Multiple Sclerosis Flashcards
What is the initial presentation on MS?
Gradual onset over days
Stabilises days to weeks
Gradual resolution
Partial or complete recovery
What is the presentation of a relapse?
Optic neuritis Sensory symptoms Limb weakness Brainstem (diplopia, vertigo/ataxia) Spinal cord (bilateral motor+sensory symptoms, bladder involvement)
What are the signs on optic neuritis?
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
What happens in a brainstem relapse?
CN involvement Pons-internuclear opthamoplegia Cerebellum - vertigo, nystagmus, ataxia UMN signs Sensory involvement
What is myelitis?
Can be partial or transverse
Sensory level often with band of hyperaesthesia
Weakness/UMN changes below level of demyelination
Bladder and bowel involvement
How does demyelination occur?
Autoimmune process
Activated T cells cross BBB causes demyelination
Acute inflammation of myelin sheath causes loss of function
Lesions or plaques on MRI scan
What can occur with further relapse?
Optic nerve damage Sensory Limb weakness Diplopia Vertigo Ataxia Sphincter disturbance
What accumulation of symptoms and signs are common in progressive phase of MS?
Fatigue, temperature sensitivity Sensory Stiffness/spasms Balance, slurred speech Bladder and bowel issues Diplopia/oscillopsia/visual loss Swallowing difficulties Cognitive - dementia/emotional liability
What are common findings of examination in MS?
Afferent pupillary defect Nystagmus/abnormal eye movements Cerebellar signs Sensory signs Weakness Spasticity Hyperreflexia Plantars extensor
What are the different types of MS?
Relapsing remitting (85%) Secondary progressive Primary progressive (10-15%)
What are the common characteristics of primary progressive MS?
Often in 5th and 6th decade No relapses Spinal symptoms Bladder symptoms Poor prognosis
How is MS diagnosed?
Can be clinical or MRI based diagnosis Posers criteria (clinical) Macdonald criteria (MRI)
What is the differential diagnosis of MRI lesions and plaques?
Acute disseminated encephalomyelitis (ADEM) Other auto-immune conditions Sarcoidosis Vasculitis Infection Adrenoleucodystrophy
What is the differential for optic neuritis?
Neuromyelitis optica Sarcoidosis Ischaemic optic neuropathy Toxic/drugs/B12 deficiency Wegeners granulomatosis Local compression Lebers hereditary optic neuropathy Infection - TB, HIV
What is the differential diagnosis of myelitis?
Inflammation Infection Tumour Paraneoplastic process Stroke
What other investigations are good for diagnosing MS?
Lumbar puncture
Visual/somatosensory evoked response
Bloods (inflammatory)
CXR
How is MS treated?
General health and diet
Symptomatic treatment
Multi-disciplinary approach
How is acute relapse treated?
Oral prednisolone (IV)
Rehabilitation
Symptomatic treatment
What is the 1st line treatments for MS?
Injection: beta-interferons/glatiramer acetate
Oral: teriflunomide, dimethyl fumarate
What are the 2nd line agents for MS?
Natalizumab Fingolimod Cladribine Ocrelizumab Alemtuzumub
What are the cons of disease modifying treatment?
Not a cure Reduce relapse rate Do not slow progression Side effects Immunosuppression
What are symptomatic treatment for spasticity?
Muscle relaxants
Antispasmodics
Physiotherapy
What are symptomatic treatment for dysaesthesia?
Amitriptyline Rx
Bladder stimulator
Catherisation
What are the symptomatic treatments for constipation?
Laxatives
What are the symptomatic treatments for sexual dysfunction?
Sildenafil
What are the symptomatic treatments for fatigue?
Graded exercise
Medication
What are the symptomatic treatments for depression?
CBT
Medication
What are the symptomatic treatments for cognitive symptoms?
Memory aids
What are the symptomatic treatments for tremor?
Aids
Medication
What are the symptomatic treatments for vision/oscillopsia?
Carbamazepine
What are the symptomatic treatments for speech/swallowing issues?
SALT
What are the symptomatic treatments for motor/sensory impairment?
Multi-disciplinary team
What MDT staff are involved in MS care?
MS nurse Physiotherapy Occupational therapy Speech and language therapy Dietician Rehab specialists Continence advisor Psychology/psychiatry
