ICS-Multiple Sclerosis Flashcards
Criteria for diagnosis of multiple sclerosis
2+ lesions in CNS white matter separated in time & space. Slow progression over 6+ months. 2+ episodes. 10-50 years old. MRI findings.
Young, female and northern hemispheres.
All seen in populations with increased incidence of MS.
A 21 year old female presents to the office with a 2 day history of left eye pain. The pain is worse when she moves her eye. She says her vision is worse, she can’t really see color and that there is a central blind spot. What do you need to rule out before diagnosing her with multiple sclerosis? What fundoscopic exam may indicate MS?
Optic neuritis. Note the contrast-enhancing lesion in the optic nerve that is classic of optic neuritis. On fundoscopic exam you would see optic atrophy if the patient had MS. Note that it take 6+ months to develop optic atrophy.
A 28 year old male presents with tingling and numbness in his legs. Over the next day it rises up both legs to the bellybutton. He complains of feeling like their is a tight band around his waist and clumsiness when walking. What do you need to rule out before diagnosing him with MS? What would you expect to see on MRI in a patient with MS?
Transverse myelitis, inflammation of the spinal cord damaging different tracts causing Brown-Sequard syndrome. On MRI you would see a cigar-shaped enhancement in the spinal cord (arrow).
A 26 year old female presents with double vision and imbalance. Physical exam reveals decreased adduction in the right eye and dissociated nystagmus on the left. What condition do you need to rule out before diagnosing this patient with MS?
Internuclear Ophthalmoplegia. This is an MLF lesion that prevents CN VI nucleus stimulation of CN III nucleus and prevents medial rectus stimulation.
A 23 year old male presents with paralysis of his right face muscles, right arm clumsiness and left arm hemiparesis w/upper motor neuron signs. He has a family history of MS. Where is that likely lesion?
Brainstem. Note the ipsilateral CN, ipsilateral cerebellar and contralateral long tract involvement that hints at the brainstem.
Why do you sometimes see trigeminal neuralgia in patients with MS?
It attacks the white matter of CN V fascicles.
Most common early symptoms of MS
Somatosensory (dorsal column or lateral spinothalamic tract).
Pseudobulbar affect
Patients have difficulty controlling emotions and associating them with appropriate emotions.
Why do MS patients present with increased symptom severity when placed in a hot bath?
Nerve conduction decreases when core temperature goes up.
CSF findings in MS
Oligoclonal IgG bands, WBC > 50, Protein > 100mg/dL
What are characteristic lesions of MS found on MRI?
Juxtacortical (just below cortex) and Periventricular (ex: Dawson’s finger lesion perpendicular to lateral ventricle). Infratentorial (brainstem & cerebellum. Spinal cord.
What is the most common course followed by multiple sclerosis?
Relapsing-remitting. The others are secondary progressive, primary progressive and progressive relapsing.
MS Treatment
IV Solumedrol (steroid that helps patient recover from attack). Symptomatic treatment. Disease modifying therapy (beta interferon 1b/1a, glutarimer acetate, natalizumab)
Tysabri risk factor
JC virus, immunosuppression or long duration of treatment. Patients can develop progressive multifocal leukencephalopathy.
