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year 2 neuro - Robbie > Multiple Sclerosis > Flashcards

Multiple Sclerosis Flashcards

1
Q

Is MS a common or rare neurological disease?

A

common

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2
Q

MS is said to be a disease of _____ people

A

young

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3
Q

Describe the presentation, severity and prognosis of MS

A

presentation - diverse

severity - variable

prognosis - uncretain

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4
Q

Are all MS cases similar?

A

no they are all very different

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5
Q

Where does MS effect in the body?

A

the CNS

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6
Q

Where in the CNS does MS effect?

A

white matter

Causes demyelination - ”inflammation”

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7
Q

What is the common course of MS?

A

relapsing remitting course - presentation of disease symptoms that become worse over time (relapsing), followed by periods of less severe symptoms that do not completely cease (remitting)

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8
Q

What do most patietns with MS develop?

A

most patients develop progressive disability

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9
Q

What is the prevalence of MS?

A

Approx 5 new cases per week in Scotland

50-60 new cases per year in Aberdeen

Average GP has 2-4 patients

1-3 of whom are significantly disabled

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10
Q

When does MS usualy present?

A

symtpoms often first seen 20-40 but can appear later

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11
Q

What is the initial presentation of MS?

A

relapse - demyelination/“inflammation”

Gradual onset over days

Stabilises days to weeks

Gradual resolution

Partial or complete recovery

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12
Q

After a patient has their first relapse what happens after?

A

they may make a partial or full recovery and may not have any more symptoms for a long time or may have problems affecting them for a long time

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13
Q

What do the symptoms of a relapse of MS depend upon?

A

where the inflammation has occured

this means that there is many different presentations

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14
Q

What are the different things that may be experienced during a relapse?

A
  • Optic neuritis
  • Sensory symptoms
  • Limb weakness
  • Brainstem

Diplopia

Vertigo/Ataxia

• Spinal cord

bilateral motor and sensory symptoms

Bladder involvement

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15
Q

What is optic/retrobulbar neuritis?

A

when your optic nerve becomes inflamed

ON can flare up suddenly from an infection or nerve disease

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16
Q

What may been seen in a patient with optic neuritis?

A

Subacute visual loss

Pain on moving eye

Colour vision disturbed

Initial swelling optic disc

Optic atrophy seen later

Relative afferent pupillary defect

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17
Q

How long does it take for optic neuritis to resolve?

A

Usually resolves over weeks

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18
Q

How do you test for optic neuritis?

A

Light in normal eye causes constriction in both eyes which is normal

but if you shine it in the bad eye then it is very slow to react and looks like it isn’t contracting

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19
Q

What can happen during brainstem relapse?

A

Cranial nerve involvement - may cause double vision

Pons - internuclear ophthalmoplegia - affected eye shows imapirment of adduction

Cerebellum - vertigo, nystagmus, ataxia

Upper motor neurone signs limbs

Sensory involvement

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20
Q

What is myelitis?

A

inflammation of the spinal cord which can disrupt the normal responses from the brain to the rest of the body, and from the rest of the body to the brain

Inflammation in the spinal cord, can cause the myelin and axon to be damaged resulting in symptoms such as paralysis and sensory loss

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21
Q

What are the 2 forms of myelitis?

A

Partial or Transverse (complete)

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22
Q

What does myelitis cause?

A

Sensory level often with band of hyperaesthesia (excessive physical sensitivity, especially of the skin)

Weakness/upper motor neurone changes below level of demyelination

Bladder and bowel involvement

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23
Q

What is demyelination?

A

An auto immune process

Activated T cells cross blood brain barrier causing demyelination

Acute inflammation of myelin sheath

Loss of function

Nerve impulses slow or even stop, causing neurological problems.

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24
Q

What happens after the inflammation?

A

Repair

Recovery of function

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25
Q

What symptoms may be experienced after inflammation?

A

Post inflammatory gliosis -nonspecific reactive change of glial cells in response to damage to the central nervous system (CNS). proliferation or hypertrophy of several different types of glial cells, including astrocytes, microglia, and oligodendrocytes

may have functional deficit

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26
Q

How does demyelination show on a MRI scan?

A

Lesions or plaques on MRI scan

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27
Q

What is clinically isolated syndrome (CIS)?

A

no further episodes of relapse

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28
Q

What is MS classed as?

