Multiple Sclerosis (MS)

Question 1

Definition

Answer 1

Autoimmune inflammatory disorder

Demyelination of the CNS (brain + SC)

Question 2

There is damage to ????

Answer 2

Myelin sheath

Question 3

More common in males/females

Answer 3

Females

Question 4

Which age does it usually present around?

Answer 4

Age 20-40

Question 5

Causes - environmental

Answer 5

Association with high latitude

Relationship with vitamin D deficiency

Question 6

Causes - genetics

Answer 6

HLA DRB1

Question 7

MS is an unpredictable condition. True or false?

Answer 7

True

Question 8

There are a variety of clinical courses. What is the most common clinical course?

Answer 8

Relapsing remitting

Question 9

Name the 4 main clinical courses

Answer 9

Relapsing remitting
Primary progressive
Progressive relapsing
Secondary progressive

Question 10

Which clinical course is most disabling?

Answer 10

Relapsing remitting

Question 11

Which type of cell is damaged ?

Answer 11

Oligodendrocyte damage

Question 12

Oligodendrocyte damage causes what?

Answer 12

Disrupts neuronal conduction and results in demyelination. There is limited capacity to remyelinate after damage

Question 13

Demyelination

Answer 13

Characterised by defects in the rate and consistency or neuronal conduction
Preferential damage to the myelin sheath
Relative preservation of axons

Question 14

MS is principally a grey/white matter disease ? and why?

Answer 14

White matter disease

- myelinated axons are concentrated at white matter

Question 15

Exterior surface of the brain typically appears normal/abnormal?

Answer 15

Normal

Question 16

Cut surface of the brain shows which abnormality?

Answer 16

Plaques

Question 17

Plaques in MS

Answer 17

Well demarcated
Irregular shaped areas
Glassy almost translucent appearance
Vary from very small to very large lesions

Question 18

Where are plaques located

Answer 18

Can occur at any site in the CNS but most common locations are

• adjacent to lateral ventricles
• corpus callosum
• optic nerves and chiasm
• brainstem

Question 19

Plaques tend to be distributed in a symmetrical manner. True or false?

Answer 19

False

- non-symmetrical

Question 20

What are the 2 types of plaque

Answer 20

Active (acute) plaque

Inactive (chronic) plaque

Question 21

Active (acute) plaque

Answer 21

Shows active inflammation and ongoing demyelination

Abundant microglia

Question 22

Active (acute) plaque - macroscopic appearance

Answer 22

Demyelinating plaques are yellow/brown with an ill defined edge which blends into surrounding white matter

Question 23

Inactive (chronic) plaque

Answer 23

Inflammation dampens down
Predominated by scarring
Little remaining myelinated axons

Question 24

Inactive (chronic) plaque - macroscopic appearance

Answer 24

Well demarcated grey/brown lesions in with matter, classically situated around the lateral ventricles

Question 25

Inflammatory cascade

Answer 25

Immune cells pass through the BBB from the systemic circulation to CNS Immune cells may re-activate and produce cytokines Immune cells mount autoimmune attack against myelin in the CNS --> demyelination

Question 26

Patients typically present with focal/global neurological deficits

Answer 26

Focal

Question 27

Clinical features - If there are lesions in the pyramidal tracts

Answer 27

Increased tone Spasticity Weakness Upper limbs get spasticity in flexion - weakness extending elbow and flexing wrist Lower limbs get spasticity in extension - weak flexing hip, knee and dorsiflexing ankle

Question 28

Clinical features - if there are lesions in optic nerves

Answer 28

Unilateral painful visual loss Colour vision is lost first RAPD

Question 29

Clinical features - sensory symptoms

Answer 29

Either loss of sensation or too much sensation

Question 30

Clinical features - lower urinary tract dysfunction

Answer 30

``` Frequency Nocturia Urgency Urge incontinence Retention ```

Question 31

Clinical features - if there are lesions in the cerebellum

Answer 31

``` Ataxia Intention tremor Nystagmus Pendular reflexes Dysdiadokinesis (coordination problems) Dysarthria ```

Question 32

Clinical features - internuclear ophthalmoplegia

Answer 32

Fast movement of eyeballs is impaired | diplopia when trying to adduct

Question 33

Diagnostic testing is required. True or false ?

Answer 33

False | - clinical diagnosis

Question 34

Investigations

Answer 34

MRI scan | Lumbar puncture

Question 35

Investigations - MRI scan

Answer 35

Presence of demyelinating plaques | Dawsons fingers

Question 36

Investigations - lumbar puncture

Answer 36

Presence of IgG oligoclonal bands in CSF

Question 37

IgG oligoclonal bands found in CSF are distinct to MS. True or false?

Answer 37

False | - can be found in other conditions

Question 38

Which criteria need to be met for a diagnosis of MS to be made?

Answer 38

McDonald criteria

Question 39

Mcdonald criteria

Answer 39

At least 2 episodes suggestive of demyelination occurring at different times and places A neurological deficit implicating one neuro-anatomical site, and a MRI appreciated defect at another neuro-anatomical site Multiple distinct CNS lesions on MRI

Question 40

Management - acute moderate exacerbation

Answer 40

Oral steroids

Question 41

Management - acute severe exacerbation

Answer 41

Hospital admission | IV steroids

Question 42

Management - pyramidal dysfunction

Answer 42

Physiotherapy Occupational therapy Anti-spasmodic treatment

Question 43

Management - spasticity

Answer 43

Physiotherapy Oral: Baclofen / tizanidine Botox Intratheal : Baclofen / phenol

Question 44

Management - sensory symptoms

Answer 44

Anti-convulsant Anti-depressant (amitryptiline) Tens machine Acupuncture

Question 45

Management - fatigue

Answer 45

Amantadine | Modafnil

Question 46

Disease modifying therapy = First line therapy

Answer 46

Interferon beta - avonex - rebif Glitiramer Acetate (copaxone) Tecfedira

Question 47

Disease modifying therapy has an increased risk of malignancy. True or false?

Answer 47

True

Question 48

Disease modifying therapy - second line therapy

Answer 48

Monoclonal antibody

Question 49

When do you accelerate from first line to second line therapy?

Answer 49

If first line therapy isn't making any change to the MRI scan appearance

Question 50

Which MAb therapy must be given on the ward as it causes cardiac problems?

Answer 50

Fingolimond

Question 51

Which MAb is for patients with highly active relapsing remitting MS ?

Answer 51

Lemtrada | Tysabri

Question 52

Disease modifying therapy - third line therapy

Answer 52

Stem cell transplantation

Question 53

``` Which of the following are treatment options for the sensory symptoms in ms? (More than one correct answer) TENS machine Oxybutinin Gabapentin Baclofen Amitryptiline ```

Answer 53

TENS machine Gabapentin Amitryptiline

Question 54

Which steroid is used in the treatment of mod-severe Acute attacks of MS? A prednisolone B dexamethasone

Answer 54

A

Question 55

What investigation has a vital role in assessing response to disease modifying therapy in ms?

Answer 55

MRI