory symptoms
Lower urinary tract dysfunction
Cerebellar & brain stem features
Cognitive impairment

However, almost anything can happen as nerves become affected

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9
Q

Describe pyramidal dysfunction

A

Increased tone - velocity dependant
Spasticity

Weakness:
Extensors of upper limbs
Flexors of lower limbs

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10
Q

What is optic neuritis

A

Painful visual loss - usually unitlateral
Caused by inflammation in the nerves that move the eyes
Worse on movement of the eye
Will get a RAPD

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11
Q

What are the sensory symptoms of MS

A

Pain
Paraesthesia
Dorsal column loss - proprioception and vibration
May get burning sensation or the feeling of water running down legs
Trigeminal neuralgia
Numbness

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12
Q

You should scan everyone with trigeminal neuralgia - true or false

A

True

Need to rule out MS as the cause

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13
Q

How does cerebellar dysfunction present

A 
Dysdiadokinesis 
Ataxia 
Nystagmus 
Intention tremor
Speech issue - dysarthria 
Pendular reflexes
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14
Q

What causes diplopia in MS

A

CN VI palsy

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15
Q

What can lead to facial weakness in MS

A

CNVII palsy

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16
Q

How does internuclear ophthalmoplegia present

A

Distortion of binocular vision
Failure of adduction leading to diplopia
Nystagmus
Lag -one eye will move quickly and the other will drag behind it

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17
Q

What symptoms of lower urinary tract dysfunction are common in MS

A 
Increased frequency 
Nocturia 
Urgency 
Urge incontinence 
Retention
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18
Q

How can you treat fatigue

A

Amantadine
Modafinil if sleepy
Hyperbaric oxygen

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19
Q

What investigations would you do for MS

A

MRI of brain and spinal cord - will show lesions (usually in white matter)
CSF - look for IgG oligoclonal bands
Blood tests - inc. B12/folate, connective tissue screen

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20
Q

What other diagnosis can present similarly to MS

A 
Vasculitis
Granulomatous disorder
Vascular disease 
Structural lesion
Infection - HIV, syphilis and Lyme disease 
Metabolic disorder
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21
Q

What would you expect to to see in the CSF of someone with MS

A

Unmatched oligoclonal bands

seen in 90% of cases

22
Q

How do you manage an acute exacerbation of MS

A

Mild - just symptomatic
Moderate - oral steroids
Severe - admit and give IV steroids

Balance risk of steroids with benefits of treatment

23
Q

What are the risks of steroid treatment

A

Hypertension

AVN

24
Q

How can you treat pyramidal dysfunction

A

Physiotherapy
Occupational therapy
Anti-spasmodic agent - baclofen, tizanidine, botox

25
Q

How can you treat the sensory symptoms of MS

A

Gabapentin or amitriptyline for pain
Tens machine
Acupuncture - specialist nurse service
Lignocaine infusion

26
Q

What is dyssynergia of the bladder

A

Where the bladder neck and detrusor contract at the same time
Uncoordinated so doesn’t work properly

27
Q

How can you treat lower urinary tract dysfunction in MS

A

Bladder drill
Anti cholinergic eg., oxybutynin
Desmopressin
Catheterisation

28
Q

What are the first line DMARDs in MS

A 
Used for those with relapses 
Interferon beta 
Glitiramer acetate
These are injectable 
Tecfedira - oral
29
Q

What are the second line DMARDs in MS

A

Used for continued relapse after 1st line or in those with severe presentations
Monoclonal antibodies - tysabri
Cladrabine/fingolimod - oral

30
Q

What are the 3rd line DMARDs in MS

A

This is end stage treatment
Mitoxantrone
Stem cell transplant

31
Q

What is the role of MRI in prescribing DMARDs

A

Repeat scans to monitor disease progression

Determines whether treatment with DMARDs needs escalated

32
Q

What is the risk of giving monoclonal antibodies such as tysabri in MS treatment

A

Can cause Progressive multifocal leukoencephalopathy (PNL) if the patient has John Cunnigham (JC) virus in their system
This virus is usually harmless but in low immune states can cause this fatal issue
Also seen in AIDS patients and those post-chemo

33
Q

How are monoclonal antibodies such as tysabri administered

A

Given as an infusion on the wards

34
Q

How do monoclonal antibodies work in MS

A

The monoclonal antibodies stop the inflammatory cascade by blocking the lymphocytes from passing through the BBB

35
Q

What is demyelination

A

When there is damage to the myelin sheath of nerves
Relative preservation of axons
Leads to defects in the rate and consistency of conduction in the axons

36
Q

What is the most common demyelinating disease

A

MS

37
Q

What can cause demyelination

A

Inflammation - MS
Infarction
Trauma

38
Q

What are the primary demyelinating conditions

A

MS

Acute disseminated encephalomyelitis - self-limiting and usually recover but may be left with a neurological deficit

Acute haemorrhagic leukoencephalitis - high mortality, rapidly fatal and acute form of ADE

39
Q

What are the secondary demyelinating conditions

A

Progressive multifocal leukoencephalopathy- viral
Metabolic syndromes - CPM
Toxic insults - cyanide, CO2 etc

40
Q

What is needed for a clinical diagnosis of MS

A

Need at least 2 distinct episodes occurring at different times
Excluded alternative diagnosis
A neurological defect implicating one neuro‐anatomical site

41
Q

How does MS present on MRI

A

White lesions throughout the brain

Usually in the white matter

42
Q

What causes internuclear opthalmoplegia

A

Brain stem lesions

43
Q

What are plaques

A

Areas of brain inflammation which later undergo gliosis
Can be active or inactive
Well demarcated but irregularly shaped areas
Have an almost translucent appearance

44
Q

Describe an active MS plaque

A

Will contain inflammatory cells and microglia
The microglia are recruited and engulf/digest the myelin
Ongoing demyelination
Yellow/brown appearance

45
Q

Describe an inactive MS plaque

A

Have gliosis - scarred
Few remaining myelinated axons
Reduction in number of oligodendrocytes and axons

46
Q

Which place has the highest incidence of MS in the world

A

Orkney!

47
Q

How does migration affect MS risk (as it has geographical links)

A

If you move from a high prevalence area before the age of 12 your risk drops to that of the new area
This is not the case if over 18

So adults who migrate have the risk of their original home whereas children have the risk of their new home

48
Q

How would optic neuritis present on eye examination

A

RAPD on the affected side
Reduced visual acuity on affected side
A pale disc may be seen after optic neuritis

49
Q

Does MS present with upper or lower motor neurone signs

A

Upper
Spasticity, pyramidal pattern of weakness, brisk reflexes, extensor plantars, and if spinal cord involvement, sensory disturbance suggestive of partial cord involvement

50
Q

Why is it important that MS patients stop smoking

A

Smoking adversely affects brain health and is associated with worse outcomes in MS

51
Q

Vitamin D supplements should be suggested to all MS patients - true or false

A

True

Those who are low in vitamin D may have a more aggressive disease course and therefore vitamin D is recommended to all.

Neurology (18 decks)

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