A

episodes of demyelination disseminated in space and time - so mor than one episode at different locations

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29
Q

When do further relapses of MS occus?

A

may occur within months of years of the first relapse

30
Q

What sites may be effected on a further relapse?

A

Optic nerve

Sensory

Limb weakness

Diplopia

Vertigo

Ataxia

Sphincter disturbance

31
Q

During a relapse there is often a underlying _______ 25-30%

A

Underlying infection 25-30%

32
Q

How do relapses chance change during pregnancy?

A

Fewer relapses during pregnancy

Increased risk in first 3 months post partum (after birth)

33
Q

What is important in the disease progression and the development of a persistent disability?

A

Axonal loss important in disease progression and development of persistent disability

34
Q

How does axonal loss appear on a MRI?

A

black holes

later seen as cerebral atrophy

35
Q

What happens during a progessive phase of MS?

A

• Accumulation of symptoms and signs:

Fatigue, temperature sensitivity

Sensory

Stiffness or spasms

Balance, slurred speech

Bladder & bowel

Diplopia/oscillopsia (when you look at something it moves)/visual loss

Swallowing

Cognitive-dementia/emotional lability

36
Q

What would be seen on examination of a patient with MS?

A

Depends on where demyelination has occurred and stage of disease:

Afferent pupillary defect

Nystagmus or abnormal eye movements

Cerebellar signs - ataxia (affects co-ordination, balance and speech)

Sensory signs

Weakness

Spasticity

Hyperreflexia

Plantars extensor

37
Q

What are the different types of MS?

A

Relapsing remitting - 85% at outset (RRMS)

Secondary progressive (SPMS) (may not get picked up until this stage)

Primary progressive - 10-15% (PPMS) - no relapses, just a build up of disability

38
Q

What type of MS is shown

A

RELAPSING REMITTING

39
Q

What type of MS is shown

A

SECONDARY PROGRESSIVE

40
Q

What type of MS is shown

A

PRIMARY PROGRESSIVE

41
Q

When does primary progressive MS often present?

A

often presents in the 5th or 6th decade

42
Q

Does a person have relapses in primary progressive MS?

A

no relapses

43
Q

What symptoms may be experienced in primary progressive MS?

A

Spinal symptoms

Bladder symptoms

44
Q

What is the prognosis of primary progressive MS like?

A

poor prognosis

45
Q

What is the ratio of males to females for primary progressive MS?

A

M:F = 1:1

46
Q

This image hsows the different courses tht MS could take

A
47
Q

How is the diagnosis of MS made?

A

Evidence of demyelination separated in time and space (at least two different times that myelination has happened and in at least 2 different areas)

May be clinical or MRI based diagnosis:

Posers criteria (clinical)

Macdonald Criteria (MRI)

48
Q

How do areas of demyelination show on a MRI?

A

lesions or plaques

49
Q

What is gadolinium?

And why when contrast is used that some lesions/plaques are no longer there?

A

Gadolinium is a contrast medium

Areas that light up are new and active as takes the gadolinium up but the older white blobs are form previous episodes of demyelination and this shows relapses

50
Q

What is a differential diagnosis?

A

the process of differentiating between two or more conditions which share similar signs or symptoms

51
Q

Can a differential diagnosis occur with MS?

A

Depends on symptoms and signs and on whether a first relapse or progressive disease

52
Q

What are some differential diagnosis of MS?

A
  • Acute Disseminated Encephalomyelitis (ADEM) - an immune-mediated inflammatory demyelinating condition that predominately affects the white matter of the brain and spinal cord
  • Other Auto-immune conditions eg SLE
  • Sarcoidosis - disease involving abnormal collections of inflammatory cells that form lumps known as granulomas
  • Vasculitis - inflammation of your blood vessels
  • Infection eg Lyme disease, HTLV-1
  • Adrenoleucodystrophy - congenital - a result of fatty acid buildup caused by the relevant enzymes not functioning properly, which then causes damage to the myelin sheath of the nerves, resulting in seizures and hyperactivity
53
Q

WHat are differnetial diagnosis for optic neuritis?

