Multipel Sclerosis Flashcards by Sumaya L

What is multiple sclerosis characterized by?

Demyelination of the CNS

Caused by various aetiologies including environmental factors, genetics, and molecular mimicry.

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Name two environmental factors associated with multiple sclerosis.

Epstein-Barr virus
Human herpes virus-6

These factors are linked to the onset of multiple sclerosis.

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What is the genetic susceptibility linked to in multiple sclerosis?

HLA DR-2 drives the destruction of the myelin sheath and scar tissue on the axon called sclera of the oligdendrocytes via IL-1, IL-6 and TNF-alpha, causing vasodilation and increases capillary permeability.

Plasma cells infiltrate the brain tissue and produce IgG antibodies and T cells and macrophages; excessive cell infiltration is known as pelocytosis.

This genetic marker is associated with an increased risk of developing multiple sclerosis.

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What drives the destruction of the myelin sheath in multiple sclerosis?

Molecular mimicry

This process involves immune responses that mistakenly target the myelin sheath.

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What is the epidemiology of multiple sclerosis?

It is more common in women and those aged 20-40 years old.

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What are the types of multiple sclerosis?

Relapsing remitting multiple sclerosis
Secondary progressive multiple sclerosis
Primary progressive multiple sclerosis
Progressive relapsing multiple sclerosis

Each type has distinct patterns of flare-ups and progression.

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What is relapsing emitting multiple sclerosis?

Relapsing emitting multiple sclerosis will have cycles of flare up and remission which reduces neurological function with each flare. This can develop into secondary progressive MS

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What is secondary progressive multiple sclerosis?

Secondary progressive multiple sclerosis is continuous decrease in neurological function which typically follows an intial relapsing-remitting phase. There will be gait and ladder disorders

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What is primary progressive multiple sclerosis?

Primary progressive multiple sclerosis will have consistent loss of neurological function and is more common in older people.

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What is progressive relapsing multiple sclerosis?

Primary progressive multiple sclerosis will have consistent loss of neurological function and is more common in older people.

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What do T2 weighted images show in multiple sclerosis?

hyperkineses bright lesions with periventiruclar plaques.

These images help in identifying areas of demyelination.

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What is a feature of lumbar puncture in MS?

high levels of IgG antibodies, oligoclonal banding and pleocytosis

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What are oligocloncal bands?

Oligoclonal bands are a pattern of several, distinct protein bands (specifically, immunoglobulins) found on an electrophoresis test of cerebrospinal fluid (CSF) that indicate the presence of an immune response occurring within the central nervous system. CSF will also show increased intrathecal synthesis of IgG.

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What is Charcot’s triad in multiple sclerosis?

Nystagmus
Dysarthria
Intention tremors

These symptoms are commonly observed in patients with multiple sclerosis.

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Which cranial nerve is primarily affected in multiple sclerosis?

Optic nerve

It is the first structure to be affected, leading to optic neuritis and visual disturbances.

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What is a key feature on examination for patients with multiple sclerosis?

On neurological examination, patient will have relative afferent pupillary defect where shining light causes pupil dilation rather than constriction.

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Which eye movement disorder may be seen in MS?

Bilateral inter nuclear opthalplegia due to damage to the medial longitudinal fasiculus connections between CNVI and CNIII.

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How does bilateral inter nuclear opthalplegia present?

CNVI function is preserved but connection is affected to CNII.

It is characterised by limited inward movement (adduction), nystagmus (involuntary eye twitching) in the excessively abducting eye which is unopposed from the CNIII dysfunction, and often a “wall-eyed” appearance where the eyes point outward in the primary (straight-ahead) gaze position.

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Which other Facial feature may be present in MS?

Corticobulbar tract may be affected and cause pseudobulbar palsy; The corticobulbar tract innervates the lower motor neurons of cranial nerves V, VII, IX, X, XI, and XII, which control the muscles of the face, head, and neck

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How does pseudobulbar palsy present?

Results in reduction in chewing and increased jaw jerk reflex
Absent facial expressions
Dysphagia and dysphonia
Spastic tongue and dysarthria

-> If high order centres are affected, may cause ataxia and intention tremor, tested with nose to finger touch test.

