Multiple Sclerosis Flashcards
What is it?
What does RRMS mean?
What does SPMS mean?
What does PPMS mean?
Chronic autoimmune disease of the CNS
Relapsing-remitting MS - 85% start of as episodic
Secondary progressive MS - 80% eventually progress to this
Primary progressive MS
- 20% progressive MS from the beginning
- 2% feature progressive disease + exacerbation (progressive-relapsing MS)
Pathophysiology:
What is happening in the relapsing-remitting phase?
Why does it remit?
What does it eventually progress to?
Characterised by T-cell mediated autoimmune damage, causing discreet plaques of demyelination throughout the CNS
Some degree of healing occurs the following damage
A neurodegenerative process including axonal loss
What sex is it more common in?
Mean age of onset?
Women
30 for RRMS
40 for PPMS
Presentation - Relapses:
How long should symptoms last before it is classed as a relapse?
Clinical features:
When do symptoms peak?
When do they tend to resolve?
How many neurological deficits does it present with?
How often do relapses occur?
What is a clinically isolated syndrome (CIS)?
What happens to relapses during pregnancy and post-partum?
> 24 hrs
Hours/days
Days-wks-months
1 deficit at a time
Once a yr but it varies
First MS-like episode - 90% will have a second attack, meeting the criteria
Decreases during pregnancy, then increases post-partum
Common presentations of MS around the body:
What happens to the eyes that increases the suspicion of MS?
What happens to the spinal column?
What part of the brain is also attacked?
Optic neuritis
Transverse myelitis (TM)
Brainstem
Common presentations - Optic neuritis:
What part of the vision is impaired?
What happens to the vision itself that means it is impaired?
What may they also see?
Where do they have pain?
What makes the pain worse?
Is it usually uni/bilateral?
Impaired central vision
Blurring to reduced colour vision (ESPECIALLY RED) , to complete loss of vision
Flashes - phosphenes
Periorbital and retro-ocular pain
Worse on eye movement
Unilateral
Common presentations - Optic neuritis (ON):
Signs:
- What type of pupillary defect would you find?
- What would happen to the optic disc?
- What does delayed optic evoked potential mean?
- What would the death of the retinal ganglion cell axons that comprise the optic nerve lead to on fundoscopy?
How long does it take to fully resolve?
Relative afferent pupillary defect
Disc swelling
Measures how long it takes the brain to respond to messages sent by the eyes - usually slowed by 10 milliseconds.
Optic atrophy
Days to weeks
Common presentations - Transverse myelitis (TM):
What is it?
What type of motor neurone signs do you get below the lesion?
What happens below the lesion - motor and sensory?
What else may be affected, just like in cauda equina?
How long does it take to fully resolve?
Inflammation of both sides of one section of the spinal cord.
This neurological disorder often damages the insulating material covering nerve cell fibres (myelin).
Transverse myelitis interrupts the messages that the spinal cord nerves send throughout the body.
UMN
Weakness
Sensory alteration
Altered sphincter function - bowel and urine incontinence
Months
Common presentations - Brainstem attacks:
Eyes:
- What is INO?
- What is diplopia?
Balance:
- How may it present? - 2
Weakness in face and speech. How may they present?
Bilateral Intranuclear opthalmoplegia
Double vision
Vertigo
Ataxia
Face palsy
Dysarthria
Other presentations - focal lesions can happen anywhere in the CNS:
Sensory:
- Dysaesthesia - what is it?
- How else may it present? - 2
- What severe nerve pain originating from the CN V may present?
- Is the distribution dermatomal or not?
Motor - one symptom
Eyes - 2
Where might the symptoms be originating from if there is gait and balance issues?
GI - 2
GU:
- Men
- Inability to achieve orgasm
- Seen in DM
- Others
Feels like water trickling or electric shock
Pin and needles
Reduced vibration
Trigeminal neuralgia
Spastic weakness
Hemianopia
Pupillary defects
Cerebellar symptoms
Dysphagia
Constipation
ED, anorgasmia, urinary retention, incontinence, frequency
Other presentations - non-focal features:
- Energy?
- What part of cognition may be impaired?
- How might autonomic dysfunction occur?
- What frontal lobe changes cause?
Fatigue
Memory problems
Bladder and bowel symptoms
Orthostatic hypotension
Postural tachycardia
Sweating
What is Uhthoff’s phenomenon?
