Multiple Sclerosis/ demyelination Flashcards
MS
General
life expectancy 7-14 year rreduction
>1/2 death related to complications
most frequesnt source of permanent disability in young adults aside from trauma.
The most common immune-mediated inflammatory demyelinating disease of the central nervous system
Females > Males
Mean age of onset 28-31
Possible genetic susceptibility
Familial
3-23%
Environmental
Viral
Vitamin D deficiency
Geography
MS
Pathophys
Characteristic feature
presence of focal demyelinated plaques in CNS
Optic nerve
Spinal cord
Brainstem
Cerebellum
Juxtacortical/ periventricular white matter
MS
Dx
Multiple sclerosis is a clinical diagnosis
Good clinical history
Physical Examination
Imaging (MRI)
MS
Clinical manifestations
No unique clinical findings
Presenting symptoms
Monosymptomatic = Single lesion
Polysymptomatic = > than 1 lesion
Typical presentation
Young adult
Clinically distinct episode(s) of CNS system dysfunction
Partial or full resolution
MS
S/Sx
Numbness/tingling
Tightness
“MS hugs” - chest discomfort
“Anaconda sign” - constricting sensation
Coldness
Swelling of limbs/trunk
Intense itching sensation
Usually unilateral and in cervical dermatomes
MS
Neurologic Symptoms
Cognitive impairments
Cognitive impairment (common)
Difficulty with attention
Short term memory
Speed of information processing
Abstract conceptualization
Frank dementia < 5%
MS
Unilateral Optic Neuritis
Painful monocular vision loss
visual blurring
partial vision loss
90% regain vision within 2-6 months
MS
pain symptoms
Paroxysmal (sudden) pain
Persistent pain
burning
cold dysesthesias
Musculoskeletal
Soft tissue
MS
Heat Sensitivity
Uhthoff syndrome
Uhthoff phenomenon: increase in body temp worsens symptoms
More than half of patients
Small increases in body temperature temporarily worsen symptoms
Conduction block in central pathways as temp increases
demyelinated nerves occur faster
MS
Genitourinary Symptoms
Urge incontinence
Overactive bladder
Functional bladder outlet obstruction
Symptoms
Hesitancy
Interrupted stream
Incomplete emptying
Erectile dysfunction
Decreased libido
MS
GI Symptoms
Urge incontinence
Constipation
Poor evacuation
Incontinence
MS
Neurologic PE
Signs
Paraplegia/paraparesis
lesions in the descending tract of spinal cord
Spasticity
Tonic: resistance to movement
Phasic: involuntary jerks and spasms
Diminished deep tendon reflex
lesions interrupting the reflex arc
Lhermitte Sign
Electric shock shooting down the spine or into the limbs most often after flexion of the neck
Intention tremors
45% of MS patients
Difficulty with coordination
Dysmetria: inability to control the distance, speed, ROM necessary to perform coordinated movements
Hypotonia: weak muscle tone
Gait disturbances
Cerebellar dysarthria (eg, scanning speech)
MS
Sensory Findings
Vibration/joint position sense impairment
Patchy areas of reduced pain and light touch perception in limbs/trunk
Brown-Sequard syndrome: weakness or paralysis and proprioceptive deficits ipsilateral to lesion with loss of pain and temp sensory contractural to lesion.
Testing sensation with sharp object, feeling is increased or spreads like a ripple effect
Contralateral weakness
MS
Ocular Findings
Optic neuritis
Afferent pupillary defect (Marcus-Gunn pupil) with swinging flashlight test (defect is in retina, optic nerve, chiasm, or anterior optic tract)
Disc edema if involves head of the optic nerve
MS
Abnormal eye movements
Internuclear ophthalmoplegia
Pendular nystagmus
MS
MRI brain
Diagnostic image of choice
Hyperintense white matter lesions on T2 sequence
Plaques
Ring enhancing
Ovoid
“Black hole” lesions
Severe demyelination and axonal loss
MS
MRI Spine
Less likely to be asymptomatic
Size ≥3 mm but < 2 vertebral segments in length
Occupy only part of the spinal cord
Little to no cord swelling
Focal
Clearly delineated
Well circumscribed
Chronic lesions
Smaller
Well-defined margins
Acute lesions
Larger
Ill defined
More gadolinium uptake
Dissipates over a few weeks
Rarely up to 8 weeks
MS
Lumbar Puncture
If clinical picture and imaging insufficient
Atypical clinical or imaging features
Atypical population (children and older adults)