Neuro - Multiple sclerosis

Question 1

Diagnosis of MS - what investigations would you do?

Answer 1

1. Bloods to exclude mimics such as sarcoidosis, vasculitis or CT disease, TFTs (hypothyroid) and B12 deficiency.
2. MRI Head + whole spine
3. Consider LP - CSF IgG oligoclonal bands
4. Visual/auditory/somatosensory evoked potentials (will be delayed)

Use the MacDonald criteria for diagnosis based on clinical presentation and MRI/CSF results with dissemination in time (>30d) and space.

Question 2

What are the different types of MS

Answer 2

Majority are RR-MS, with initial recovery. Recovery then becomes incomplete = disability accumulates => secondary progression.
10% progressive MS with steady decline.
Small minority have no progressive disablement.

Question 3

What are some poor prognostic signs in MS?

Answer 3

older age at onset,
male,
motor features at presentation,
many early relapses
multiple plaques on MRI
axonal loss (in addition to demyelination)

Question 4

What is the management of MS?

Answer 4

MDT approach!
Hollistic: stop smoking, regular exercise, avoid stress

1st line (offered to all RR-MS):
interferon beta, glatiramer, fingolimod.
If more aggressive MS: offer monoclonals:
- ocrelizumab
- natalizumab

Baclofen for spasticity
Amantadine/ SSRI/CBT for fatigue
ISC if residual urine >100ml.

Question 5

How do you treat an MS relapse acutely?

Answer 5

1. Rule out infection
2. Methylprednisolone IV/PO for 3 - 5 days