- inflammatory DEMYELINATING d.o of the cns

MULTIPLE SCLEROSIS Flashcards by Shiv Krishnan

What is MS?

inflammatory DEMYELINATING d.o of the cns

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When is the usual time of onset of MS and in whom?

females

- 30s and 40s

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How does MS present as on imaging?

MRI

- plaques disseminated in time and place

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What predisposes you to MS?

a monozygotic twn= 1 in 3 chance
1st degree relative== 12% chance
GENETIC makeup is HUGE in pathology

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Main clinical fts of MS?

optic neuritis
pyramidal dysfxn (h/t and weakness)
sensory symptoms
Lr urinary tract dysfxn
cerebellar & brain stem fts
cognitive impairment

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What occurs from pyramidal dysfxn?

incr. TONE
spasticity
weakness
involves EXTENSORS of UPPER limbs
flexors of lower limbs

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What occurs with optic neuritis?

PAINFUL vision loss

- most will improve (1-2weeks)

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WHat is the 1st presentation of MS?

pain of moving eyes

- i.e. OPTIC NEURITIS

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How to test for optic neuritis?

shine light in both the eyes (alternating between the 2)
—-find the eye with the pathology NOT constricting with the light
= RAPD (relative afferent pupillary defect)

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Are sensory symtoms present in MS?

YES

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What are some sensory symtptoms?

PAIN
paraesthesia (burning feeling/ water going down the leg)
DORSAL column loss (VIBRATION and PROPRIOCEPTION)
numbness
trigeminal neuralgia

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What are some symptoms of cerebellar dysfxn?

ataxia
nystagmus
dysarthria
intention tremor
past pointing
pendular reflexes
dysdiadokinesis

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How does brain stem dysfxn present as?

DIPLOPIA (VI nerve palsy)

- facial weakness (VII palsy)

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What is affected in internuclear ophthalmoplegia to result in DIPLOPIA?

pathology of the MEDIAL LONGITUDINAL FASCICULUS

distorts the binocular vision

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What is seen clinically with INO?

failure of ADDUCTION
> DIPLOPIA
——nystagmus in normal abducting eye
—lag

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WHat urinary tract symptoms are seen?

nocturia
freq. (d.t irritability(
urgency
URGE incontinence
retention (d.t incr. tone)

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How do you manage fatugability in MS?

amantadine
MOdafinil is SLEEPY
HYPERBARIC oxygen

How is the urinary tract dysfxn managed?

bladder drill
anti-cholinergics (OXYBUTIN–> retention causing detrusor overactivity)
desmopressin (given for LONG journeys)
catheterisation

Criteria for dx MS?

at least 2 episodes suggestive of demyelination

dissemination in time and place

What ivx can be done for confirming MS dx?

-Clinical
- MRI
CSF
- NEUROPHYSIOLOGY
- BLOODTEST

What are some ddx for MS?

vasculitis
granulomatous disorder
vascular disease
tumor
infection (HIV, LYME)
metabolic disease (B12 folate def.)

What blood tests can be done?

plasma viscosity, FBC and CRP should be NORMAL
renal, liver and bone profile
auto anti-body screen
borellia, HIV, syphilis serology
B12 and folate
Vitamin D

What should be looked for in CSF?

raised proteins
incr. proportion of immunoglobulins
presence of oligoclonal bands in the CSF
- in 90% of cases

How variable is relapse?

could happen in one year or 10 years

What does prophylactic rx for MS entail?

- initiation of disease modifying therapy - escalation to second line - MRI

How is a MILD acute exacerbation treated?

symptomatically

How is a MODERATE acute exacerbation treated?

ORAL steroids | - oral methylprednisolone (0.5g x 5 days)

How is a SEVERE acute exacerbation treated?

- admit - IV steroids ----just to SHORTEN the length of the ACUTE relapse (does not mean pt returns to baseline)

How is pyramidal dysfxn treated?

- physiotherapy - occupational therapy - ANTI-SPASMODIC agent

How is spasticity managed?

- physiotherapy - oral medication (BACLOFEN/GABAPENTIN) - intrathecal BACLOFEN/ PHENOL (bed bound pts) - cannabis and botulinum toxin (apparent help)

How are sensory symtoms treated?

``` 1- anticonvulsants (GABAPENTIN) 2- anti-depressant (amitriptyline) 3- TENS machine 4- Acupuncture 5- Lignocaine infusion ```

Why are urinary symtpoms presented in MS?

- d.t INcr. tone at bladder neck - detruser hypersensitivity - detruser sphyncteris dyssenergia (bladder and urethra contracts simultaneously)

What is FIRST line for MS disease modifying therapy?

1. Beta Interferon 2. Glatiramer acetate 3. Tecfidera 4. Natalizumab

Name interferons?

avonex | rebif

How effective are interferon?

- decr. relapse rate by 1/3 | - severity of relapse decr. by 50%

What is first line for relapse-remitting MS?

- TECFIDERA (oral agent) ----reduces relapse by 44%

When to move to second line?

- emergence of new plaques | - foundon mri

Name the second line rx for MS.

- Fingolimod/Cadrabine - ORAL agents -monoclonal antibody (Tysabri), ocrevus

How effective is the second line?

>50% reduction in relaspe rate | - significant effect in disease progression

What is given in those with high disease activity and rapidly evolving severe relapsing remitting MS?

single disease modifying therapies | Tysabri

Decribe the inflammatory cascade in MS. `

- immune cells pass the BBB - these cells re-activate and produce CYTOKINE - immune cells MOUNT and autoimmune attack against myelin

What is the mode of axn of Tysabri?

- prevents leukocyte migration ACROSS BBb - prevents leukocyte priming and activation - modulates leukocyte apoptosis