Systems: Neurology AB > Multiple Sclerosis > Flashcards

Multiple Sclerosis Flashcards

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1
Q

Who is usually affected by MS?

A
  • It is a disease of young people

- F:M 2-3:1

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2
Q

What is MS?

A

It is a white matter disease of the centre nervous system with focal disturbance of function

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3
Q

What do most MS patients develop?

A

Progressive disability

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4
Q

What type of course does MS have?

A

Relapsing remitting course

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5
Q

What is demyelination?

A

An auto immune process where there is acute inflammation of myelin sheath which leads to loss of function

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6
Q

What is the cause of demyelination?

A

Activated T cells cross blood brain barrier causing demyelination

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7
Q

What signs of demyelination may be seen on MRI?

A

Lesions or plaques

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8
Q

What may post inflammatory gliosis produce?

A

May have functional deficits

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9
Q

What process may be important in disease progression?

A

Axonal loss may be important in disease progression and development of persistent disability

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10
Q

What suggest cerebral atrophy on MRI?

A

Black holes on MRI

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11
Q

What is the prevalence of MS?

A

Prevalence ~190 per 100 000 in Scotland

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12
Q

What is MS associated with?

A

It has complex genetic inheritance and is associated with autoimmune disease

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13
Q

Where is MS commoner?

A

Temperate climate

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14
Q

What do 80% of MS cases present with?

A

A relapse

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15
Q

What is the usual timeline of initial presentation of MS?

A
  • Gradual onset over days
  • Stabilises days to weeks
  • Gradual resolution to complete or partial recovery-
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16
Q

How may MS relapse present?

A
  • Optic neuritis -Sensory symptoms
  • Limb weakness
  • Brainstem Diplopia/Vertigo/Ataxia
  • Spinal cord-bilateral symptoms and signs +/- bladder
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17
Q

Describe optic/retrobulbar neuritis which can occur in MS.

A
  • Subacute visual loss
  • Pain on moving eye
  • Colour vision disturbed
  • Usually resolves over weeks
  • Initial swelling optic disc
  • Optic atrophy seen later
  • Relative afferent pupillary defect
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18
Q

What is the differential diagnosis for optic neuritis?

A
  • Neuromyelitis optica
  • Sarcoidosis
  • (Ischaemic optic neuropathy)
  • Toxic/ drugs/ B12 deficiency
  • Wegeners granulomatosis
  • (Local compression)
  • Lebers hereditary optic neuropathy
  • Infection-borrelia
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19
Q

What signs/symptoms can occur with a brainstem relapse?

A
  • Cranial nerve involvement
  • Pons- internuclear ophthalmoplegia
  • Cerebellum -vertigo, nystagmus, ataxia
  • Upper motor neurone changes limbs
  • Sensory involvement
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20
Q

How does myelitis present?

A
  • Partial or Transverse (complete)
  • Sensory level often with band of hyperaesthesia
  • Weakness/ upper motor neurone changes below level
  • Bladder and bowel involvement
  • May be painful
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21
Q

What is the differential for myelitis?

A
  • Inflammation: Devics, SLE, sarcoidosis
  • Infection/Post infection: HIV, HTLV, HSV, TB, Borrelia, Mycoplasma
  • Tumour
  • Paraneoplastic process
  • Stroke
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22
Q

What must occur for a diagnosis of MS?

A

Separate episodes of demyelination disseminated in space and time

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23
Q

When may further relapses occur?

A

May occur within months or years of first relapse

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24
Q

How can further relapses present?