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What is Lhermitte’s sign?

An uncomfortable, brief, ‘electrical shock’-like sensation down the spine

typically triggered by flexing the neck forward. It is caused by damaged or sensitized nerve fibers in the spinal cord and is a well-known symptom of MS.

It is triggered by flexing the neck forward and is a symptom of multiple sclerosis.

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When else does Lhermitte sign occur?

B12 deficiency
Radiotherapy

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What is the 1st line diagnostic test for multiple sclerosis?

MRI of brain/spinal cord without contract

It identifies lesions in the periventricular matter, brain stem, and spinal cord.

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What do T1 weighted images show in multiple sclerosis?

Hypointense dark lesions

These images help in identifying areas of demyelination.

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What is the **2nd line diagnostic criteria** for multiple sclerosis?

Visual evoked potentials on EEG because optic nerve is first to be affected. During the test, small electrodes are placed on your scalp while you look at a screen displaying a flashing or patterned image, such as a checkerboard. The electrodes record the brain's electrical response. There will be a low conduction velocity. ## Footnote This test assesses the conduction velocity of the optic nerve.

What is the **1st line treatment** for acute relapses in multiple sclerosis?

High dose corticosteroids for 5 days ## Footnote Steroids shorten the duration of a relapse but do not alter recovery.

What do steroids do for MS?

steroids shorten the duration of a relapse and do not alter the degree of recovery

What is second line treatment of MS?

plasmapharesis

What are the supportive therapies for MS?

Supportive therapies for spasticity includes dantrolene and baclofen TCAs for depression Gabapentin and TCA’s for paraesthesia

What are the indications for DMARDs in multiple sclerosis?

*relapsing-remitting disease + 2 relapses in past 2 years + able to walk 100m unaided * secondary progressive disease + 2 relapses in past 2 years + able to walk 10m (aided or unaided)

Name two **disease-modifying drugs** for multiple sclerosis.

* Natalizumab * Ocrelizumab ## Footnote These drugs help reduce the risk of relapse in patients with specific criteria.

What is the action of natalizumab?

a recombinant monoclonal antibody that antagonises alpha-4 beta-1-integrin found on the surface of leucocytes.

What is the action of ocrelizumab?

humanized anti-CD20 monoclonal antibody and is often used first-line; it is given intravenously

What is the role of **interferon-beta** in multiple sclerosis treatment?

Inhibits T cells for cytokine release ## Footnote It is used as a preventative treatment for multiple sclerosis.

What is the NICE reccomendations for management of fatigue?

Once other secondary problems have been excluded, NICE reccomended a trial of amantadine

What is the NICE recccomendation of spasticity management?

first line is baclofen and gabapentin -> alternative dantrolene

What is a common symptom of **bladder dysfunction** in multiple sclerosis?

* Urgency * Incontinence * Overflow ## Footnote Management may involve ultrasound assessment and self-catheterization.

What is the management of bladder dysfunction in multiple sclerosis?

Ultrasound Must be done to assess the bladder

What is **oscillopsia**?

Visual fields appear to oscillate ## Footnote Gabapentin is the first-line treatment for this symptom.

What is the management of oscilloscopsia?

gabapentin

What is given for acute managmeent of multiple sclerosis attacks?

IV methylprednisolone every 24 hours for 3 days

What is given to reduce relapse rate?

-> Natalizumab for severe disease with two or more disabling relapses -> Beta-interferon for mild to moderate relapsing-remitting disease

How does optic neuritis present?

loss of central vision, loss of red desaturation and painful eye movements

How does multiple sclerosis prevent on imaging?

periventricular white matter lesions seen on MRI disseminated in time and space

When can oligoclonal bands also appear in CSF other than multiple sclerosis?

Lyme disease, SLE and neurosarcoid.

What criteria is used for multiple sclerosis diagnosis?

McDonald’s criteria

What is used for diagnosis of multiple sclerosis according to McDonald’s criteria?