Worsening of MS symptoms with increased temperature (e.g. exercise, hot food, hot bath, warm weather)
Paroxysmal symptoms:
What does this mean?
What does it not mean?
Possible features:
- What other features might be present?
You may also get Lhermitte’s sign. What is it?
Brief symptoms lasting from seconds to minutes - usually repeated.
Not a full attack
Trigeminal neuralgia
Epilepsy
Tonic spasms
Electrical sensation down back into limbs - worse on bending neck
Progressive disease:
What may occur with repeated relapsing-remitting phase?
How does the progressive phase then differ from the RR phase?
What happens by half of MS patients by the age of 60?
Some end-stage symptoms - list them
The gradual accumulation of disability
There is a steady decline in function as opposed to episodic flare-ups
Need a walking stick to walk
Spastic tetraparesis Optic atrophy Brainstem signs Pseudobulbar palsy Urinary incontinence Dementia
Risk factors:
- A lack of a specific vitamin
- Always a risk
- Lifestyle
Vit D deficiency and/or low sunlight exposure
FH - 10x more likely
Smoking
Obesity
DDx:
Focal neurological episode:
- What might the optic neuritis be?
- What are other causes of transverse myelitis?
- Other common neuro causes?
Isolated ON - 30% progress to MS within 5 yrs - 50% within 15 yrs
Infection - NMO, SLE etc.
Stroke
Epilepsy
DDx:
Episodic neurological disease - just view and lookup
Progressive neurological decline?
- Thyroid
- Vitamin deficiency
- Infection
Sarcoidosis Cerebral vasculitis - SLE Multiple strokes -------- Hypothyroidism B12 deficiency
HIV
Lyme
Syphilis
DDx:
Signs suggesting non-MS cause - just view and lookup
Fever N&V Meningism Malaise Seizures Aphasia Bilateral optic neuritis
Investigations:
MRI brain and spinal cord are used for diagnosis.
What do plaques look like on:
- T2-weighed MRI
- T1 MRI
What does axonal loss look like on T1 MRI?
What else can be used to diagnose MS?
What does NICE recommend is done before referring to neurology?
MRI brain and spinal cord
Plaques - hyperintense lesions on T2-weighed MRI or enhancement via gadolinium-enhanced T1 MRI.
Black holes
Spinal tap - testing CSF - you’d find oligoclonal IgG - shows there is inflammation in the CNS
Test to rule out other causes
Other investigations:
Why are FBC and CRP done?
Why is B12 measured?
Why is TSH done?
What else may cause neuropathy and eye disease?
What chronic infection may have various neurological manifestations?
What criteria is used to diagnose MS?
Signs of inflammatory disease
Cause neurological disease
Eye disease
DM
HIV
McDonald criteria
Management:
How often should they be reviewed by a specialist?
What can they be referred for?
What can the person do that may help their symptoms?
What can be cut out that may reduce progression?
Who needs to be contacted?
Annually
Support groups
Exercise
Stop smoking
Contact DVLA
Management - Disease-modifying therapy (DMT):
Initial therapy - IB, G, D
Therapy for resistant disease or initial therapy in highly active disease - N, A, O, F
Why are these not used in PPMS?
Interferon beta
Glatiramer acetate
Dimethyl fumarate
Alemtuzumab
Natalizumab
Ocrelizumab
Fingolimod
No benefit
Management - Symptomatic relief:
What can be used to treat fatigue? - 1 PD drug and 2 conservative Rx
Spasticity:
- One muscle relaxant - Tania used
- One anticonvulsant - G
Why can be given for emotional instability? - an AD - A
What can be given for neuropathic pain? - A, D, G, P
What can be prescribed to treat an overactive bladder? - O
Amantadine
Physiotherapy Psychotherapy ----- Baclofen Gabapentin ------ Amitriptyline ------- Amitriptyline Duloxetine Gabapentin Pregabalin ----- Oxybutynin
Management - Relapses:
What is first-line?
Why is IVIg used as second-line?
What might trigger a flare-up and needs to be ruled out before giving the first-line drug?
Methylprednisolone - reduces relapse severity and duration.
Not to be used >3 times a yr due to side effects.
Intravenous immunoglobulin - beneficial in the treatment of acute relapses and in the prevention of new relapses.
Infection/illness (e.g. UTI) due to pre-existing lesion.
