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CU Child Neurology Neuroimmunology > Multiple Sclerosis > Flashcards

Multiple Sclerosis Flashcards

1
Q

What is multiple sclerosis (MS) defined as?

A

inflammatory demyelinating disorder the central nervous system (brain and spinal cord)

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2
Q

What name is given to the specific areas of inflammation in MS ?

A

Plaques

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3
Q

Plaques are disseminated in time and space. What does this mean?

A

Plaques appear in different places at different times

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4
Q

Describe the Female:Male ratio of MS

A

3:1

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5
Q

When are most initial presentations of MS?

A

30s-40s

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6
Q

How is MS thought to be distributed geographically?

A

Further from equator = higher risk of MS

Also countries with low Vitamin D levels shower higher rates of MS

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7
Q

What type of course can a patient’s MS take after their diagnosis?

A

1) Relapsing and Remitting Course
2) Secondary progressive (starts like number 1 but can progress)
3) Progressive Relapse (No. 1 but always progressing)
4) Primary progressive

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8
Q

What are the main clinical features of MS?

A
  • Pyramidal dysfunction
  • Optic neuritis
  • Sensory symptoms
  • Lower urinary tract dysfunction
  • Cerebellar and brain stem features
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9
Q

What is meant by pyramidal dysfunction?

A
  • Increased tone => increased reflexes also
  • Spasticity
    Weakness in:
  • Extensors of upper limbs
  • Flexors of lower limbs
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10
Q

What is an optic neuritis and how many MS patients have this as their initial presentation?

A
  • Painful visual loss lasting 1-2 weeks (due to inflammation of nerves around eye)
  • Most of these improve
  • around 1/2 of MS patients initially present with ON
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11
Q

What sensory symptoms may a patient with MS experience?

A
  • pain
  • Paraesthesia “burning” or “water running down leg”
  • Loss of Proprioception and vibration
  • Numbness
  • trigeminal neuralgia
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12
Q

What symptoms may indicate a patient has cerebellar dysfunction due to MS?

A 
Ataxia
Intention Tremor
Nystagmus
Dysdiadokinesis (cant perform rapid alternating movements)
Dysarthria
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13
Q

What symptoms can indicate brainstem dysfunction in MS patients?

A 
Diplopia (CN VI palsy)
Facial weakness (CN VII palsy)
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14
Q

What is internuclear ophthalmoplegia?

A

Inability to coordinate both eyes moving at same time

Failure of adduction in affected eye
=> it lags behind and causes a diplopia

Nystagmus is seen in abducting eye whilst lagging eye is catcing up

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15
Q

What symptoms indicate lower urinary tract dysfunction?

A
  • frequency
  • nocturia
  • urgency
  • urge incontinence
  • retention
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16
Q

Why do patients with MS often have lower urinary tract dysfunction?

A

Increased muscle tone at the bladder neck

Increased irritability of the detrusor muscle

17
Q

How is the symptom of fatigue tackled in patients with MS?

A
  • Amantadine (BEWARE can cause heart failure)
  • Modafinil if sleepy (used less often now)
  • Hyperbaric oxygen therapy
    => air pressure increased to 3x normal air pressure
    => lungs can gather more O2 to transport in blood
18
Q

How is MS usually diagnosed?

A
  • At least 2 episodes suggestive of demyelination
  • Dissemination in time and place on MRI
- McDonald criteria - 1 yr disability 
\+ 2 of:
- hyperintense brain lesions
- hyperintense spinal lesions 
- oligoclonal bands in CSF
19
Q

What other differentials diagnoses may mimic MS?

A 
Vasculitis
Granulomatous disorder (e.g. sarcoidosis)
Vascular disease 
Tumour
Infection
Metabolic disorder

AKA any disorders causing inflammation!

20
Q

What investigations can be used for MS diagnosis and what are you looking for?

A

MRI - hyperintensities

CSF - oligoclonal bands

Blood tests - raised inflammatory markers

Neurophysiology - specific pattern for demyelination injury

21
Q

What are the 3 stages at which MS is managed?

A
  • Acute exacerbation (relapse)
  • Symptomatic treatment
  • Disease modifying therapy
22
Q

How are acute relapses of MS usually treated?

A

Mild Relapse - symptomatic treatment

Moderate Relapse - Oral steroids (500mg methylprednisolone daily)

Severe Relapse - Admit / IV steroids

23
Q

How are pyramidal symptoms treated in MS?

A
  • physiotherapy
  • occupational therapy
  • anti spasmodic agent (baclofen, tizanidine)
24
Q

Other than oral medication, what anti-spasmodic treatments are available?

A

Botulinum toxin

Intrathecal baclofen / phenol (for bed bound patients)

25
Q

How are sensory symptoms such as pain and parasthesia treated?

A
  • anti convulsant eg. gabapentin
  • anti depressant eg. amitriptyline
  • tens machine
  • Acupuncture clinic
  • Lignocaine infusion (to reset baseline pain threshold)
26
Q

What symptomatic management is available for lower urinary tract dysfunction?

A
  • bladder training
  • anti cholinergics eg., oxybutynin (USE WITH CAUTION)
  • Desmopressin (used less now)
  • catheterisation
27
Q

When is the best time to intervene for an MS patient?

A

During a relapse

28
Q

What disease modifying drugs are used to manage MS relapses?

A

1st Line:

  • Interferon Beta (INJ.)
  • Glitiramer Acetate (INJ.)
  • Tecfedira (ORAL)

2nd line - worsening relapses:

  • Monoclonal antibody – Tysabri, Lemtrada
  • Fingolimod

3rd Line - end stage:
- Mitoxantrone (chemo drug)

29
Q

How are interferon beta and glitiramer acetate delivered into the body, and how effective are they at reducing relapse?

A

Subcutaneous injections

reduce relapse by 1/3

30
Q

How does the oral first line agent, Tecfidera, compare to the s/c injections?

A

It reduces relapse rate by 44%

BUT it is newer and therefore long term data is not available

31
Q

What are the advantages and disadvantages of placing MS patients on 2nd or 3rd line drugs?

A

Advantages: larger reduction in relapse rates

Disadvantages: more toxic

32
Q

When is the monoclonal antibody Ocrelizumab used?

A

Early primary progressive MS

33
Q

What do monoclonal antibodies such as ocrelizumab do to reduce progression of inflammation in MS?

A
  • Attach to integrins on leukocytes and prevent them from crossing BBB to cause more inflammation.
  • also enhance apoptosis of leukocytes already across in CNS

CU Child Neurology Neuroimmunology (6 decks)

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