2 or more attacks (relapses) 2 or more objective clinical lesions

What is given for optic neuritis?

Oral methylprednisolone

What is interferon beta given for?

Relapsing remitting multiple sclerosis in patinets who cannt walk unaided

What is a worse prognosis for multiple sclerosis?

Older, male, motor signs at onset, early relapses, many MRI lesions and axonal loss

What is first line for multiple sclerosis?

Natalizumab is a monoclonal antibody against α4-integrin, which prevents lymphocyte migration into the central nervous system.

What is a risk with use of natalizumab?

progressive multifocal leukoencephalopathy (PML) due to JC virus reactivation, requiring regular JC virus antibody monitoring.

What is given first line for mid to moderate relapsing-remitting MS?

Dimethyl fumarate, an oral disease modifying therapy which reduces inflammation via Nrf2 pathway

How to manage patient who cannot safely swallow?

Gastrostomy tube

What nutritional support is given for short term support?

NG tube feeding in acute illness for stroke, post surgery or infection

What type of MS will have acute transverse myelitis with oligoclonal banding?

Primary progressive MS -> there will be a single hospital event with deterioration

Normal protein and glucose Oligoclonal band

Which type of MRI is done for MS?

MRI with contrast to see demyelination lesions

What is the most common subtype of multiple sclerosis?

Relapsing-remitting disease

What is first line for spasticity?

Baclofen Gabapentin

What is a common precipitating of myasthenia gravis?

Beta blockers

What is the pattern of weakness in MS?

pyramidal pattern of weakness (with flexors affected more than extensors in the lower limbs)

What is given for long term nutrition?

Percutaneous gastrostomy tube (PEG

What is considered a relapse in multiple sclerosis?

Paraesthesia worsening Worsening of motor symptoms

What is the most common subtype for multiple sclerosis?

Relapsing-remitting, often seen in females between ages 20-30

What is used to reduce risk of relapse during remission phase?

Natalizumab

When are steroids given?

To reduce the length of an acute relapse

Which T score is osteopenia?

-1 to -2.5

Tonic-colonic

What is the best medication for relapses in multiple sclerosis?

Natalizumab monoclonal antibody

What to give for oscilloscopsia (oscillation of visual fields)

Gabapentin

What is Uhthoff’s phenomen?

neurological symptoms are exacerbated by increases in body temperature in MS

What is McArdle sign?

transient exacerbation of weakness following greater than 10% neck flexion

How to investigate patient with multiple sclerosis and bladder dysfunction?

Ultrasound of kidneys, ureters and bladder

Which feature in MS indicates other cause requiring more than steroid treatment?

Right eye being down and out indicating oculomotor nerve palsy, so requires urgent CT brain

Is optic neuritis unilateral or bilateral?

Unilateral

What causes bilateral optic neuritis?

Neuromyelitis optica, caused by aquaporin 4 antibodies against optic nerves and spinal cord

How does neuromyrlitis optica present?

triad of optic neuritis, transverse myelitis, and the presence of antibodies to Aquaporin 4. It will have relapsing remitting disorder, causing damage with each flare.

How does the transverse myelitis manifest in neuromyelitis optica?

weakness or paralysis of the limbs, sensory disturbances (usually with a spinal level), back pain and bowel or bladder dysfunction.

What is a key investigation for neuromyelitis optica?

MRI Head and Spine reveals demyelinating lesions which, unlike those in Multiple Sclerosis, affect both peripheral white matter tracts and central components of the spinal cord.

How to manage acute flares of neuromyrlitis optica?

high dose steroids and, if refractory, plasma exchange

How to manage chronic flares of neuromyrlitis optica

Long term immunosuppression with steroid-sparing agents such as Azathioprine or, in refractory cases, Rituximab.

What eye abnormality is associated with multiple sclerosis?

Unilateral lateral gaze nystagmus from Inter nuclear Opthalmoplegia

Which eye abnormality is seen in multiple sclerosis?

Unilateral lateral gaze nystagmus from inter nuclear Opthalmoplegia

Multipel Sclerosis Flashcards

(87 cards)