Multiple Sclerosis

A comprehensive overview of multiple sclerosis in association with Kumar and Clarke!

 

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Video Duration: 15 minutes

  • Multiple Sclerosis
    Created by Eimear McClenaghan
    General
    Epidemiology

    Chronic inflammatory condition of the CNS.

    Pathology

    Demyelination of CNS with plaques disseminated in time and space.

    Common sites for demyelination:

    • Optic nerve
    • Brainstem and cerebellar connections
    • Cervical spinal cord (posterior columns and spinothalamic tracts i.e. sensory pathways)

    Thought to be CD4 T cell driven attack on myelin.

    Top three causes

    None

    Clinical Features
    Symptoms

    Patterns:

    1. Relapsing Remitting (85%) - multiple episodes of neurological disability followed by complete/partial recovery. These are often followed by secondary progressive disease which is neurological disability that becomes more severe with each attack.
    2. Primary Progressive (10%) - neurological disability with no recovery and gradual deterioration.
    3. Fulminant (<10%) - explosive disease, usually fatal within months.

    Presentation:

    Optic Neuropathy

    • asymmetrical (affects one more than the other)
    • blurred vision within hours/days - described as looking through frosted glass
    • mild occular pain

    Brainstem Demyelination

    • diplopia (CNVI/INO lesion)
    • vertigo with or without nystagmus
    • pseudobulbar palsy - dysarthria and dysphagia

    Spinal Cord

    • spastic parapesis
    • patchy sensory loss
    • urinary incontinence


    End Stage Disease

    • spastic tetraparesis
    • ataxia and nystagmus
    • urinary incontinence
    • pseudobulbar palsy
    • dementia


    Death

    • uraemia often with bronchopneumonia
    Signs

    Optic Neuropathy

    • if retrobulbar no signs
    • disc swelling (optic neuritis)
    • RAPD (relative afferent pupillary defect)
    • recovery within two months


    Spinal Cord

    • Lhermitte's sign - neck flexion produces feeling of electric shocks in limbs.
    Investigations
    Cultures

    LP for CSF - oligoclonal IgG bands, cell count raised

    Bloods

    None

    Imaging

    MRI of brain and spinal cord - 85% show plaques

    Scopic/Biopsy

    None

    Functional

    Electrophysiology - delayed VEP (visual evoked potential): optic neuropathy

    Treatment
    Conservative

    None

    Medical

    Acutre relapse: short IV methyprednisolone (decreases severity)

    Prevent relapse: subcutaneous Beta interferon (very expensive, decreases relapse rate)

    NOTE OUTCOME IS NOT AFFECTED

    Incontinence: oxybutinine +/- self catheterization

    Spasticity: physio + relaxants e.g. baclofen

    Surgical

    None

  • Multiple Sclerosis
    Created by Charlotte Dewdney
    General
    Epidemiology
    • MS: Chronic autoimmune disease of the central nervous system
    • 1 in 700 in general population in UK
    • Common age of onset 20-40
    • Women affected more than men, 2:1
    • More common in Caucasians
    • Further from equator = higher rates of MS
    Pathology

    Demyelination of nerve fibres

    Top three causes
    • Cause unknown
    • Other theories include:
      • Vitamin D deficiency
      • Viral infections: EBV
    Clinical Features
    Symptoms

    Eye pain, limb spasticity, weakness, tremor, ataxia, bladder dysfunction

    Signs

    Optic Neuritis

    Uhthoff's phenomenon: worsening of neurological symptoms following rise in body temperature

    Lhermitte's sign: electrical sensation that runs down the back and into the limbs when bringing the head forward

    Investigations
    Cultures

    None

    Bloods

    None

    Imaging
    • MRI scanning.
    • Patches of inflammation - usually in periventricular area
    Scopic/Biopsy

    None

    Functional
    • Lumbar puncture.
      • White cell count
      • IgG oligo-clonal bands ( > 80% of MS patients)
    • Evoked Potentials-VEPS (measure impulses)
    Treatment
    Conservative

    MDT - physiotherapy, occupational therapy

    Acupuncture

    Medical

    Oral steroids: Shorten the duration of relapses

    Beta-interferon 1a: reduce the extent of relapses by 30%,

    Amitriptyline for pain

    Baclofen for spasticity

    Surgical

    None