Multiple Sclerosis Flashcards
Do younger or older people normally get MS?
Younger
Is the presentation of MS consistent or variable?
Variable
What is MS a disease of?
The central nervous system, causing demyelination and inflammation which leads to focal disturbance of function
What is the prevalence of MS?
190/100,000 in Scotland
What does MS stand for?
Multiple sclerosis
When is the most common age of onset for MS?
About late 20s/30
What is the initial presentation of MS?
Relapse (demyelination and inflammation)
Gradual onset over days
Stabilises days to week
Gradual resolution
Partial or complete recovery
What is seen during a relapse phase of MS?
Optic neuritis
Sensory symptoms
Limb weakness
Brainstem problems (cranial nerve involvement, pons-internuclear ophthalmoplegia, diplopia, vertigo/ataxia, upper motor neurons signs)
Spinal cord problems (bilateral motor and sensory symptoms, bladder involvement)
Myelitis
What is optic neuritis?
Subacute visual loss
What are clinical signs of optic neuritis?
Pain on moving eye
Colour vision disturbed
Initial swelling optic disc
Optic atrophy seen later
Relative afferent pupillary defect
What is pons-internuclear ophthalmoplegia?
Disorder of horizontal occular movement due to a lesion on the brainstem
What is diplopia?
Double vision
What is myelitis?
Inflammation of the spinal cord
Can be partial or transverse (complete)
What are the 2 different kinds of myelitis?
Partial or transverse (complete)
What is the clinical presentation of myelitis?
Weakness/upper motor neuron changes below level of demyelination
Bladder and bowel involvement
What is responsible for demyelination in MS?
Autoimmune process
Activated T cells cross blood brain barrier causing demyelination
What can demyelination in MS be seen by?
Lesions or plaques on MRI scan
What is the process of demyelination in MS?
1) Acute inflammation of myelin sheath
2) Loss of function
3) Repair
4) Recovery of function
5) Post inflammatory gliosis
6) May have funcitonal defect
What is gliosis?
Non-specific change of glial cells in response to damage to CNS
Usually hypertrophy (growth) or proliferation (increase in numbers) of glial cells
What are the different disease courses of MS?
Clinical isolated syndrome
Relapsing-remitting MS
Primary progressive MS
Secondary progressive MS
What is clinical isolated syndrome MS?
Refers to first episode of neurologic symptoms that last at least 24 hours
Sometimes no further episodes
What are further relapses of MS usually due to?
Underlying infection (25-30%)
What is important for the progression of MS?
Axonal loss is important for disease progression and development of persistent disability
What are examples of symptoms that can accumulate during the progressive phase?
Fatigue
Temperature sensitivity
Sensory symptoms
Stiffness or spasms
Balance problems
Slurred soeech
Bladder and bowel
Diplopia/oscillopsia/visual loss
Swallowing
Cognitive dementia/emotional liability
What is oscillopsia?
Images are no longer held steady on the retina (vision loss)
What do the signs observed in examination due to MS depend on?
Where the demyelination has occured and the stage of disease
What are some things seen in examination of MS?
Afferent pupillary defect
Nystagmus or abnormal eye movements
Cerebellar signs
Sensory signs
Weakness
Spasticity
Hyperreflexia
Plantars extensor
What does RRMS stand for?
Relapsing remitting MS
What does SPMS stand for?
Secondary progressive MS
What does PPSM stand for?
Primary progressive MS
What is the most common type of MS?
Relapsing remitting MS (RRMS)
85% at outset
What is the different between the impairment level of primary and secondary progressive MS?
When does primary progressive MS usually present?
In 5th and 6th decade
In what kind of MS do no relapses occur?
Primary progressive
What are symptoms of primary progressive MS?
Spinal and bladder symptoms
What is the male to female ratio of primary progressive MS?
1:1
What is required to make the diagnosis of MS?
Evidence of demyelination seperate in time and space
May be clinical or MRI based diagnosis
What are the clinical and MRI based diagnostic criteria called?
Posers criteria (clinical)
Macdonald criteria (MRI)
What chemical can be used with an MRI scan to better show new lesions?
With gadolinium new lesions are shown as they uptake it whereas old ones do not
What are some conditions including in the differential diagnosis for MS?
Acute desseminated encephalomyelitis (ADEM)
Other autoimmune conditions such as SLE
Sarcoidosis
Vasculitis
Infection such as lyme disease
Adrenoleukodystrophy
What does ADEM stand for?
Acute disseminated encephalomyelitis
What is optic neuritis?
Inflammation of the optic nerve
What are some differentials for optic neuritis?
Neurolyelitis optica
Sarcoidosis
Ischaemic optic neuropathy
Toxic/drugs/B12 deficiency
Wegeners granulomatosis
Local compression
Lebers hereditary optic neuropathy
Infection (TB or HIV)
What are differentials for myelitis?
Inflammation (neuromyelitis optica, SLE, sarcoidosis)
Infection or post infection (HIV, HTLV, HSV, TB)
Tumour
Paraneoplasic process
Stroke
Other than MRI, what other investigations can be done for MS?
Lumbar puncture (oligoclonal bands present in CSF but not serum)
Visual/somatosenosory evoked response
Bloods to exclude other inflammatory conditions
Chest x-ray
MS never affects the activities of daily living (ADL) for how many people with it?
25%
What percentage of people with MS require a wheel chair at some point?
25%
What is the female to male ratio for MS?
2-3:1
What is the general treatment of MS?
Treatment of relapse
Disease modifying treatment
General health and diet
Symptomatic treatment
MDT approach
What is the treatment for an acute relapse of MS?
Look for underlying infection
Exclude worsening of usual symptoms with intercurrent illness
Treatment (oral prednisolone (IV), rehabilitation, symptomatic treatment)
What are some 1st line disease modifying treatments for MS?
S/C or I/M injections (beta-interferons, glatiramer acetate)
What are some 2nd line disease modifying treatments for MS?
Natalizumab
Fingolimod
Cladribine
Ocrelizumab
Alemtuzumub
What is the function of disease modifying treatments for MS?
They are not a cure, they reduce relapse rate, do not slow down progression and have side effects
Who can disease modifying treatments for MS give problems to?
People who are immunosupressed and can lead to multifocal leukoencephalopathy
What are some sympatomatic treatments for MS?
- Spasticity-muscle relaxants/antispasmodics/physiotherapy
- Dysaesthesia
- Amitriptyline, gabapentin etc
- Urinary anticholinergic Rx, bladder stimulator/catheterisation
- Constipation
- Laxatives
- Sexual dysfunction
- Sildenafil
- Fatigue
- Graded exercise, medication
- Depression
- CBT, medication
- Cognitive
- Memory aids
- Tremor
- Aids/medication
- Vision
- Carbamazepine
- Speech/swallowing
- SALT
- Motor/sensory impairment
- MDT
Who are some members of the MDT than looks after people with MS?
MS nurse
Physiotherapist
Occupational therapist
Soeech and language therapy
Dietician
Rehabilitation specialists
Continence advisor
Psychology/psychiatry
