What is multiple sclerosis?
Autoimmune condition which attacks the myelin sheaths (oligodendrocytes) of neurons resulting in demylinations.
This causes episodes of inflammation which cause temporary focal neurologcial deficits.
What are the subtypes of multiple sclerosis?
- Relapsing and remitting (most common) - acute attacks followed by periods of remission.
- Secondary progressive disease (starts as relapsing and remitting but then patients experianc neuro symptoms between attacks)
- Primary progressive (no attacks, instead has progressive deterioration form the onset)
What is the diagnostic criteria for MS?
two or more episodes of demyelination disseminated in space and time.
Whtat are some symptoms of MS?
- Optic neuritis
- Transverse myelitis
- Optic atrophy,
- Uhthoff’s phenomenon (worsening of vision with rise in body temp)
- Intranuclar opthalmoplegia (only really seen in MS)
- Sensory disturbence
- Spastic weakness,
- Ataxia
- Urinary incontinence, sexual dysfunction
- Intellectual deterioration
- Lhermitte’s syndrome - paraesthesia in limbs on neck flexion.
What is clinically isolated syndrome in the context of MS?
It is the first episode of neurological symptoms which last for 24 hours
What are some symptoms which may develop into MS?
Optic neuritis,
Transverse myelitis,
Clinically isolated syndromes,
Radiologically isolated syndromes
What is optic neuritis?
Inflammation and demylination of otpic nerve. It causes painful vision loss
What is transverse myelitis?
Inflammation of the spinal cord which may cause weakness, sensory loss, sexual dysfunction or incontinence
What are radiologically isolated symptoms in the context of MS
When brain scan shows evidence of MS but patient has no symptoms. It is an incidental finding
What are the causes of multiple sclerosis?
EBV,
Low vitamin D,
Smoking,
Obesity
What are contraindications for a MS diagnosis?
Sudden onset,
Peripheral signs such as Areflexia, muscle waiting, fasciculations.
Major cognitive impairment,
Reduced consciousness,
Prominent seizures,
Pyrexia,
Normal MRI scan,
What are the investigations for suspected MS?
- MRI brain and spine with gadolinium contrast. May show Dawson fingers on FLAIR images.
- Lumbar puncture to look for oligobands.
- Visual evoked potentials (can show slow conduction in the optic nerve)
What are oligoclonal bands?
Immunoglobulin band seen on electrophoresis of blood and spinal fluid.
if present in spinal fluid but not blood then it suggests immunoglobulin production/inflammation in CNS
What is the definition or relapse vs psuedo-relapse
Relapse - New neurological deficit which lasts more than 24h without pyrexia/infection.
Pseudo-relapse - re-emergence of previous neurological symptoms related to an area of old demyelination in the context of heat/infection
What is the management of an acute relapse of MS?
500mg of oral methylprednisolone for 5 days with PPI for gastric protection
What are the indications for introducing disease modifying drugs in MS?
- Relapsing and remitting disease with 2 relapses in past 2 years and able to walk 100m unaided
- Secondary with two relapses in past two years and able to walk ten meters unaided
What are some examples of immunomodulators used in MS?
- First line injectables = beta-interferon.
- Oral agents = dimethyl fumarate, fingolimod.
- Biologics = Natalizumab, Alemtuzumab
What drug is used in primary progressing multiple sclerosis?
Ocrelizumab
What drug is used in secondary progressive MS?
Siponimod.
What drug can be used in pregnant women with MS?
Copaxone
What can be used to treat fatigue in MS?
Amantadine
What can be used to treat spasticity in MS?
Baclofen and gabapentin. Physio is also important
What is the management of bladder dysfunction in MS?
Patient’s may present with urgency, incontinence, overflow.
Do bladder scan.
If residual volume then self catheterise. If not significant residual volume then anticholinergics may improve urinary frequency.
What is oscillopsia?
A visual problem where objects seem to move/jiggle. Manage with gabapentin or memantine
