Multiple sclerosis

Question 1

what is MS?

Answer 1

progressive inflammatory demyelinating disorder of CNS

axons have limited capacity for remyelination > defects in rate and consistency of neuronal conduction

Question 2

most common phenotype?

Answer 2

relapsing and remitting (baseline with occasional flare ups)

Question 3

areas of demyelination are referred to as ____

these can be active or inactive- difference?

Common areas of demyelination?

Answer 3

plaques

active: ongoing demyelination and inflammation
inactive: ‘burnt out’

corpus callosum, optic nerve, cerebellar and peri-ventricular white matter

Question 4

risk factors?

Answer 4

• higher latitude areas (north, south pole)
• previous EBV infection
• HLA DRB1
• young females

Question 5

clinical features can be broadly categorised into which groups?

Answer 5

Pyramidal dysfunction
Sensory symptoms
Ocular symptoms
Other

Question 6

features of pyramidal dysfunction?

Answer 6

UMN dysfunction: spasticity, weakness, hyperreflexia etc. Tend to affect upper limb extensors and lower limb flexors

Tonic spasms: frequent, brief spass of the lower limbs. Closely associated with MS

Question 7

mental image

Answer 7

think of a skiier (legs flexed, arms extended)

in the north pole (higher latitudes)

wearing big goggles (ocular symptoms)

cold is freezing their face (trigeminal neuralgia)

Question 8

ocular symptoms?

Answer 8

Optic neuritis: painful eye movements/ visual loss. Colour desaturation, loss of visual acuity, RAPD, pale optic disease

Horizontal diplopia (brainstem demyelination affecting MLF). Causes INO: right sided INO means unable to look to ADduct the right eye and nystagmus of left eye on attempting left gaze

Bilateral INO is pathognomonic of MS

Question 9

sensory symptoms?

Answer 9

• sensation of water trickling down skin
• loss of DCML function (>clumsiness, loss of proprioception)
• numbness/ paraesthesia
• trigeminal neuralgia
• lhermitte’s sign
• uhthoff’s phenomenon

Question 10

other symptoms?

Answer 10

cerebellar dysfunction (DANISH)
fatigue
LUT symptoms (urge incontinence, retention)

Question 11

how is a diagnosis made?

Answer 11

must be 2 distinct neurological deficits occurring at different times implicating lesions of
white matter which are spatially and functionally distinct.
Confirmed using
• MRI: white matter plaques in brain/ spinal cord
• CSF Analysis: IgG Oligoclonal bands

Question 12

management can be broken into which 3 main areas

Answer 12

acute relapse management
disease modifying therapy
symptom management

Question 13

management of acute relapse?

Answer 13

mild: symptom mangement
moderate: oral prednisolone
severe: hosp admission and IV methylprednisolone

Question 14

disease modifying therapy?

Answer 14

1st line for relapsing-remitting: Tecfidera, Beta-Interferon, Glatiramer acetate

Where 1st line therapy has failed: Tysabri, Fingolimod, Ocrelizumab

Question 15

symptom management?

Answer 15

Spasticity: physio + oral baclofen/ gabapentin

Sensory: gabapentin (neuropathic pain)

Fatigue: amantadine +/- modafinil if excessive daytime somnolence

Bladder: bladder physio, catheterisation in retention, anticholinergic drugs (Oxybutynin) in urge incontinence

Question 16

what is lhermitte’s sign?

Answer 16

electric shock like sensation down the upper limbs and trunk on neck flexion

Question 17

what is uhthoff’s phenomenon

Answer 17

exacerbation of symptoms in hot environments e.g. post-shower

Question 18

which medication is first line in primary progressive MS

Answer 18

Ocrelizumab