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What is multiple sclerosis?

immune-mediated disease of the CNS in which myelin sheaths of axons in the brain and spinal cord are damaged (which slows, but does not eliminate conduction of nerve impulses) - over time may lead to severing of axons and permanent loss of nerve function


What are the initial (presenting) symptoms of MS?

fatigue (most common), change in sensation in the arms/legs/face, optic neuritis, weakness, double vision (diplopia), unsteady gait, problems with balance, unilateral vision loss, bladder problems, vertigo


What is Lhermitte's sign?

electrical sensation that runs down the back and into the limbs that is produced by neck flexion - suggests lesion of the dorsal columns of the cervical cord or caudal medulla


What is Uhthoff's phenomenon?

worsening of neurologic symptoms when the body is overheated from hot weather, exercise, fever, or saunas/hot tubs


What features are suggestive of MS?

relapses and remissions, onset between 15 and 50, optic neuritis (inflammation of optic nerve), Lhermitte sign, internuclear ophthalmoplegia, fatigue, Uhthoff's phenomenon (heat sensitivity)


What are shadow plaques?

plaques that have been partially remyelinated by a remyelinating oligodendrocyte


What are the core requirements for diagnosis of MS?

dissemination in time and place - evidence that damage has occurred in at least two separate areas of the CNS at different points of time, with no other explanation


What are the McDonald MS Diagnostic Criteria?

objective clinical evidence of CNS lesions in both time and space: (1) disseminated in space - 1 or more lesions in at least 2 of 4 MS-typical regions or development of further clinical attach implicating different CNS site and (2) disseminated in time - presence of lesions in two separate MRI images or evidence of two separate clinical attacks


What are the four MS-typical regions of the CNS?

periventricular (area around the ventricle of the brain), juxtacortical (next to the cerebral cortex), infratentorial (area located below the tentorium cerebelli), and spinal cord


What types of cells are seen in the CSF of patients with MS?

oligoclonal IgG bands


What are black holes in MS?

areas in the brain where myelin has been completely lost and nerve cells have been damaged beyond repair


What is the imaging test of choice for MS?

MRI - demonstrates plaques and black holes


What are evoked potentials?

electrical events generated in the CNS by peripheral stimulation of a sensory organ - used to detect subclinical/abnormal CNS function that may not be visible via routine imaging


What are oligoclonal bands?

a protein (immunoglobulin - IgG) - presence suggests inflammation of the CNS due to infection or another disease - if similar bands aren't present in your blood, may indicate multiple sclerosis


What is clinically isolated syndrome in MS?

first neurological event suggestive of demyelination - high risk for developing clinically definite MS


What is the characteristic of progressive relapsing MS?

steady decline since onset of symptoms with super-imposed attacks


What is the characteristic of secondary progressive MS?

initial relapsing/remitting MS that suddenly begins to decline without periods of remission and relapse - diagnosis made retrospectively 10-20 years after disease onset


What is the characteristic of primary progressive MS?

gradual progression from onset without relapse or remission


What is the characteristic of relapsing/remitting MS?

unpredictable attacks that may or may not leave permanent deficits followed by periods of remission (85-90% of cases at onset)


What is the Expanded Disability Status Scale (EDSS)

method of quantifying disability in MS based on 8 functional systems: (1) pyramidal (ability to walk), (2) cerebellar (coordination), (3) brain stem (speech and swallowing), (4) sensory (touch and pain), (5) bowel and bladder, (6) visual, (7) mental, and (8) other (any other neurological finding)


What is the primary class of medication treatment of MS?

immunomodulating agents


What are some indicators of poor prognosis in MS?

frequent/multifocal attacks early on, pyramidal involvement, ataxia, cognitive difficulties, spinal progression


How are relapses managed in MS?

relapse = new symptoms or sudden worsening of symptoms lasting 24 hours with objective change in neurologic findings - Tx with corticosteroids (3-5 days of high dose intravenous methylprednisolone)


How is spasticity treated in MS?

eliminate sources of pain, exercise (ROM, weight bearing), cryotherapy (cooling and stretching), casting, EMG biofeedback, electrical stimulation, baclofen (Lioresal), Botox


What is a pseudoexacerbation in MS?

temporary worsening of MS symptoms (e.g., in response to elevation in core body temperature) - use cooling strategies


Where is cerebrospinal fluid produced?

choroid plexus in the lateral, third, and fourth ventricles - circulates through the subarachnoid space between arachnoid and pia mater


What is the normal CSF volume in adults?

125-150 mL - 20% contained in the ventricles


What is the normal rate of CSF production?

20 mL/hour


How is CSF absorbed?

in the arachnoid villi - one-way valves permitting unidirectional flow of CSF into the blood


What types of molecules can cross the blood-brain barrier?

lipid-soluble molecules or drugs - ionically charged molecules require active transport