Finals Neurology > Multiple Sclerosis (MS) > Flashcards

Multiple Sclerosis (MS) Flashcards

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1
Q

Define Multiple Sclerosis (MS) & it’s potential causes

A

Inflammatory condition of CNS

Discrete plaques of demyelination occurs at multiple sites due to T-Cell mediated immune responce

Cause: Unknown

  • Further from equator = Inc incidence & prevalence!
    • Childhood exposure to sunlight/ vit D reduces risk/ severity of MS
    • Children <15 aquire the risk of where they settle [migration studies]
  • Genetic component?
    • HLA Chromodome 6
    • 30%: MZ twins, 15% DZ twins
  • Viral: EBV? (low evidence)
  • Trauma triggering MS?
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2
Q

Outline the prevelence, sex distribution & age of onset of MS

A
  • Further from equator = inc prevalence & incidence
    • England 42/100k
    • Scotland 200/100k
    • Lifetime UK risk 1/1k
  • Women 3:1 Men
  • 30yrs = avg age of onset
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3
Q

Outline the common presentations of MS

Inc Symptoms & Signs

A
  1. Unilateral Optic Neuritis
    • Pain on movement
    • Rapid dec central vision
    • Red desaturation
    • Signs: Marcus Gunn pupil
  2. Brainstem/ Cerebellum
    • Cerebellar signs
      • Trunk/ limb ataxia
      • Intention tremor
      • Scanning speech
      • Falls
    • Brainstem signs
      • Long-tract (myelopathy) signs
      • Cranial nerve lesions [taste, smell, balance, hearing]
  3. Spinal Cord [often worse 1 side]
    • Numbness & paraesthesia
    • Weakness
    • Transverse myeltis [motor + sensory loss of both legs + bowels + bladder]
    • Autonomic
      • Neurogenic bladder
      • Bowel problems
      • Sexual problems
  4. Rarer
    • Hemiparesis (sub-cortical)
    • Seizures
    • Psychiatric symptoms (depression)
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4
Q

What is a Marcuss Gunn pupil?

A

**Marcus Gunn Pupil **aka Relative Afferant Pupil Defects

  • Both pupils respond individually to light/ dark
  • Swinging Light Test
    • Light on 1 side [constrict to small size] then move light to other side [when light hits it should constrict again]
    • RAPD: …then move light to other side [pupil continues to dilate dispite light hitting it]

https://www.youtube.com/watch?v=HSYo7LhfV3A

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5
Q

Outline the diagnosis criteria for MS

A

McDonald critera for diagnosing MS (2010)

Simplistically, you need 2 disseminations of time and 2 disseminations in space

  • Time
    • Attacks at different times
    • MRI evidence
  • Space
    • Attack at new site
    • MRI evidence
    • +CSF & MRI: 2+ lesions consistent of MS

Clinical presentations & steps needed for diagnosis

  • 2:2 - 2+ attacks & 2+ objective clinical lesions
    • Nothing more required [imaging desirable: must conform to MS]
  • 2:1 - 2+ attacks & 1 lesion
    • MRI: dissemination in space
    • +CSF & 2+ MRI: typical MS lesions
    • 2nd attack at new site
  • 1:2 - 1 attack & 2+ lesions
    • MRI: dissemination in time
  • 1:1 - 1 attack & 1 lesion [monosymptomatic presentation]
    1. Dissemination in space: MRI OR +CSF & 2+ MRI: typical MS lesions
    2. AND Dissemination in time: MRI or 2nd attack
  • Insidious neurological progression (primary progressive MS)
    • +CSF
    • Dissemination in space: MRI
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6
Q

What MRI findings may be present in MS?

A

MRI abnormalities;

  • Periventricular lesions [95%}
  • Discrete white matter abnormalities [90%]
  • Focal demyelination: Plaques
    • Active or inactive: contrast agents
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7
Q

What findings in CSF may be present in MS?

A

Rise in total protein, normal glucose

<50 WCC/mL

Increase Oligoclonal bands of IgG on electrophoresis [not present in serum]

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8
Q

What are Evoked Potentials (EP) and what findings are present in MS?

A

Electrical potential recorded via nervous sytem following presentation of a stimulus

  • Delayed Evoked Potentials
    • **Visual **[VEP common test]
    • Auditory
    • Somatosensory
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9
Q

What are prognostic factors for MS?

