Neurology - Multiple Sclerosis

Question 1

What is multiple sclerosis (MS)?

Answer 1

A chronic and progressive autoimmune condition involving demyelination in the central nervous system

Immune system attacks the myelin sheath of myelinated neurones

Question 2

What age group is most commonly affected by multiple sclerosis?

Answer 2

Young adults (under 50 years)

More common in women

Question 3

What cells produce myelin?

Answer 3

Oligodendrocytes in the central nervous system

Schwann cells in the peripheral nervous system

Question 4

When can re-myelination occur?

Answer 4

Early disease

Symptoms can resolve

Question 5

What is a characteristic feature of MS lesions?

Answer 5

Lesions vary in location, described as ‘disseminated in time and space’

Question 6

What are potential causes of multiple sclerosis?

Answer 6

Influenced by:
* Multiple genes
* Epstein–Barr virus (EBV)
* Low vitamin D
* Smoking
* Obesity

Question 7

What is the onset like in MS?

Answer 7

Sumptoms usualyl progress over more than 24 hours

Symptoms last days to week at first then improve

Question 8

How does optic neuritis present in MS?

Answer 8

Unilateral reduced vision, developing over hours to days

Caused by demyelination of the optic nerve, develops over hours to days

Question 9

What are key features of optic neuritis?

Answer 9

Key features include:
* Central scotoma
* Pain with eye movement
* Impaired colour vision
* Relative afferent pupillary defect

Question 10

What is a relative afferent pupillary defect?

Answer 10

Affected eye constricts more when shining light in other eye

Reduced response on direct reflex

Question 11

What are other causes of optic neuritis?

Answer 11

Other causes include:
* Sarcoidosis
* Systemic lupus erythematosus
* Syphilis
* Measles or mumps
* Neuromyelitis optica
* Lyme disease

Question 12

What is the treatment for optic neuritis?

Answer 12

High-dose steroids

Question 13

What is an MRI used for in optic neuritis?

Answer 13

Predicts which patients will develop MS

Question 14

What eye movement abnormalities can occur due to lesions in cranial nerves III, IV, or VI?

Answer 14

Can cause double vision (diplopia) and nystagmus

Question 15

What is Oscillopsia?

Answer 15

Visual sensation of the environment moving

Unable to create a stable image

Question 16

What is internuclear ophthalmoplegia?

Answer 16

Caused by a lesion in the medial longitudinal fasciculus, nerve fibres connect cranial nerve nuclei that control eye movements- ensures nerves cooardinate eye movements

Impairing adduction on the same side as the lesion and nystagmus in the contralateral abducting eye

Question 17

What does a CNVI lesion cause?

Answer 17

CNVI (abducens) controls the lateral rectus muscle

Affect eye cannot abduct

Causes diplopia when abducting with non-affected eye

Question 18

What focal neurological symptoms can MS present with?

Answer 18

Focal weakness
- Incontinence
- Horner syndrome
- Facial nerve palsy
- Limb paralysis

Focal sensory
- Trigeminal neuralgia
- Numbness
- Paraesthesia
- Lhermitte’s sign

Question 19

What is Lhermitte’s sign?

Answer 19

An electric shock sensation that travels down the spine and into the limbs when flexing the neck

Indicates disease in cervical spinal cord in dorsal column

Caused by stretched demyelinated dorsal column

Question 20

What is transverse myelitis?

Answer 20

A site of inflammation in the spinal cord causing sensory and motor symptoms depending on the lesion’s location

Question 21

What is ataxia?

Answer 21

A problem with coordinated movement, which can be sensory or cerebellar

Question 22

What causes sensory ataxia?

Answer 22

Loss of proprioception due to lesion in dorsal columns

Positive Romberg’s test

Question 23

What causes cerebellar ataxia?

Answer 23

Cerebellar lesion

Question 24

What are the classifications of multiple sclerosis disease patterns?

Answer 24

Classifications include:
* Clinically isolated syndrome
* Relapsing-remitting MS
* Secondary progressive MS
* Primary progressive MS

Question 25

What is clinically isolated syndrome?

Answer 25

The first episode of demyelination and neurological signs and symptoms

May never have another episode or develop MS

Lesions on MRI suggest more likely to progress to MS

Question 26

What characterises relapsing-remitting MS?

Answer 26

Most common when diagnosed

Episodes of disease and neurological symptoms followed by recovery

Symptoms occur in different areas with each episode

Active- New symptoms developing, new lesions appearing on MRI
Not active- No new symptoms or MRI lesions are developing
Worsening- Overall worsening of disability over time
Not worsening- No worsening of disability over time

Question 27

What is Secondary progressive MS?

Answer 27

There was relapsing-remitting disease

Now progressive worsening of symptoms with incomplete remissions

Symptoms increasingly permanent

Can further be classified if disease is active or progressing

Question 28

What is Primary progressive MS?

Answer 28

Worsening disease and neurological symptoms from diagnosis without relapses and remissions

Further classified based on if it is active or progressing

Question 29

How is MS diagnosed?

Answer 29

Diagnosis made by neurologist based on picutre and symptoms

Other causes for symptoms need to be excluded

Question 30

What investigations are used to support MS diagnosis?

Answer 30

MRI
- Demonstrate lesions

LP
- Oligoclonal bands in CSF

Question 31

How are relapses in MS treated?

Answer 31

Steroids
- 500mg PO daily for 5 days

or
- 1g IV daily for 3–5 days

Question 32

Who is involved in a MS MDT?

Answer 32

Neurologists
Specialist nurses
Physiotherapists
Occupational therapists

Question 33

What are some symptomatic treatments for MS?

Answer 33

• Exercise- Maintain acvitiy and strength
• Amantadine, modafinil, SSRIs -fatigue
• Amitriptyline or gabapentin- neuropathic pain
• Antidepressants- depression
• Antimuscarinic medications- urge incontinence
• Baclofen or gabapentin- spasticity
• Gabapentin or memantine- oscillopsia