multiple sclerosis

Question 1

what is a MS

Answer 1

immune-mediated inflammatory, demyelinating, condition that affects both the brain and spinal cord

demyelination of the white matter of the CNS that tends to favour the optic nerves, brainstem, periventricular areas + spinal cord

demyelination decreases conduction velocity and some of the signal dissipates causing information to be lost

Question 2

when does it start

Answer 2

MS is commoner in women than men and typically occurs in temporal regions. Symptoms typically commence in early life (20s and 30s) in the form of visual or sensory disturbances.

Question 3

symptoms of MS

Answer 3

Visual

• optic neuritis: common presenting feature
  optic atrophy, pale disc
• Uhthoff’s phenomenon: worsening of vision following rise in body temperature
• internuclear ophthalmoplegia

Sensory

• paraesthesia - pins/needles
• numbness
• trigeminal neuralgia
• Lhermitte’s syndrome: paraesthesiae in limbs on neck flexion

Motor
spastic weakness: most commonly seen in the legs
- horners
- bells
- incontinence

Cerebellar
ataxia: more often seen during an acute relapse than as a presenting symptom
tremor worst on movement

Others
urinary incontinence
sexual dysfunction
intellectual deterioration

Question 4

what is bulbar palsy

Answer 4

9, 10, 11, 12

Question 5

Ix for MS

Answer 5

neurological examination

• Symptoms have to be progressive over a period of 1 year to diagnose primary progressive MS.
  1. MRI of brain or spinal cord - will demonstrate demyelination plaques
  2. Immunoelectrophoresis of CSF - will show oligoclonal bands of IgG

MRI - dorsum fingers
LP - elevated levels of IgG Oligoclonal bands
increase WBCs

Question 6

3 main patterns of clinical presentation

Answer 6

1. Relapsing remitting
2. Secondary progressive
3. Primary progressive

Question 7

what is relapse remitting MS

Answer 7

they occur in different areas and different episodes

when you have attacks for at least 24 hours and then get better

Question 8

what is secondary progressive

Answer 8

when you start off with remitting and then it gradually gets worse without relapses

Question 9

what is primary progressive MS

Answer 9

it gets worse from the beginning

Question 10

symptoms of optic neuritis

Answer 10

• Central scotoma. This is an enlarged blind spot.
• Pain on eye movement
• Impaired colour vision
• Relative afferent pupillary defect

Question 11

McDonald criteria for MS

Answer 11

1. Lesions consistent with an inflammatory process
2. No alternative diagnosis
3. Multiple lesions in time and space (Relapsing remitting MS)
4. Progressive neurological deterioration for 1 year (Primary progressive MS)

Question 12

how can a MS relpase be diagnosed

Answer 12

1. Develops new symptoms
2. Has rapid worsening of existing symptoms
3. Symptoms last for more than 24 hours in the absence of infection or other cause after a stable period
   of one month or more

Question 13

treatment for MS relapse

Answer 13

500mg 5 days course of ORAL steroids

OR

IV of steroids in hospital

METHYLPREDNISOLONE

Question 14

fatigue treatment for MS

Answer 14

amantadine

other options include mindfulness training and CBT

Question 15

spasticity treatment for MS

Answer 15

baclofen or gabapentin

Other options include diazepam, dantrolene and tizanidine
physiotherapy is important

Question 16

oscillopisa?

Answer 16

when the eye moves side to side, up and down

images jump, hazy

Question 17

treatment for oscillopsia

Answer 17

gabapentin

Question 18

emotional lability treatment

Answer 18

amitryptilline

Question 19

Tx for neuropathic pain

Answer 19

amitryptilline
duloxetine
gabapentin
pregablin

Question 20

Tx for depression

Answer 20

citalopram
fluoxetine
paroxetine
sertraline.

Question 21

Tx for incontinence

Answer 21

ultrasound first to assess bladder emptying - anticholinergics may worsen symptoms in some patients

if significant residual volume → intermittent self-catheterisation
if no significant residual volume → anticholinergics may improve urinary frequency

1) behavioural management programme
2) antimuscarinic - oxybutinin

Question 22

reducing the frequency and duration of the relapses of MS

Answer 22

interferon beta or glatiramer acetate

active disease
Teriflunomide + dimethylfumerate

highly active disease
natalizumab + alemtuzumab

Question 23

planning to get pregnant what advise do u give for MS

Answer 23

fertility not affected

glatiramer acetate

stop DMTs 1 -12 months

Question 24

what is Uhthoff’s phenomenon

Answer 24

worsening of symptoms in higher temperatures

Question 25

factors influencing demyelination

Answer 25

Multiple genes
Epstein–Barr virus (EBV)
Low vitamin D
Smoking
Obesity

Question 26

what is internuclear opthalmoplegia

Answer 26

inability to move both your eyes together when looking to the side.
amage to the medial longitudinal fasciculus, a group of nerve cells leading to the brain. It’s common in young adults and older people.
diplopia

Question 27

poor prognosis

Answer 27

exhibiting nrainstem Sx such as tremor, nystagmus, ataxia as well as experiencing frequent attacks