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MS lecture from the 17th December 2012
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Lecture Notes on Multiple Sclerosis - Professor Gavin Giovannoni (17 Dec 2012)
1. Definition
Pathological Definition: Inflammatory disease of the CNS characterised by demyelination and variable
degrees of axonal loss and gliosis.
Clinical Definition: Objective CNS dysfunction, i.e. involvement of two or more white matter structures
separated by time (1 months), with no other aetiology.
2. Pathology
Gross Pathology - plaques (periventricular white matter, optic nerves, brainstem, cerebellum, spinal cord)
Histopathology - perivascular inflammation (venules) extending into the white matter parenchyma (cell
mediated (lymphocytes and macrophages, rare plasma cells), demyelination, axonal loss and gliosis.
3. Aetiology
Unknown; complex disease involving genes and environment
Possible viral aetiology (disease clusters / migration studies) and/or autoimmune (definitive evidence of it
being autoimmune is lacking; but is the current dogma accepted by most people)
Genetic risk (concordance monozygotic twins 30% / dizygotic twins 5%, increased risk in family members)
4. Epidemiology
Age of onset - 3rd
/ 4th
decade (10 - 50 years)
Prevalence - ~125/100,000 (UK); varies with latitude (probably due to vD; i.e. vD is protective)
Life Span - slightly reduced (~10 year)
Sex - F > M (2:1) ; incidence appears to be increasing in females (not known why)
Race - Caucasians (uncommon in Chinese / ? Viking ancestral genes)
Risk factors – Genes (HLA and others), EBV infection and infectious mononucleosis, smoking and vitamin D
deficiency
5. Diagnosis
Clinical - typical clinical course / exclusion of other diseases
MRI - abnormal white matter
Evoked Potentials - delayed conduction
CSF - immunological abnormalities (intrathecal synthesis of oligoclonal IgG bands)
6. Clinical (Symptoms and Signs – positive and negative phenomena)
Motor - spasticity, weakness, gait abnormalities, spasms (clonic, tonic and flexor)
Sensory - positive (pins & needles, pain, etc) and negative sensory phenomena (loss of sensation).
Cerebellum - inco-ordination, ataxia, nystagmus, dysarthria, etc.
Brain Stem - diplopia, vertigo, nystagmus, dysarthria
Optic Nerves - optic neuritis (blurred vision, reduced colour vision, central or paracentral scotomas, reduced
visual acuity, afferent pupillary defect, optic disc pallor)
Bladder and Bowel – incontinence, frequency, urgency, hesitancy
Higher Functions - depression, poor concentration, forgetfulness, cognitive impairment
Fatigue – complex (exercise induced, temperature-related)
7. Course
Relapsing Remitting
Progressive (secondary or primary)
8. Prognosis
Highly variable - 30% benign disease / 10 yrs 30% wheel chair / 15 yrs 50%
Good prognosis - young, female, relapsing course, optic neuritis or sensory onset, long gap between first and
second relapses, good recovery from initial attack and low baseline lesion load on MRI.
Survival slightly reduced
9. Treatment
Disease Modifying
Acute Relapse - high dose corticosteroids
Relapsing cases - interferon beta, glatiramer acetate, natalizumab, fingolimod and mitoxantrone
Drugs in development: Teriflunomide, BG12, Laquinimod, Alemtuzumab, Ocrelizumab, Daclizumab
Progressive cases - immunosuppression (poor evidence base) there is a need for neuroprotection.
Symptomatic
Spastcity (Baclofen, tizanidine, gabapentin, diazepam, etc.)
Bladder and bowel care, fatigue, depression, pain, infections, skin and foot care
Physiotherapy
Occupational Care
10. Reading List:
Compston A, Coles A. Multiple sclerosis. Lancet. 2008 Oct 25;372(9648):1502-17.
Ramagopalan et al. Multiple sclerosis: risk factors, prodromes, and potential causal pathways. Lancet Neurol
2010; 9: 727–39.
