Multiple Sclerosis Flashcards
What is multiple sclerosis (MS)? [1]
idiopathic inflammatory demyelinating disease of the CNS that results in acute episodes of inflammation which are associated with focal neurological deficits
Name and describe the types of multiple sclerosis [5]
-
Relapsing Remitting MS
- unpredictable attacks which may or may not leave permanent deficits followed by periods of remission
-
Primary Progressive MS
- steady increase in disability without attacks
-
Secondary progressive MS
- initial relapsing-remitting MS that suddenly begins to have decline without periods of remission
-
Progressive Relapsing MS
- steady decline since onset with super-imposed attacks
- Benign MS
Name the syndromes that may lead to MS [4]
- Optic neuritis
- Clinically isolated syndromes
- Transverse myelitis
- Radiologically isolated syndromes
What is optic neuritis? [1]
Painful visual loss that comes on over a few days and may resolve after a few weeks
What is transverse myelitis and how does it clinically present? [4]
- Inflammation of the spinal cord that can result in:
- Weakness
- Sensory loss
- Incontinence
What are clinically isolated syndromes and what is the other cause of it (other than MS)? [2]
- Single episode of neurological disability due to focal CNS inflammation
- Can include optic neuritis and traverse myelitis
- May be a first attack of MS
- Can also happen after infection and be not related to MS
What criteria is required for MS to be diagnosed? [1]
MS is diagnosed when there is evidence of 2 or more episodes of demyelination disseminated in space and time
When should you suspect MS (“hidden relapses”)? [5]
- Optic neuritis/visual disruption
- Bell’s Palsy
- Labyrinthitis
- Sensory symptoms
- Bladder symptoms in young men/women without children
List the symptoms of MS under the following headings:
- central? [4]
- visual? [3]
- speech? [1]
- throat? [1]
- MSK? [3]
- sensation? [3]
- bowel? [3]
- urinary? [3]
- Central:
- Fatigue
- Cognitive impairment
- Depression
- Unstable mood
- Visual:
- Nystagmus
- Optic neuritis
- Diplopia
- Speech:
- Dysarthria
- Throat:
- Dysphagia
- Musculoskeletal:
- Weakness
- Spasms
- Ataxia
- Sensation:
- Pain
- Hypoesthesia
- Paresthesia
- Bowel:
- Incontinence
- Diarrhoea or constipation
- Urinary:
- Incontinence
- Frequency or retention
What features would lead you to suspect something other than MS? [7]
- Sudden onset
- Peripheral signs - areflexia, glove and stocking distribution, muscle wasting, fasciculations
- Major cognitive involvement
- Reduced level of consciousness
- Prominent seizures
- Pyrexia/evidence of infection
- Normal MRI scan
What investigations should you use on a patient with suspected MS? [5]
- MRI brain and cervical spine with gadolinium contrast
- Lumbar puncture
- Bloods
- Visual evoked potentials
- CXR
How do you distinguish between demyelination dissemination in space and dissemination in time on MRI? [2]
- Indication of dissemination in space:
- evidence of demyelination in 2 regions (e.g. periventricular and spinal cord)
- Indication of dissemination in time:
- if enhancing and non-enhancing areas of demyelination are seen
Why would you do a CXR on a patient with suspected MS? [1]
to exclude sarcoidosis
What things are you testing for in the CSF? [4]
- CSF oligoclonal bands (need matched blood sample)
- CSF cell counts - exclude mimics
- CSF glucose (matched blood sample)
- CSF protein
What are oligoclonal bands and what type of presentation of these bands would indicate MS? [2]
- Immunoglobulin bands seen in blood and spinal fluid after protein electrophoresis
- Presence of bands in CSF but not blood suggests immunoglobulin production in CNS
- supports diagnosis of MS but can be seen in other conditions
What blood tests would you carry out on a patient with suspected MS? [6]
- B12/Folate
- Serum ACE
- Lyme serology
- ESR/CRP - should be normal
- ANA/ANCA/Rheumatoid Factor
- Aquaporin-4 antibodies
- (if transverse myelitis/optic neuritis)
What does visual evoked potentials measure and what result would indicate optic neuritis? [2]
- Measure conduction of nerve signals in optic nerve to look for subclinical optic neuritis
- Conduction will be slower if a patient has had optic neuritis in the past
What is the difference between a relapse vs. pseudo-relapse? [2]
- A relapse usually involves a new neurological deficit that lasts for more than 24 hours in the absence of pyrexia or infection
- A pseudo-relapse is the re-emergence of previous neurological symptoms or signs related to an old area of demyelination in the context of heat or infection
What are the 2 steroid regimens used for MS relapses? [2]
- 1g of IV methylprednisolone for 3 days
or
- 500mg of oral methylprednisolone for 5 days AND
- PPI for gastroprotection
Name the 2 powerful drugs for MS [2]
- Alemtuzumab
- Natalizumab
What are the 2 oral treatments for MS? [2]
- Fingolimod
- Dimethyl Fumarate
What is cladribine? [1]
Old chemotherapy drug that targets B-cells and m]ay stop MS activity for many years
What type of stem cell transplant can be used for very aggressive relapsing-remitting MS? [1]
Autologous haemopoietic stem cell transplant
