Multiple Sclerosis Flashcards by Annie Caldwell

What part of the nervous system does MS affect?

CNS

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What is MS a disease of?

White matter

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Pathology of MS

Demyelination / inflammation

Myelin sheath around the nerves become inflamed during an attack or relapse

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What do symptoms of MS depend on?

Where the inflammation has occurred in the brain or spinal cord

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Pathology of demyelination

Autoimmune process
Activated T cells cross BBB causing demyelination
Acute inflammation of myelin sheath

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How can lesions of plaques be seen in MS?

MRI scan = white areas

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What can be looked at on an MRI to determine progression of MS?

Black holes - axonal loss

Later seen as cerebral atrophy

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Which gender gets MS more?

F > M

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How do 80% of cases of MS present?

With a relapse

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Features of initial presentation of MS

Gradual onset over a few days
Stabilises days to weeks
Gradual resolution to complete or partial recovery

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Where in the CNS can relapses occur?

Anywhere

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Examples of possible symptoms of a relapse

Visual

Optic Neuritis
Optic atrophy
Uhthoff’s phenomenon (worsening of vision following rise in body temp)
internuclear ophthalmoplegia

Sensory symptoms

pins and needles
numbness
trigeminal neuralgia
Lhermittes syndrome; paraesthesia in limbs on neck flexion

Motor
- spastic weakness (especially in legs)

Cerebellar

ataxia (more often seen in acute relapse as opposed to a presenting symptom)
tremor

Urinary incontinence
Sexual dysfunction
Intellectual deterioration

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Presentation of optic/retrobulbar neuritis

Subacute visual loss
Pain on moving eye
Colour vision disturbed 
Initial swelling optic disc
Optic atrophy seen later
Relative afferent pupillary defect 
- pupil dilates when shining a light on it

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Causes of optic neuritis

MS
Neuromyelitis optica
Sarcoidosis
Ischaemic optic neuropathy 
Toxic / drugs 
B12 deficiency 
Wegeners granulomatosis
Local compression 
Lebers hereditary optic neuropathy

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If there was a brainstem relapse, what possible symptoms might be seen?

Cranial nerve involvement
Pons - internuclear opthalmoplegia
Cerebellum e.g. ataxia, vertigo, nystagmus
UMN changes in limbs 
Sensory involvement e.g. weakness

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What is myelitis?

Inflammation of the spinal cord

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Presentation of myelitis

Ascending pins and needles in feet / arms to torso over a few days / a week or two
Partial or transverse (complete)
Sensory level
Weakness/UMN changes below level
May be unable to weight bound at all
Bladder and bowel involvement (constipation)

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Differential diagnosis for myelitis

Infection
Tumour
Inflammation

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Is it possible to have an isolated episode of demyelination?

Yes

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Criteria of demyelination episodes to have MS

Episodes of demyelination disseminated in space and time

Has to occur in different parts of the nervous system

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Features of the progressive phase of MS

Accumulation of symptoms and signs
- fatigue, temp sensitivity
- sensory 
- stiffness or spasms
- balance, slurred speech 
- swallowing
- bladder and bowel 
- diplopia / oscillopsia / visual loss
- cognitive - dementia/emotional lability
Not able to walk far
Have to use a stick 
Need help for the toilet

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What antibodies are seen in devics disease (neuromyelitis optica spectrum disorder)?

Aquaporin 4 antibodies

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Features of devics disease

Particularly affects

Optic neuritis
Myelitis

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Treatment of devics disease

Immunosuppression

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Associations to causes of MS

Complex genetic inheritance Autoimmune assosiations Commoner in temperature climate Age

How many people with MS never have their ADL affected?

1/4

How many people with MS become severely disabled quickly?

15%

Good prognostic indicators for MS

Female Present with optic neuritis Long interval between 1st and 2nd relapse Few relapses in 1st 5 years

Bad prognostic indicators for MS

Male Older age Multifocal symptoms and signs Motor symptoms and signs

Things in life MS can affect

``` Work Family Pregnancy Sexual function Bladder and bowel function ```

Is there a cure for MS?

What are the two criterias that can diagnose MS?

``` Posers criteria (clinical) Macdonald criteria (MRI) ```

What is posers criteria?

Two clinical episodes/relapses to make a diagnosis

What is macdonalds criteria?

MRI diagnosis | May not even have had any symptoms to go long with it

How many lesions on an MRI would it take approx. for a patient to experience 1 relapse?