Multiple Sclerosis
Professor Gavin Giovannoni
Epstein Bar Virus
Genetics
Vitamin D
Smoking
Risks
Adverse events
Differential Diagnosis
MRI
Evoked Potentials
Lumbar puncture
Blood Tests
Diagnostic Criteria
Cognition
Depression
Fatigue
Bladder
Bowel
Sexual dysfunction Tremor
Pain Swallowing
Spasticity Falls
Balance problems Insomnia
Restless legs Fertility
Clinical trials
Gait
Pressure sores
Oscillopsia
Emotional lability
Seizures
Gastrostomy
Rehab
Suprapubic catheter Intrathecal
baclofern
Physio- therapy
Speech therapy
Occupational Therapy
Functional neurosurgery
Colostomy
Tendonotomy
Studying
Employment Relationships
Travel
Vaccination
Anxiety
Driving
Nurse specialists
Counselling
Family counselling
Relapses
1st line
2nd line
Maintenance Escalation Induction
Monitoring
Disease-free
Disease progression
DMTs
Side Effects
Advanced Directive
Exercise
Diet
Alternative Medicine
Pregnancy Breast Feeding
Research
Insurance
Visual loss
Palliative Care
Assisted suicide
Social services
Legal aid Genetic counselling
Prevention
Diagnosis
DMT Symptomatic
Therapist
Terminal
Counselling An holistic approach to MS; beta ver. 2.1
Intrathecal phenol
Fractures
Movement disorders
Osteopaenia
Reading material
1. Compston A, Coles A. Multiple sclerosis. Lancet 2008 ;372:1502-17.
2. Ramagopalan et al. Multiple sclerosis: risk factors, prodromes, and potential causal pathways. Lancet Neurol 2010; 9: 727–39.
Topics to be covered
• Definition
• Pathology
• Epidemiology
• Aetiology
• Autoimmune pathogenesis
• Clinical features
• Treatment
Definition
Pathological Definition: Inflammatory disease of the CNS characterised by demyelination and variable degrees of axonal loss and gliosis.
Clinical Definition: Objective CNS dysfunction, i.e. involvement of two or more white matter structures separated by time (1 months)*, with no other aetiology.
* At least 1 month
Gross Pathology
Histopathology - inflammation
Histopathology - demyelination
Histopathology - gliosis
Epidemiology
• Age of onset - 3rd / 4th decade (16 - 50 years)
• Prevalence - ~125/100,000 (latitude dependent)
• Life Span - slightly reduced (~ 10 years)
• Sex - F > M
• Race - Caucasians
(uncommon in Chinese / ? Viking ancestral genes)
• Geography - Northern European Disease
• Familial clustering
Aetiology
• Unknown
• ? Infection
• ? Autoimmune disease
Risk Factors
• Genes
• Environment
• Sunlight/UVB
• vD
• EBV
• Smoking
Compston & Coles, Lancet 2008.
Migration studies
Geographical distribution of MS: prevalence increases away from the equator
Vukusic S et al. J Neurol Neurosurg Psychiat 2007;78:707–709.
53
55
70
47 76 71 78
51 53 51
59
77 88
103
97 100
84
93
87
95
62
82
Role of vD3: UVB and MS prevalence
1Jablonski NG, Chaplin G. J Hum Evol 2000;39:57–106. 2Chaplin G. Am J Phys Anthropol 2004;125:292–302.
45
55
70
47 76
71 78
51 53 51
59
77
62
88
103
98 100
84
82
93
87
95
MS Prevalence by Department Against UVMED minimum
3–4
4–6
6–7
Department UVMed MIN
7–9
10–11
11–13
14–16
.
Month of Birth
1Willer CJ et al. BMJ 2005;330:120–125.
Compston & Coles, Lancet 2008.
Familial Risk
Epidemics or clusters of MS
The annual incidence of MS (per 100 000 inhabitants) in the Faroe Islands since 1940
Kurtzke JF et al. Acta Neurol Scand 1993;88:161–173.
0
2
4
6
8
10
12
1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990
Changing sex ratios
Orton et al. Lancet Neurol 2006; 5: 932–36.
