Multiple Sclerosis Flashcards
Discuss a little about multiple sclerosis
Relatively common neurological disease - cause still unknown
Affects young people - average 30 yrs, F>M
Variable severity
190/100,000 in Scotland
What is MS?
episodes of demyelination - disease of the CNS (white matter disease)
It heals poorly and leads to axonal loss - communication breakdown leads to sensory, motor and cognitive problems
Over time most patients develop progressive disability as repair doesn’t occur before next relapse
Initial presentation of MS
usually monosymptomatic and usually comes as a relapse/attack of demyelination
Gradual onset over days then stabilises
Typical presenting symptoms (7)
Optic neuritis
Sensory symptoms
Limb weakness
Brainstem - Diplopia or Vertigo/Ataxia
Spinal cord - bilateral motor and sensory symptoms or Bladder involvement
What is optic neuritis
Inflammation of optic nerve
Subacute visual loss
Pain on moving eye
Colour vision disturbed
Usually resolves over weeks
Initial swelling optic disc
Optic atrophy seen later
Relative afferent pupillary defect
Give some common sensory symptoms? (4)
dysaesthesia - an unpleasant, abnormal sense of touch
pins and needles
decreased vibration sense
trigeminal neuralgia - excruciating pain from facial sensation
MS relapse due to interference in Pons area of brainstem causes what?
internuclear ophthalmoplegia - inability to perform conjugate (both eyes in same direction) lateral gaze
MS relapse due to interference in Cerebellum area of brainstem causes what?
Vertigo, nystagmus, ataxia (group of disorders that affect co-ordination, balance and speech)
What is Myelitis?
inflammation of the spinal cord
can be partial or transverse (complete)
Causes weakness/ upper motor neurone changes below level of demyelination
also can involved bladder and bowel problems
Describe how demyelination happens?
Auto immune process where activated T cells cross the blood brain barrier causing demyelination
Acute inflammation of myelin sheath
Loss of function
Repair
Recovery of function
Post inflammatory gliosis (hypertrophy of glial cells due to damage to CNS)
may have functional deficit
Lesions or plaques on MRI scan
Clinically isolated syndrome
a first episode of neurological symptoms lasting at least 24hrs. Although there may not yet be enough info to identify the underlying cause of symptoms, CIS can be an indicator of what may turn out to be multiple sclerosis.
sometimes no further episodes
when might further relapses occur after first relapse?
within months or years of first relapse
When does a female patient have fewer relapses
during pregnancy
Discuss the progression of MS
Axonal loss important in disease progression and development of persistent disability
what sign on an MRI can show further progression of MS?
Black holes - these are a marker of axonal loss and neuronal tissue destruction - this is later seen as cerebral atrophy (loss of neurons and reduction in size of neural tissue)
In the progressive phase which symptoms might be present? (10)
Fatigue
Temperature sensitivity
Sensory problems
Stiffness or spasms
Balance
Slurred speech
Bladder & bowel
Diplopia/ oscillopsia/ visual loss
Swallowing problems
Cognitive-dementia/ emotional lability
What does examination of MS depend on?
where demyelination has occurred
stage of disease
What sorts of things are examined for MS
Afferent pupillary defect
Nystagmus or abnormal eye movements
Cerebellar signs
Sensory signs
Weakness
Spasticity
Hyperreflexia
Plantars extensor
Types of MS (3)
Relapsing remitting - 85% at outset (RRMS)
Secondary progressive (SPMS)
Primary progressive – 10-15% (PPMS) - impairment increases slowly over time with no relapses
Describe Primary progressive MS
Often presents in 40-60 year olds
No relapses
spinal and bladder symptoms common
poor prognosis
M=F
Diagnosis of MS
need to exclude alternative diagnoses but if evidence suggests MS –> early diagnosis + treatment is key - reduce relapse rates
may be clinical or MRI based diagnosis
what is the Posers criteria for MS
requires evidence of two relapses, each lasting >24 hours and occurring > one month apart
also need clinical evidence of lesions in 2 places within the CNS
what is the McDonald criteria for MS
Myelin damage is disseminated in space and time, as seen in an MRI ie occurring at multiple sites, with more than or 30 days between relapses
Differential diagnoses?
Depends on symptoms and signs and on whether a first relapse or progressive disease
Includes:
Acute Disseminated Encephalomyelitis (ADEM)
Other Auto-immune conditions eg SLE
Sarcoidosis
Vasculitis
Infection eg Lyme disease,
HTLV-1
Adrenoleucodystrophy etc etc
what is Acute Disseminated Encephalomyelitis (ADEM)
Brief but widespread attack of inflammation in the brain and spinal cord that damages myelin
What can cause myelitis
Inflammation - Neuromyelitis optica, Systemic lupus erythematosus (autoimmune), sarcoidosis
Infection…or post infection - (HIV, HTLV, HSV, TB, borrelia, mycoplasma etc)
Tumour
Paraneoplastic process
Stroke
What other investigations can be done other than MRI? (4)
Lumbar puncture - high levels of antibodies in CSF but not serum - consistent with MS
Visual/ somatosensory evoked response - measure response to stimuli
Bloods - exclude other inflammatory conditions
Chest X Ray
Pathogenesis of MS
Cause unknown:
Complex genetic inheritance
Association with autoimmune disease
Female : male 3:1
More common in temperate climate
Age of exposure
unsure but maybe relationship to virus eg Epstein Barr virus or vitamin D exposure
treatment of MS
there is no cure
treat the relapse
disease modifying treatment
general health and diet changes
symptomatic treatment
MDT approach
How would you manage an acute relapse of MS
look for underlying infection
exclude worsening of usual symptoms with intercurrent illness
give IV oral prednisolone
rehab and symptomatic treatment
1st line disease modifying treatment
s/c or i/m injections or Beta-interferons or glatiramer acetate
oral - teriflunomide or dimethyl fumarate
2nd line disease modifying treatment
Natalizumab
Fingolimod
Cladribine
Alemtuzumub
describe how disease modifying agents work
they are not a cure they simply reduce relapse rate
do not slow progression of disease
consider side effects
symptomatic treatment examples (11)
Spasiticity - muscle relaxants/ antispasmodics/ physiotherapy
Dysaesthesia - amitriptyline, gabapentin etc.
Bladder problems - take urinary-anticholinergic, bladder stimulator/ catheterisation
Bowel problems - Constipation-laxatives
Sexual dysfunction - sildenafil
Fatigue - structured exercise programme that aims to gradually increase how long you can carry out a physical activity
Depression - cognitive behavioural therapy (talking therapy) or medication
Cognitive - memory aids
Tremor - aids/medication
vision/oscillopsia - carbamazepine
speech/swallowing - SALT inhale salt particles to improve lungs
Who is involved in an MS MDT? (8)
MS nurse
Physiotherapy
Occupational therapy
Speech and
language therapy
Dietician
Rehabilitation specialists
Continence advisor
Psychology/psychiatry
Describe relapsing remitting MS
Bouts of attacks/relapses happen in months or years apart and cause increasing disability
re-myelination can cause short term improvement - not often complete so usually some residual disability
Describe secondary progressive MS
quite similar to relapsing remitting type
it starts off with relapse then remission however over time the immune attack becomes constant which causes a steady progression of disability
how is numbness, pins and needles or paraesthesia caused?
plaques in the sensory pathways from skin
how are bowel/bladder problems or sexual dysfunction caused?
plaques in the autonomic nervous system
