CPT1: Multiple Sclerosis

Question 1

What is MS?

Answer 1

A slow progressive immunological disease of the CNS.

It is characterised by inflammation and plaques of demyleination and axonal loss in the white matter of the brain and spinal cord

Question 2

What is myelin and what is its function?

Answer 2

Several layers of cytoplasmic membrane wrapped around axons.

Purpose is to insulate and conduction (saltatory

Question 3

What are the glial cells which produce myelin in the CNS and PNS called?

Answer 3

CNS - oligodendrocytes

PNS - Schwan cells

Question 4

What does demyleination cause?

Answer 4

Distruption of neuronal function which leads to wither loss of cuntion or hyperfunction

Question 5

What are sclerosis and why are they caused?

Where do they occur?

Answer 5

Plaques of scarring caused by demyleination associated with inflammation, axonal loss and odema

They can be multiple plaques in different locations of the CNS at different times

Question 6

Where are common plaque locations?

Answer 6

• optical tract, soinal cord, brain stem, basal ganglia

Question 7

What are symptoms of MS?

Answer 7

• Fatigue
• Anxiety, Depression
• numbness
• altered sensation - burning/ twitching

Question 8

What are risk factors of the disease?

Answer 8

• Obestity - alters the inflammatory response
• Age - occurs late teens/ early adulthood
• Gender - Females more likely though not assoicated with x chromsome
• Genetics - HLA on chromosome 6
• Virus/ bacteria (epstein- barr virus)
• smoking
• lattitude
• vit D/ sunlight
• timing of exposure

Question 9

describe the pathology/ development of MS

Answer 9

1. At some stage you are exposed to a virus with the similar identiy/ antigens to mylein. There is activation of a peripheral immune response to get rid of the virus. There is T cell activation and poliferation.
2. Activated immune cells adhere with the brain endothelial cells and penetrate the BBB
3. There is reactivation of the immune response in the CNS. Pro inflamatory, B cells and macrophages intiate an inflamatory response and cause demyleination, axonal loss and neuronal degradation

Question 10

what types of MS is there?

Answer 10

• Relapsing Remitting (MS) - perods of disability (relapse) and periods of recovery (remission)
• Secondary Progressive (MS) - Normalm RR initally then continous relapse with no periods of recovery
• Primary progressive (MS) - Continous increase in disability with no attacks

Question 11

What causes the relapse periods?

Answer 11

• The effects of cytokines and signalling cascase on neuronal function. Mylein sheath and oligodendrocytes destroyed which blocks/ slows nerve transmission

the positions the placques occur detemrines symptoms

Question 12

What causes remission period?

Answer 12

• Limited ability of CNS to repair/ replace damage byt more a reflection of the CNS redirecting signals through alternative routes

Question 13

What is:

1. Replapse
2. Exacerbation
3. fluccuations
4. Disease progression

Answer 13

1. New signs/ symptoms that orginate from new focial demyeilnation lesions in the CNS
2. Worsening of existing symptoms
3. New temporay changes in symptoms
4. An accumulation of disability which can be continuously progressie or step wise

Question 14

What does digagnosis of MS involve?

Answer 14

• No specific tests
• Neuroologist
• 2 or more relapses in previous 2 yeras
• 2 or more clinically defined lesions

Question 15

What diagnosis tests is therE?

Answer 15

• MRI - to locate/ identify lesions
• Evoked potential - to stimulate neuronal pws to trst transmission strength and velolcity
• lumbar punctues - to measure oligo-clonal blands of IgG in cerebral spinal fluid - an inflam marker
• Differental diagnosis

Question 16

What does treatment od acute relapses involve?

Answer 16

• Use corticosteriods to shorten duration of relapse periods. Glucocortiocosteriods involved in natural feedback
• IV/Oral methylprednisolone
• Don’t give advanced supplies

Question 17

What are the side effects of corticosteriods?

Answer 17

AIRPD

• ANxiety
• insomnia
• restlessness
• psychosis
• depression

Question 18

What do DMT do?

Answer 18

• Drugs that affect or modify the course of MS
• Supress the immune response
• Not a cure but reduce number and severity of attacks
• Reduce relapse and prolong remission

Question 19

What is NICE guidance on older drug treatments?

Answer 19

Interferon Gamma and glatiramer acetate can no longer be recomended but if already on it should be used until alternative found

Question 20

What are limitations of DMTs?

Answer 20

• Not established long term time course of MS significantly altered
• Anti body treatment problamatic in longer term - body produces ABs to drig so decreases efficancy over time.
• Fingolimod - hypertension, brady cardia AV block
• Serious side effects - fever, pain, depression and sucicidal thougths

Question 21

What are managements of MS symptoms?

Answer 21

1. Muscle relaxatants for spacity in MS

• !st line - baclofen of gabapentin (long acting)
• 2nd line - tizanidine/ dantrolene
• 3rd line - BZs

spacity in MS is caused by changes in CNS not demylination of peripoheral motor nerve