Odds ratio of MS in subjects seronegative for EBV
Ascherio et al. Ann Neurol 2007;61:288-299.
Infectious mononucleosis
Thacker et al. Ann Neurol 2006;59:499–503.
Smoking is a risk factor for multiple sclerosis
Hawkes CH, Mult Scler. 2007 Jun;13(5):610-5.
Clues to autoimmunity
• Autoimmune disease
• MHC associations
• Possible associations with other autoimmune diseases
• Females > males
• Autoreactive T-cells and B-cells
• Affected by pregnancy and viral infections
• Animal models (EAE)
• Pathology
• Unable to transfer disease
Clinical Presentation - symptoms & signs
• Motor - spasticity, weakness and gait abnormalities.
• Sensory - positive (pins & needles) and negative sensory phenomena (loss of sensation).
• Cerebellum - inco-ordination and unsteady gait.
• Brain Stem - diplopia, vertigo, nystagmus, dysarthria
• Optic Nerves - optic neuritis (blurred vision)
• Bladder and Bowel - incontinence
• Higher Functions - depression, poor concentration, forgetfulness, etc.
• Fatigue
Most embarrassing symptom
Society’s perspective
MS is a severely debilitating disease with a major socio-economic burden
MS is one of the most common causes of neurological disability in young adults2
Natural history studies indicate that it takes a median time of 8, 20 and 30 years to reach the irreversible disability
levels of EDSS 4, 6 and 7, respectively3
Up to 75% increased annualized divorce rate4
Life expectancy is reduced by 5-10 years5
In a 2004 study, 2 out of 3 patients with RRMS were unemployed due to the disease6
EDSS and utilitya show a significant inverse relationship1,b
aUtility measures are derived from EQ-5D using the EuroQoL instrument. bAdapted from Orme et al 2007. Error bars depict 95% confidence intervals. Half points on EDSS are not shown on graph axis, except at EDSS 6.5.
1.Orme M et al. Value In Health. 2007;10:54-60. 2.WHO. 2008.[TK] 3. Confavreaux, Compston. 2005.[TK] 4. Coles et al. 2001.[TK] 5. Confavreaux, Vukusic. 2006.[TK] 6. Morales-Gonzales. Mult Scler. 2004;10:47-54.
Horizontal eye movements
R L
III
VI
PPRF
MLF
MLF = medial longitudinal fasiculus PPRF = parapontine reticular formation
Case history 1
• A 26 year old female, with previous history of myelitis, presents with
double vision on looking to the left.
Where is the lesion?
R L
III
VI
PPRF
MLF
Horizontal Eye Movements
R L
L R
Internuclear ophthalmoplegia
Where is the lesion?
R L
R L
L R
R L
III
VI
PPRF
MLF = =
Bilateral INO
Where is the lesion?
R L
R L
L R
R L
III
VI
PPRF
MLF
One and a half syndrome
MRI
MRI
1. Three or more white matter lesions
2. At least two of the following
i. At least 1 lesion abutting body of lateral ventricle
ii. At least 1 infratentorial lesion
iii. A lesion > 6mm
Sensitivity = 81%
Specificity = 96%
Callosal lesions
Offenbacher H, et al. Neurology 1993;43:905-9.
Evoked potentials
VEP BAEP SSEP
No. patients 1950 1006 1006
No. series 26 26 31
Rates of abnormality
Definite MS 85% 67% 77%
Probable MS 58% 41% 67%
Possible MS 37% 30% 49%
Asymptomatic 51% 38% 42%
All patients 63% 46% 58% 76%
(upper limbs) (lower limbs)
Axonal plasticity - sodium channel
Waxman SG. Nat Rev Neurosci. 2006 Dec;7(12):932-41.
Videos courtesy Hugh Bostock, Inst. Neurol., UCL
Reduced safety factor of conduction
http://www.youtube.com/watch?v=wLSxS9THnGU http://www.youtube.com/user/ggiovannoni#p/a/u/1/iC9U0Obzhh4
Case study 1
• 29 year male with early MS complains of difficulty playing squash:
• 10 – 15 minutes after starting to play he keeps missing the ball.
