Multiple Sclerosis

Question 1

Describe what multiple sclerosis is?

Answer 1

Most common neuroinflammatory disorder in western populations. A chronic auto-immune T cell mediated inflammatory disorder of the CNS. Multiple plaques of demyelination are found throughout the brain and spinal cord occurring sporadically over years.

Question 2

MS is more common in women or men?

Answer 2

women

Question 3

What age do people typically present with MS?

Answer 3

between 20-40yrs

Question 4

Describe genetics of MS?

Answer 4

not fully understood however you can have a genetic predisposition to developing the condition, if someone in your family has it you are more likely to get it

Question 5

What are the cardinal pathological features of MS?

Answer 5

plaques of demyelination 2-10mm in size

Question 6

List some common places MS plaques are found?

Answer 6

optic nerves, periventricular region, the corpus callosum, the brainstem, cerebellar connections and the cervical spinal cords

Question 7

Are peripheral myelinated nerves affected in MS?

Answer 7

NO not directly, as the condition affects the CNS

Question 8

Describe the pathology of acute relapses in MS?

Answer 8

These are caused by focal inflammation causing myelin damage and conduction block, recovery follows as inflammation subsides and remyelination occurs. When damage is severe, secondary permanent axonal destruction occurs.

Question 9

What is the pathological basis of progressive disability in progressive MS?

Answer 9

progressive axonal damage

Question 10

Describe some symptoms of pyramidal dysfunction that may occur in MS?

Answer 10

increased tone
spasticity
weakness
extensors of upper limbs are weak and flexors of lower limbs are weak

Question 11

Describe optic neuritis and how someone might present with MS?

Answer 11

painful visual loss in an eye developing over 1-2 weeks
pain on eye movements
very rarely complete blindness usually loss of central vision with colour desaturation
RAPD
most improve with time

Question 12

Describe sensory symptoms someone with MS might experience?

Answer 12

unusual sensations
reduced vibration and proprioception
pain
paraesthesia

Question 13

Describe symptoms of cerebellar dysfunction that may be experienced in MS?

Answer 13

dysarthria (poor articulation, difficulty speaking)
ataxia (broad based gait, unstable, veers to side)
nystagmus (involuntary eye movements)
intention tremor (as the cerebellum controls movements guided by eyes)
dysdiadochokinesia (impaired ability to perform fast alternating movements e.g. clumsy alternating supination pronation of the hands)

Question 14

Describe symptoms that may appear if MS was affecting the brain stem?

Answer 14

6th cranial nerve palsy (diplopia)

7th cranial nerve palsy (facial weakness)

Question 15

Describe symptoms that may appear if MS was affected the lower urinary tract?

Answer 15

bladder hyper-reflexia causing urinary urgency and frequency

Question 16

What is a common symptom many people with MS complain of?

Answer 16

fatigue

Question 17

Describe the requirements for diagnosis of MS?

Answer 17

at least 2 episodes suggesting demyelination
evidence of damage to the CNS that is disseminated in time and space ie damage occurred on different dates and different places

Question 18

Describe investigations done to rule in or out MS?

Answer 18

blood tests done to exclude other inflammatory disorders and infections e.g. borrelia, syphylis
MRI is the definitive investigation as it demonstrates areas of demyelination with high sensitivity
Lumbar puncture is abnormal in most patients with MS, get oligoclonal bands in the CSF with no corresponding bands in the serum

Question 19

Describe lumbar puncture results in MS?

Answer 19

Lumbar puncture is abnormal in most patients with MS, get oligoclonal bands in the CSF with no corresponding bands in the serum

Question 20

Name the 4 types of MS?

Answer 20

relapsing remitting
secondary progressive
primary progressive
relapsing progressive

Question 21

What is the most common type of MS?

Answer 21

relapsing remitting MS

Question 22

Describe relapsing remitting MS?

Answer 22

most common, symptoms in attacks which get better fully or partially over weeks, may accumulate disability over time if don’t fully recover after relapses

Question 23

Describe secondary progressive MS?

Answer 23

late stage MS, 75% of RRMS evolve into this within 35yrs of onset where there is gradually worsening disability

Question 24

Describe primary progressive MS?

Answer 24

gradually worsening disability without relapses or remissions

Question 25

Describe relapsing progressive MS?

Answer 25

least common, relapses on pattern of progressive disability from the outset

Question 26

Describe treatment of an acute exacerbation of MS?

Answer 26

mild - observation and or symptomatic treatment
moderate- oral steroids over 5 days (methylprednisolone)
severe - admit for IV steroids

Question 27

Describe symptomatic management of pyramidal dysfunction?

Answer 27

physio, OT, oral antispasmodic agents e.g. baclofen

Question 28

Describe symptomatic management of sensory dysfunction?

Answer 28

gabapentin, amitriptyline if resistant lignocaine

Question 29

Describe symptomatic management of urinary tract issues?

Answer 29

most patients just receive bladder training advice

anti-cholinergics e.g. oxybutynin sometimes given to reduce detrusor excitability

Question 30

Describe symptomatic treatment of fatigue?

Answer 30

fatigue diaries with the OT, amantadine works for some, modafinil if sleepy, hyperbaric oxygen

Question 31

Describe disease modifying therapy for MS?

Answer 31

First line (for those with RRMS)- tecfidera (oral) interferons and glitiramer acetate (injection) all shown to reduce relapse rate
Second line (for those 1st line not worked or v aggressive on initial presentation) - fingolimod, cladribine, monoclonal antibodies, actually more effective at reducing relapses but these drugs are very toxic