A

Vary in site and severity

  • Optic nerve
  • Sensory
  • Limb weakness
  • Diplopia
  • Vertigo
  • Ataxia
  • Sphincter disturbance
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25
What can occur in the progressive phase of MS?
Accumulation of symptoms and signs - Fatigue, temperature sensitivity - Sensory - Stiffness or spasms - Balance, slurred speech - Swallowing - Bladder & bowel - Diplopia/ oscillopsia/ visual loss - Cognitive-dementia/ emotional lability
26
What may be found on examination of MS?
Depends on where demyelination has occurred and stage of disease: - Afferent pupillary defect - Nystagmus or abnormal eye movements - Cerebellar signs - Sensory signs - Weakness - Spasticity - Hyperreflexia - Plantars extensor
27
How can MS be diagnosed?
May be clinical or MRI based diagnosis - Posers criteria (requires 2 clinical episodes) - Macdonald Criteria (MRI)
28
What is a lesion/plaque?
Area of demyelination on MRI scan
29
How do lesions correspond to relapses?
For 10 lesions (approximately) patient experiences 1 relapse
30
How should MRIs be interpreted?
- White areas do not necessarily mean MS | - Active lesions will appear white whereas old lesions cannot be seen without contrast
31
How should MS be investigated?
Depends on clinical picture…… - Lumbar puncture-oligoclonal bands present in CSF but not serum - Visual/ somatosensory evoked response - Bloods-exclude other inflammatory conditions - Chest X Ray
32
What does the differential diagnosis for MS depend on?
Depends on symptoms and signs and on whether a first relapse or progressive disease
33
What types of MS are there?
- Relapsing remitting-85% at outset (RRMS) - Secondary progressive (SPMS) - Primary progressive – 10-15% (PPMS) - Sensory – 5% - Malignant
34
Describe relapsing remitting MS.
- Episodes vary in severity | - Vary in duration
35
Describe secondary progressive MS.
- Relapses with recovery | - Followed by progressive relapse with no recovery
36
Describe sensory MS
-Relapsing with low severity
37
How can MS progress?
- 1/4 MS never affects activities of daily living (ADL) - 15% severely disabled quickly - 1 in 4 will require a wheel chair at some point
38
What are good prognostic indicators for MS?
- Female - Present with optic neuritis - Long interval between 1st and 2nd relapse - Few relapses in 1st 5 years
39
What are bad prognostic indicators for MS?
- Male - Older age - Multifocal symptoms and signs - Motor symptoms and signs
40
Describe primary progressive MS.
First episode does not resolve but progresses a continuous episode
41
When does primary progressive MS usually present?
Often presents in 5th and 6th decade
42
What types of symptoms are present in primary progressive MS?
- Spinal symptoms | - Bladder symptoms
43
Who is affected by primary progressive MS?
M:F 1:1
44
What is the prognosis of primary progressive MS?
Poor
45
What is another name for neuromyelitis optica spectrum disorder?
Devic's disease
46
How does NOSD (Devic's disease) present?
- Optic neuritis - Myelitis - Aquaporin-4 antibodies - Antibody negative in some cases
47
How is MS treated?
- General health and diet - Treatment of relapse - Symptomatic treatment - Multi-disciplinary approach - Disease modifying treatment
48
What should you look for with an acute relapse?
- Look for underlying infection | - Exclude worsening of usual symptoms with intercurrent illness
49
How should acute relapses be treated?
- Oral prednisolone (Intravenous) - Rehabilitation - Symptomatic treatment
50
What accounts for 25-30% of further relapses?
Underling viral infection therefore vaccination is usually advised
51
When may a women have fewer relapses?
Pregnancy
52
When may a women have an increased risk of relapse?
First 3 months post partum
53
What disease modifying treatments are 1st line?
s/c or i/m injections - Beta-interferons - Glatiramer acetate Oral treatments - Teriflunomide - Dimethyl Fumarate
54
What are the side effects of 1st line disease modifying treatments?
Flu-like symptoms Injection site reaction Abnormalities of blood count and liver function
55
How effective are 1st line disease modifying treatments?
- Reduce relapse rate ~1/3 - No effect on progression of disability - Not a cure
56
What are the 2nd line agents?
- Natalizumab monthly infusion - Fingolimod tablets - Alemtuzumub annual infusion
57
How effective is natalizumab?
Reduce relapse rate ~2/3
58
What is there a risk of with fingolimod?
Risk of developing Cardiac: bradyarrythmias
59
What is there risk of with alemtuzumub?
Risk of developing Autoimmune thyroid disease/ Goodpastures/ immune thrombocytopenic purpura
60
What causes multifocal leukencephalopathy?
JC virus
61
How is PML screened for?
- MRI annual | - Check for JC antibody blood and urine 6 monthly
62
Who is usually affected by PML?
Immunosuppression (AIDS) - Natalizumab - Dimethyl fumarate - Fingolimod
63
What symptomatic treatment is there?
- Spasiticity-muscle relaxants/ antispasmodics/ physiotherapy - Dysaesthesia-amitriptyline, gabapentin etc. - Urinary-anticholinergic Rx, bladder stimulator/ catheterisation - Constipation-laxatives - Sexual dysfunction-sildenafil - Fatigue-graded exercise, medication - Depression-CBT, medication - Cognitive-memory aids etc - Tremor-aids/ pharmaceutical - Vision/ oscillopsia-carbamazepine - Speech/ swallowing-SALT - Motor/ sensory impairment- multi-disciplinary team
64
Who is involved in the MDT?
- MS nurse - Physiotherapy - Occupational therapy - Speech and language therapy - Dietician - Rehabilitation specialists - Continence advisor - Psychology/psychiatry
65
What can the differential diagnosis of MS include?
- Acute Disseminated -Encephalomyelitis (ADEM) - Other Auto-immune conditions eg SLE - Sarcoidosis - Vasculitis - Infection eg Lyme disease, HTLV-1 - Adrenoleucodystrophy etc etc
Systems: Neurology AB
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