A
  • Neuromyelitis optica - central nervous system disorder that primarily affects the eye nerves (optic neuritis) and the spinal cord (myelitis)
  • Sarcoidosis
  • Ischaemic optic neuropathy
  • Toxic/drugs/B12 deficiency
  • Wegeners granulomatosis
  • Local compression
  • Lebers hereditary optic neuropathy
  • Infection - TB, HIV
54
Q

What are the differential diagnosis for myelitis?

A

• Inflammation

- Neuromyelitis optica

- SLE

- sarcoidosis

• Infection…or post infection

- (HIV, HTLV, HSV, TB, borrelia, mycoplasma etc)

  • Tumour
  • Paraneoplastic process
  • Stroke
55
Q

What other investigations may be carried out for MS?

A

All depends on clinical picture if other investigations are needed or not

Lumbar puncture - oligoclonal bands (bands of immunoglobulins) present in CSF but not serum

Visual/somatosensory evoked response:

Looking for a delay in a response as demyelination causes nerves to pass a signal more slowly e.g. stimulating foot and recording the signal in the brain with a EEG

Bloods - exclude other inflammatory conditions

Chest X Ray

56
Q

What is the progression of MS?

A

1/4 MS never affects activities of daily living (ADL)

15% severely disabled quickly

1 in 4 will require a wheel chair at some point

Very difficult to predict

57
Q

What is the pathogenesis of MS?

A
  • Complex genetic inheritance
  • Association with autoimmune disease
58
Q

What is the male to female ratio for MS?

A

Female:male

2-3:1

59
Q

Where in the world is MS more common?

A

Commoner in temperate climate

more common the further a person is from the equator

60
Q

What is the treatment of MS?

A

Treatment of relapse

Disease modifying treatment

General health and diet

Symptomatic treatment

Multi-disciplinary approach

61
Q

How do you treat an acute relapse of MS?

A

LOOK FOR UNDERLYING INFECTION

Exclude worsening of usual symptoms with intercurrent illness

Oral prednisolone (Intravenous)

Rehabilitation

Symptomatic treatment

62
Q

What are the 2 main categories of disease modifying agents?

A

1st line treatments

2nd line treatments

63
Q

What are disease modifying agents?

A

Reduce the relapse rate

Don’t slow progression of disease

Have to be having relapses often enough to be given one of these

64
Q

What are some 1st line disease modifying agents?

A

• s/c or i/m injections

  • Beta-interferons
  • glatiramer acetate

• Oral treatments

  • Teriflunomide
  • Dimethyl Fumarate (anti-inflammatory)
65
Q

What are some 2nd line disease modifying agents?

A
  • Natalizumab
  • Fingolimod
  • Cladribine
  • Ocrelizumab (?PPMS)
  • Alemtuzumub
66
Q

When would you change a patient form 1st line to 2nd line treatment?

A

If a patient continues to have relapses on a first line agent then they get a second line agent

Stronger the treatment = more monitoring and more risks

67
Q

What do disease modifying agents do?

A

Not a cure

Reduce relapse rate

Do not slow progression

Side effects

68
Q

How do disease modifying agents affect the immune system?

A

• Immunosuppression

? Risks

Progressive multifocal leukoencephalopathy (PML) - a demyelinating disease of the central nervous system (CNS) characterized by widespread lesions due to infection of oligodendrocytes by JC virus. Immunosupprsion allows JC virus to reactivate and be worse

69
Q

What symptomatic treatment can be sued for MS?

A

Spasiticity - muscle relaxants/antispasmodics/physiotherapy

Dysaesthesia - amitriptyline, gabapentin etc.

Urinary - anticholinergic Rx, bladder stimulator/catheterisation

Constipation - laxatives

Sexual dysfunction - sildenafil

Fatigue - graded exercise, medication

Depression - CBT, medication

Cognitive - memory aids etc

Tremor - aids/medication

Vision/oscillopsia - carbamazepine

Speech/swallowing - SALT

Motor/sensory impairment - multi-disciplinary team

70
Q

WHat needs ot be considered when using symptomatic treatment?

A

Ask directed questions about symptoms Eg bladder and mood

Treat the symptom not the “MS Symptom”

71
Q

Who is involved in a multi-disciplinary team for the care of MS?

A
  • MS nurse
  • Physiotherapy
  • Occupational therapy
  • Speech and language therapy
  • Dietician
  • Rehabilitation specialists
  • Continence advisor
  • Psychology/psychiatry

year 2 neuro - Robbie (48 decks)

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