Diagnosis of MS

Question 1

Multiple Sclerosis is:

Answer 1

An inflammatory demyelinating disease of the CNS where there is:

Dissemination in space
Dissemination in time
No alternative neurological disease which may explain the symptoms and signs (“no better explanation”)

Question 2

the diagnosis of MS is..

Answer 2

clinical

Question 3

what are the three subtypes of MS?

Answer 3

Relapsing-remitting (85% at onset)
Circa 80% subsequently go on to Secondary

Progressive

Primary progressive (10%)

Progressive Relapsing (5%)

Question 4

what are three commonest initial presentations of MS

Answer 4

optic nerve inflammation 14-20%

Weakness (10-40)
Sensory Loss (13-39)

Question 5

optic neuritis in MS is:

Answer 5

1. Typically unilateral
2. Retrobulbar
3. Typically painful
4. Some recovery expected
5. No retinal exudates
6. No macular star
7. Disc hemorrhages infrequent

Question 6

Myelitis in MS is:

Answer 6

1. Partial sensory or motor
2. Sensory more common
3. Lhermitte sign
4. Bowel and bladder dysfunction is common
5. “Band-like” abdominal or chest pressure
6. Acute dystonias

Question 7

what are 5 common brainstem/cerebrum features of MS

Answer 7

1. Ocular motor syndromes (e.g., internuclear ophthalmoparesis/nystagmus)
2. Hemisensory, crossed sensory syndromes
3. Hemiparesis
4. Trigeminal neuralgia
5. Hemifacial spasm

Question 8

all diagnostic criteria for MS require…

Answer 8

‘dissemination in time and space’ (& ‘no better explanation

Question 9

what are the four types of MS in the poser diagnostic criteria?

Answer 9

Clinically definite MS
Lab supported definite MS
Clinically probable MS
Lab Supported probable MS

Question 10

what defines clinically definite MS in the poser criteria?

Answer 10

either a) 2 attacks + 2 lesions on examination

OR
2 attacks + 1 lesion + 1 paraclinical lesion

Question 11

what defines laboratory supported definite MS?

Answer 11

B1) 2 attacks + 2 lesions on examination,
B2) 1 attack +2 lesions on examination +abnormal CSF
B3) 1 attack +1 lesion on examination + l paraclinical lesion + abnormal CSF

Question 12

what supports clinically probably MS in the poser criteria?

Answer 12

C1) 2 attacks + 1 lesion on examination
C2) 1 attack + 2 lesions on examination
C3) 1 attack + 1 lesion on examination +1 paraclinical lesion

Question 13

what supports lab supported probable MS in the poser criteria

Answer 13

D1) 2 Attacks + abnormal CSF

Question 14

the McDonald criteria 2001: lesions must meet at least 3 of the 4 following stringent MRI criteria:

Answer 14

1) at least 1 Gd lesion, or at least 9 T2 lesions
2) at least one infratentorial lesion
3) at least one juxtacortical lesion
4) at least 3 periventricular lesions

Question 15

what both criteria must be met for MRI +CSF criteria in McDonald (2001)

Answer 15

> 2 lesions consistent with MS

CSF showing OCB or increased IgG index

Question 16

what are the McDonald criteria for dissemination in time (2001)

Answer 16

If MRI is >3 months after first event:

> 1 Gd lesion not at site of original attack; or
MRI 3 months later showing a new T2 or Gd lesion

if MRI is <3 months

New Gd lesion on the second MRI
Later MRI showing new T2 or Gd lesion

Question 17

DIS (Dissemination in Space) can be established by what i the 2010 McDonald criteria?

Answer 17

> 1 t2 lesion at least 2 of 4 areas of the CNS:

periventricular
juxtacortical
infratentorial
spinal cord

Question 18

DIT dissemination in time can be established by what criteria on McDonald 2010

Answer 18

1) a new T2 and/or Gd enhancing lesion(s) on follow up MRI

2) simultaneous presence of asymptomatic Gd enhancing and non-enhancing lesions at any time

Question 19

CSF OCB are not….

Answer 19

Specific to MS:

lupus
sarcoidosis
behcet Dz and various other diseases

Question 20

what is the risk factor for subsequent MS in clinically isolated syndrome of Optic Myelitis

Answer 20

60-80%

Question 21

what are the risk factors for conversion from CIS to MS in optic myelitis

Answer 21

History of minor neurological symptoms
Unilateral optic neuritis
Brain MRI lesions
Abnormal CSF
Abnormal VERs

Question 22

what are the risk factors for conversion from CIS to MS for transverse myelitis

Answer 22

Incomplete transverse myelitis
Asymmetric motor or sensory findings
Brain MRI lesions
Abnormal CSF
Abnormal VER and SSEPs

Question 23

what are two differential diagnosis for MS

Answer 23

Neuromyelitis Optica (Devic Syndrome)

Postinfectious encephalomyelitis or ADEM

Question 24

what are the qualities of neuromyelitis optica?

Answer 24

Relapsing (65%), monophasic (35%)

Myelitis & optic neuritis usually severe

MRI: long cord lesions, chiasmal signal changes

CSF: generally >100 wbc, increased protein, rare OCB

Question 25

what are the qualities of Postinfectious encephalomyelitis or ADEM

Answer 25

Monophasic with preceeding event common (70%)
Most common in children
Altered level of consciousness and seizures common
MRI: bilateral lesions of the same age

Question 26

what are the red flags for Misdiagnosing MS

Answer 26

MRI changes without symptoms or signs typical for MS

Known psychiatric disease

Normal neurological examination

Atypical clinical features

• Disease onset at the extremes of age
• Extraneural systemic disease
• Prominent gray matter symptoms