Multiple Sclerosis

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Multiple Sclerosis

• neurological symptoms separated in time and focus
• disease characterised by focal plaques of Demyelination
• often a young patient
• slightly more common in women
• prevalence 1:1000

Presentation

• usually between 20-40
• reason for present admission e.g.
  • difficulty walking
  • loss of balance 
  • double vision
  • bladder symptoms
  • respite

History

• when / how first presented
• course of illness to date
  • Relapsing / Remitting
    • number / frequency of episodes
    • nature of relapses
  • secondary progressive
  • Chronic progressive
  • progressive relapsing
• level of disability in 'steady state'
• bladder symptoms
  • urgency
  • urge incontinence
  • recurrent Urinary Tract Infections
  • catheterisation
    • intermittent self
    • urosheath
    • indwelling
• Uhthoff's phenomenon
• Lhermitte's sign
• impotence
• fatigue

FHx

• no clear cut pattern of inheritance
  • 5-15 x risk if first degree relative

DHx

• spasticity
  • baclofen
• urge incontinence
  • anticholinergics
• recent relapse
  • IV steroids

ROS

SHx

• able to work
• invalidity benefit
• other allowances
• ambulant
• wheelchair
• able to transfer
• carer
• district nurse
• home help

Examination

General

• depressed / euphoric / anxious

CNS

• cerebellar dysarthria
  • staccato speech
• Cranial Nerves
  • bilateral optic disc pallor
  • Nystagmus
  • internuclear ophthalmoplegia

Limbs

• spasticity 
  • legs > arms
• clonus
• pyramidal weakness
  • legs > arms
• reflexes very brisk
  • finger flexion jerks
  • Hoffman's sign 
• absent abdominal reflexes
• bilateral extensor plantars
• sensory disturbance
  • patchy
• finger-nose ataxia
• gait 
  • spastic
  • ataxic

Investigations

• visual evoked responses
  • delayed=slow conduction in white matter
• CSF
  • slight increase in mononuclear cells (30%)
  • slight increase in protein (40%)
  • oligoclonal bands (90%)
• MRI
  • high signal lesions esp. periventricular

Pathology

Macroscopic

• plaques of variable size
  • usually <2cm
• smoothly rounded contours
• usually in white matter or occasionally across grey/white junction
• preference for
  • optic nerves
    • Optic Neuritis
    • Retrobulbar Palsy
  • optic chiasm
  • corona radiata
  • brainstem
  • periventricular areas
  • spinal cord

Microscopic

• loss of myelin
• axons preserved
• a few lymphocytes cluster around small vessels
• influx of macrophages
• considerable oedema
• demyelination is total within plaques
• neuronal bodies spared
• ageing plaques acquire astrocytes and glial processes → impaired structural integrity of axons

Course

• relapses with complete recovery between
• frequent relapses
• relapses with incomplete recovery
  • +/- change to chronic progressive
• chronic progressive

Treatment

• Acute relapse
  • IV steroids improve rate of recovery 
• Interferons may work

Prognosis

• favourable outcome if
  • onset of sensory symptoms
  • optic neuritis (if young)
• adverse outcomes
  • progressive course
  • incomplete recovery from initial attack
  • cerebellar ataxia
  • persistent weakness
• 20-30 years
  • death from respiratory paralysis or UTI

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