• Why?
Carl Pulfrich (1858 to 1927)
The Pulfrich effect is a psychophysical percept wherein
lateral motion of an object in the field of view is interpreted by the visual cortex as having a depth component, due to a relative difference in signal timings between the two eyes.
Wilhelm Uhthoff
Circadian and hypothermia-induced effects on visual and auditory evoked potentials in multiple sclerosis
Romani et al. Clinical Neurophysiology 111 (2000) 1602-1606.
Sustained-release oral fampridine in multiple sclerosis: a randomised, double-blind, controlled trial
Goodman et al. Lancet 2009; 373: 732–38.
IEF - Oligoclonal IgG Bands
local OCBs
local & systemic OCBs
systemic OCBs
normal / polyclonal
CSF
Serum
Intrathecal or central compartment
Systemic or peripheral compartment
CSF OCBs
Test % Abnormal
Quantitative Abnormal blood CSF barrier function (Albumin quotient > 7 x 10-3)
12%
Increased IgG quotient (IgG index > 0.88)
70-80%
Increased cell count (> 4/ l)
50%
Qualitative Agarose 60% Acrylamide 75-85%
IEF - oligoclonal bands 95-98%
relapsing-remitting MS secondary progressive MS
Clinical course
MS Expanded Disability Status Scale - EDSS
Treatment Disease Modifying
– Acute Relapse - high dose corticosteroids
– Relapsing cases - interferon beta & glatiramer acetate
– Highly active cases – fingolimod, natalizumab, mitoxantrone
– Drugs in development – Teriflunomide, BG12, laquinimod, alemtuzumab,
ocrelizumab, daclizumab
– Progressive cases – nothing licensed; need for effective neuroprotectants
– Prevention – strategies need to be tested
– Cure –early aggressive immune system rebooters have the greatest chance of a
cure
Symptomatic
– Spasticity (baclofen, etc.)
– Bladder and bowel function
– Fatigue
– Depression
– Infections
– Skin and foot care
– Pain
– Physiotherapy
– Occupational Care
Prognosis
Highly variable*
– 30% benign disease (depends on follow-up)
– 15 yrs ~30% wheel chair
– 20 yrs ~50% wheel chair
– 50% unemployment rate 8-10 yrs post diagnosis
Good prognostic
– young, female
– relapsing course
– optic neuritis or sensory onset
– long gap between first and second relapses.
– full recovery from initial attack
– low baseline lesion load on MRI
Survival slightly reduced
* old natural history data, which will have improved with DMTs
Epstein Bar Virus
Genetics
Vitamin D
Smoking
Risks
Adverse events
Differential Diagnosis
MRI
Evoked Potentials
Lumbar puncture
Blood Tests
Diagnostic Criteria
Cognition
Depression
Fatigue
Bladder
Bowel
Sexual dysfunction Tremor
Pain Swallowing
Spasticity Falls
Balance problems Insomnia
Restless legs Fertility
Clinical trials
Gait
Pressure sores
Oscillopsia
Emotional lability
Seizures
Gastrostomy
Rehab
Suprapubic catheter Intrathecal
baclofern
Physio- therapy
Speech therapy
Occupational Therapy
Functional neurosurgery
Colostomy
Tendonotomy
Studying
Employment Relationships
Travel
Vaccination
Anxiety
Driving
Nurse specialists
Counselling
Family counselling
Relapses
1st line
2nd line
Maintenance Escalation Induction
Monitoring
Disease-free
Disease progression
DMTs
Side Effects
Advanced Directive
Exercise
Diet
Alternative Medicine
Pregnancy Breast Feeding
Research
Insurance
Visual loss
Palliative Care
Assisted suicide
Social services
Legal aid Genetic counselling
Prevention
Diagnosis
DMT Symptomatic
Therapist
Terminal
Counselling An holistic approach to MS; beta ver. 2.1
Intrathecal phenol
Fractures
Movement disorders
Osteopaenia