What can cause the white blobs on the MRI?

Demyelination - MS Hypertension Smoking

Investigations of MS

``` MRI (with contrast) LP Visual/somatosensory evoked response Bloods Chest XR ```

How may a LP support the diagnosis of MS?

Oligoclonal bands present in CSF but no matched band in serum or blood If matches - then just shows widespread inflammation going on. If isolated to CSF - supports diagnosis of MS

Why would you do bloods in investigations for MS?

To exclude other inflammatory conditions

Differentials for MS

``` Acute disseminated encephalomyelitis Other autoimmune causes e.g. SLE Sarcoidosis Vasculitis Infection e.g. Lyme disease Adrenoleukodystrophy ```

Types of MS

``` Relapsing remitting (RRMS) Secondary progressive (SPMS) Primary progressive (PPMS) Sensory Malignant ```

What % of people with MS have RRMS?

85%

What % of people with MS have PPMS?

10-15%

What % of people with MS have sensory MS?

What is sensory MS?

People who only have mild sensory inflammation so do not have much disability problems as others

What can happen in malignant MS?

Can get very extensive disability

When does PPMS often present?

5th/6th decade

Features of PPMS

No relapses Spinal symptoms Bladder symptoms

Prognosis of PPMS

Poor

Which gender gets PPMS more?

F = M

First line treatments for disease modifying treatments of MS

Beta-interferons/glatiramer acetate Teriflunomide Dimethyl fumarate

How are beta-interferons given?

IM/SC Injection daily - weekly

Side effects of first line disease modifying treatments of MS

Flu like symptoms Injection site reaction Abnormalities of blood count and liver function

2nd line agents of disease modifying treatments of MS

Natalizumab Fingolimod Alemuzumub

Overall treatment plan of MS

Disease modifying treatment General health and diet Treatment of relapse Symptomatic treatment

What is progressive multifocal leukencephlopathy (PML)?

Aggressive brain disease

Pathology of PML

Can come on when a virus reactivates in your blood when you are immunosuppressed JC virus antibodies can be carried and gives you risk to develop PML

Treatment of an acute relapse of MS

Look for underlying infection and treat Oral methylprednisolone (IV if need) Rehab Symptomatic treatment

25-30% of the time what causes further relapses?

Underlying viral infection

What is usually advised in MS?

Vaccination

Relapses in pregnancy

Fewer relapses during pregnancy | Increased risk in the first 3 months post partum

Symptomatic treatment for spasticity

Baclofen and gabapentin - 1st line Diazepam Dantrolene Physio

Symptomatic treatment for dysesthesia

Amitriptyline | Gabapentin

What is dysaesthesia?

An abnormal unpleasant sensation felt when touched due to damage to peripheral nerves

Symptomatic treatment for urinary symptoms

Anticholinergic Bladder stimulation Catheterisation

Symptomatic treatment for constipation

Laxatives

Symptomatic treatment for fatigue

Graded exercise Medication Trial of amantadine

Symptomatic treatment for depression

CBT | Medication

Symptomatic treatment for cognitive problems

Memory aids etc

Symptomatic treatment for tremor

Aids | Pharmaceutical

Symptomatic treatment for oscillopsia

Gabapentin 1st line | Carbamazepine

What is oscillopsia?

Objects in the visual fields appear to oscillate

Features of relapsing remitting disease

Acute attacks (e.g. 1 - 2 months) followed by periods of remission

Features of secondary progressive disease

Relapsing remitting patients who develop neurological signs and symptoms in between relapses Gait and bladder problems usually seen

What % of relapsing remitting patients go onto develop secondary progressive disease within 15 years of diagnosis?

65%

Who is primary progressive MS more common in?

Elderly

What can you see on MRI in MS?

``` High signal T2 lesions Periventricular plaques Dawson fingers (hyperintense lesions penpendicular to corupus callosum) Brain atrophy Axonal loss (black areas) Demyelination (white areas) ```

What is looked at in the CSF for MS?

``` Oligoclonal bands (not in serum) Increased intrathecal synthesis of IgG ```

What is seen on visual evoked potentials in MS?

Delayed, but well preserved waveform

Criteria to be able to use beta interferon in MS

1. RRMS + 2 relapses in last 2 years + able to walk 100m unaided 2. Secondary progressive disease + 2 relapses in last 2 years + able to walk 10m (aided or unaided)

Risk factors for MS

Smoking Previous infectious mononucleosis Genetics Hypovitaminosis D