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Multiple Sclerosis (MS)

Multiple Sclerosis (MS) is a chronic, progressive condition characterised by plaques of demyelination and eventual axonal loss in the CNS. It typically presents in women around 20-50 yrs. The main 2 charasteristics of it are:

  • Clinical attack of MS e.g. optic neuritis

  • Disseminated in Time and Space

    • Time - neurological damage occurring at multiple points in time

    • Space - damage affecting multiple areas of the CNS

“Normal nerve cell with myelinated axon in comparison to a nerve cell with multiple sclerosis and damaged myelin sheath” © Mjeltsch CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0/)

Classification

  • Relapsing-Remitting (80%)

  • Primary Progressive - disease gets worse from beginning

  • Secondary Progressive - disease starts off as relapsing-remitting before becoming progressively worse


N.B. Myelin cells are called Oligodendrocytes in the CNS, and Schwann cells in the PNS.


Presentation

Common presenting features are:

  • Optic Neuritis - blurred vision, painful eye movements, and colour blindness (esp. red)

  • Patchy parasthaesia - sensory disease


Other features include:

  • Internuclear ophthalmoplegia - lesion in MLF (medial longitudinal fasciculus) of the brainstem

    • Impaired adduction ipsilateral to the lesion

    • Nystagmus contralateral to the lesion

  • Ataxia - sensory or cerebellar

  • Spastic paraparesis


N.B. MS is a CNS disease, so the pt shouldn’t present with any LMN signs!


Investigations

  • History and examination

  • Bloods - FBC (WCC), CRP

  • MRI Brain + Spine w/Contrast - typically see periventricular white matter lesions

    • A plain MRI would be used to look for evidence of demyelination, whilst the contrast (gadolinium) enhances some lesions and not others to demonstrate dissemination in space.

  • LP - presence of CSF Oligoclonal bands, which indicates an autoimmune process in the CNS


N.B. Important to rule out infection before treating.

“Multiple sclerosis as seen on MRI” © James Heilman, MD CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0/)

Management

Acute attack - Methylprednisolone 1g IV


Long-term:

  • Disease-modifying therapies e.g. Beta-interferon

  • Baclofen and botox for spasticity

  • Anticholingerics (e.g. Oxybutynin) for bladder incontinence

  • Gabapentin/Pregabalin for neuropathic pain


N.B. Intermittent self-catherisation can be an option in those with a neuropathoic bladder.



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