A

Worse if;

  • Older male
  • Motor signs at onset
  • Many relapses early on
  • Many MRI lesions [plaques[
  • Axonal loss
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10
Q

Outline the different progressions of MS

A
  • Relapsing & Remitting
    • Attacks come & go
    • Accumulation of disability
  • 2ndary Progressive
    • Often from R&R [19yrs]
    • Over 6months massive accumulation of disability
  • Primary Progressive [10%]
    • ​Over 6 months massive accumulation of disability
    • Middle aged men
    • Untreatableish
  • **Relapsing Progressive **[5-10%]
    • ​Attacks as freqent as R&R
    • Accumulation of disability as Primary Progressive
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11
Q

Outline the management of MS

(not symptomatic/ palliation)

A

Acute Relapses

  1. Methylprednisolone
    • ½-1g /24hr IV/PO for <3d
    • No more than 2x/year
    • Risks;
      • Glucose levels
      • Psyhosis
      • GI bleed [give PPI]
      • Avascular necrosis of femoral head

Disease Modifying Therapy [↓relapses]

  1. Interferons [-1B & 1a] [mainly R&R]
    • ↓Relapses by 1/3 in R&R
    • ↓Lesion accumulation on MRI
    • Does not delay disability/ affect prognosis
  2. Monocloncal ABs [mainly R&R]
    • Alemtuzumab: acts against T-cells in R&R
    • Natalizumab: acts again VLA-4 receptors that allow immune cells to cross BB barrier
      • ↓Relapses by 2/3 in R&R
  3. Glatiramer (Copaxone) [mainly R&R]
    • Mimics Myelin
    • ↓Relapses by 1/3 in R&R
    • Daily SC injection
  4. Mitoxantrone [mainly 2ndary progressive]
    • Doxorubicin analogue
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12
Q

Outline the symptomatic/ palliative treatments available in MS

A
  • Spasticity
    • Sometimes mobility is dependent on spasticity..
    • Baclofen (GABA agonist)
    • Diazepam (benzo)
    • Dantrolene (muscle relaxant)
    • Tizanidine (muscle relaxant)
  • Tremor
    • Botulinum toxin type A injectives
  • Urinary/ frequency
    • Post-micturition residual urine >100mL
      • Intermittent self-catheterization
    • … <100mL
      • Tolterodine Tolteerodine (antimuscarinic)
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13
Q

What is Transverse Myelitis?

A

Loss of motor, sensory, autonomic, reflex and sphincter function below level of lesion

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14
Q

What is Devic’s syndrome?

Outline;

  • Defintion
  • Diagnosis
  • Treatment
A

Devic’s syndrome aka **Neuromyelitis Optica (NMO) **aka Opticospinal MS

  • Recurrent & simultaneous Optic Neuritis & Transverse myelitis + NMO-IgG
    • ​Long spinal cord lesion through 3+ vertebral segments in length
    • Brain MRI lesion atypical for MS
  • Diagnosis
    • NMO-IgG
  • Treatment
    • IV steroids
    • Plasma exchange therapy
    • Immunosppressive for relapses
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15
Q

What is Lhermitte’s sign?

When is it found?

A

Lhermitte’s sign; neck flexion causes ‘electric shocks’ in trunks/ limbs

Found in;

  • MS
  • Cervical spondylosis
  • Cord tumours
  • Subacute combined degeneration of the cord (↓B12)
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16
Q

What comprises the MS-related central pain disorders?

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A
  • Lhermitte’s sign
  • Dysaesthetic pain
  • Trigeminal neuralgia
  • Painful tonic MS spasms
17
Q

What is Charles-Bonnet syndrome?

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A

Those with Optic Neuritis causing;

  • ↓acuity/ blindness & complex visual hallucinations of faces

[Mentally healthy patients]

18
Q

What is Uhthoff’s phenomenon?

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A

Wosening of neurological symptoms (eg in MS) when body gets overheated from hot weather/ exercise/ fever/ saunas/ hot tubs etc

Eg. ↓vision on exercise

Temp effect on nerve conduction?

19
Q

What is Pulfrich effect?

Study These Flashcards
A

Unequal eye latencies

  • Causin disorientation in traffic as straigt trajectories seem curved & distances are misjudges on looking sideways
20
Q

What is an Argyle Robertson-type pupil?

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A
  • Normal accomodation on near objects
  • DO NOT constrict on bright light
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