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2ND YEAR SYSTEMS: Neuro > Multiple Sclerosis > Flashcards

Multiple Sclerosis Flashcards

1
Q

Discuss a little about multiple sclerosis

A

Relatively common neurological disease - cause still unknown

Affects young people - average 30 yrs, F>M

Variable severity
190/100,000 in Scotland

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2
Q

What is MS?

A

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

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3
Q

Initial presentation of MS

A

usually monosymptomatic and usually comes as a relapse/attack of demyelination

Gradual onset over days then stabilises

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4
Q

Typical presenting symptoms (7)

A

Optic neuritis

Sensory symptoms

Limb weakness

Brainstem - Diplopia or Vertigo/Ataxia

Spinal cord - bilateral motor and sensory symptoms or Bladder involvement

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5
Q

What is optic neuritis

A

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

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6
Q

Give some common sensory symptoms? (4)

A

dysaesthesia - an unpleasant, abnormal sense of touch

pins and needles

decreased vibration sense

trigeminal neuralgia - excruciating pain from facial sensation

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7
Q

MS relapse due to interference in Pons area of brainstem causes what?

A

internuclear ophthalmoplegia - inability to perform conjugate (both eyes in same direction) lateral gaze

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8
Q

MS relapse due to interference in Cerebellum area of brainstem causes what?

A

Vertigo, nystagmus, ataxia (group of disorders that affect co-ordination, balance and speech)

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9
Q

What is Myelitis?

A

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

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10
Q

Describe how demyelination happens?

A

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

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11
Q

Clinically isolated syndrome

A

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

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12
Q

when might further relapses occur after first relapse?

A

within months or years of first relapse

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13
Q

When does a female patient have fewer relapses

A

during pregnancy

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14
Q

Discuss the progression of MS

A

Axonal loss important in disease progression and development of persistent disability

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15
Q

what sign on an MRI can show further progression of MS?

A

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)

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16
Q

In the progressive phase which symptoms might be present? (10)

A

Fatigue

Temperature sensitivity

Sensory problems

Stiffness or spasms

Balance

Slurred speech

Bladder & bowel

Diplopia/ oscillopsia/ visual loss

Swallowing problems

Cognitive-dementia/ emotional lability

17
Q

What does examination of MS depend on?

A

where demyelination has occurred

stage of disease

18
Q

What sorts of things are examined for MS

A

Afferent pupillary defect

Nystagmus or abnormal eye movements

Cerebellar signs

Sensory signs

Weakness

Spasticity

Hyperreflexia

Plantars extensor

19
Q

Types of MS (3)

A

Relapsing remitting - 85% at outset (RRMS)

Secondary progressive (SPMS)

Primary progressive – 10-15% (PPMS) - impairment increases slowly over time with no relapses

20
Q

Describe Primary progressive MS

A

Often presents in 40-60 year olds

No relapses

spinal and bladder symptoms common

poor prognosis
M=F

21
Q

Diagnosis of MS

A

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

22
Q

what is the Posers criteria for MS

A

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

23
Q

what is the McDonald criteria for MS

A

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

24
Q

Differential diagnoses?

A

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

25
Q

what is Acute Disseminated Encephalomyelitis (ADEM)

A

Brief but widespread attack of inflammation in the brain and spinal cord that damages myelin

26
Q

What can cause myelitis

A

Inflammation - Neuromyelitis optica, Systemic lupus erythematosus (autoimmune), sarcoidosis

Infection…or post infection - (HIV, HTLV, HSV, TB, borrelia, mycoplasma etc)
Tumour
Paraneoplastic process
Stroke

27
Q

What other investigations can be done other than MRI? (4)

A

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

28
Q

Pathogenesis of MS

A

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

29
Q

treatment of MS

A

there is no cure
treat the relapse

disease modifying treatment

general health and diet changes

symptomatic treatment

MDT approach

30
Q

How would you manage an acute relapse of MS

A

look for underlying infection

exclude worsening of usual symptoms with intercurrent illness

give IV oral prednisolone
rehab and symptomatic treatment

31
Q

1st line disease modifying treatment

A

s/c or i/m injections or Beta-interferons or glatiramer acetate

oral - teriflunomide or dimethyl fumarate

32
Q

2nd line disease modifying treatment

A

Natalizumab
Fingolimod
Cladribine
Alemtuzumub

33
Q

describe how disease modifying agents work

A

they are not a cure they simply reduce relapse rate

do not slow progression of disease

consider side effects

34
Q

symptomatic treatment examples (11)

A

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

35
Q

Who is involved in an MS MDT? (8)

A

MS nurse

Physiotherapy

Occupational therapy

Speech and
language therapy

Dietician

Rehabilitation specialists

Continence advisor

Psychology/psychiatry

36
Q

Describe relapsing remitting MS

A

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

37
Q

Describe secondary progressive MS

A

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

38
Q

how is numbness, pins and needles or paraesthesia caused?

A

plaques in the sensory pathways from skin

39
Q

how are bowel/bladder problems or sexual dysfunction caused?

A

plaques in the autonomic nervous system

2ND YEAR SYSTEMS: Neuro (32 decks)

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