Multiple Sclerosis (MS) Flashcards
Definition
Autoimmune inflammatory disorder
Demyelination of the CNS (brain + SC)
There is damage to ????
Myelin sheath
More common in males/females
Females
Which age does it usually present around?
Age 20-40
Causes - environmental
Association with high latitude
Relationship with vitamin D deficiency
Causes - genetics
HLA DRB1
MS is an unpredictable condition. True or false?
True
There are a variety of clinical courses. What is the most common clinical course?
Relapsing remitting
Name the 4 main clinical courses
Relapsing remitting
Primary progressive
Progressive relapsing
Secondary progressive
Which clinical course is most disabling?
Relapsing remitting
Which type of cell is damaged ?
Oligodendrocyte damage
Oligodendrocyte damage causes what?
Disrupts neuronal conduction and results in demyelination. There is limited capacity to remyelinate after damage
Demyelination
Characterised by defects in the rate and consistency or neuronal conduction
Preferential damage to the myelin sheath
Relative preservation of axons
MS is principally a grey/white matter disease ? and why?
White matter disease
- myelinated axons are concentrated at white matter
Exterior surface of the brain typically appears normal/abnormal?
Normal
Cut surface of the brain shows which abnormality?
Plaques
Plaques in MS
Well demarcated
Irregular shaped areas
Glassy almost translucent appearance
Vary from very small to very large lesions
Where are plaques located
Can occur at any site in the CNS but most common locations are
- adjacent to lateral ventricles
- corpus callosum
- optic nerves and chiasm
- brainstem
Plaques tend to be distributed in a symmetrical manner. True or false?
False
- non-symmetrical
What are the 2 types of plaque
Active (acute) plaque
Inactive (chronic) plaque
Active (acute) plaque
Shows active inflammation and ongoing demyelination
Abundant microglia
Active (acute) plaque - macroscopic appearance
Demyelinating plaques are yellow/brown with an ill defined edge which blends into surrounding white matter
Inactive (chronic) plaque
Inflammation dampens down
Predominated by scarring
Little remaining myelinated axons
Inactive (chronic) plaque - macroscopic appearance
Well demarcated grey/brown lesions in with matter, classically situated around the lateral ventricles
Inflammatory cascade
Immune cells pass through the BBB from the systemic circulation to CNS
Immune cells may re-activate and produce cytokines
Immune cells mount autoimmune attack against myelin in the CNS –> demyelination
Patients typically present with focal/global neurological deficits
Focal
Clinical features - If there are lesions in the pyramidal tracts
Increased tone
Spasticity
Weakness
Upper limbs get spasticity in flexion - weakness extending elbow and flexing wrist
Lower limbs get spasticity in extension - weak flexing hip, knee and dorsiflexing ankle
Clinical features - if there are lesions in optic nerves
Unilateral painful visual loss
Colour vision is lost first
RAPD
Clinical features - sensory symptoms
Either loss of sensation or too much sensation
Clinical features - lower urinary tract dysfunction
Frequency Nocturia Urgency Urge incontinence Retention
Clinical features - if there are lesions in the cerebellum
Ataxia Intention tremor Nystagmus Pendular reflexes Dysdiadokinesis (coordination problems) Dysarthria
Clinical features - internuclear ophthalmoplegia
Fast movement of eyeballs is impaired
diplopia when trying to adduct
Diagnostic testing is required. True or false ?
False
- clinical diagnosis
Investigations
MRI scan
Lumbar puncture
Investigations - MRI scan
Presence of demyelinating plaques
Dawsons fingers
Investigations - lumbar puncture
Presence of IgG oligoclonal bands in CSF
IgG oligoclonal bands found in CSF are distinct to MS. True or false?
False
- can be found in other conditions
Which criteria need to be met for a diagnosis of MS to be made?
McDonald criteria
Mcdonald criteria
At least 2 episodes suggestive of demyelination occurring at different times and places
A neurological deficit implicating one neuro-anatomical site, and a MRI appreciated defect at another neuro-anatomical site
Multiple distinct CNS lesions on MRI
Management - acute moderate exacerbation
Oral steroids
Management - acute severe exacerbation
Hospital admission
IV steroids
Management - pyramidal dysfunction
Physiotherapy
Occupational therapy
Anti-spasmodic treatment
Management - spasticity
Physiotherapy
Oral: Baclofen / tizanidine
Botox
Intratheal : Baclofen / phenol
Management - sensory symptoms
Anti-convulsant
Anti-depressant (amitryptiline)
Tens machine
Acupuncture
Management - fatigue
Amantadine
Modafnil
Disease modifying therapy = First line therapy
Interferon beta
- avonex
- rebif
Glitiramer Acetate (copaxone)
Tecfedira
Disease modifying therapy has an increased risk of malignancy. True or false?
True
Disease modifying therapy - second line therapy
Monoclonal antibody
When do you accelerate from first line to second line therapy?
If first line therapy isn’t making any change to the MRI scan appearance
Which MAb therapy must be given on the ward as it causes cardiac problems?
Fingolimond
Which MAb is for patients with highly active relapsing remitting MS ?
Lemtrada
Tysabri
Disease modifying therapy - third line therapy
Stem cell transplantation
Which of the following are treatment options for the sensory symptoms in ms? (More than one correct answer) TENS machine Oxybutinin Gabapentin Baclofen Amitryptiline
TENS machine
Gabapentin
Amitryptiline
Which steroid is used in the treatment of mod-severe Acute attacks of MS?
A prednisolone
B dexamethasone
A
What investigation has a vital role in assessing response to disease modifying therapy in ms?
MRI
