Multiple Sclerosis (3Q)

Question 1

MS: Patient

Answer 1

Usually under 55 yo, F>M. Western European or non-tropical ancestry.

Question 2

MS: symptoms

Answer 2

Sx occur suddenly and last a few days to weeks:

Weakness, numbness, tingling, diplopia, sphincter disturbance (urgency/hesitancy).

Question 3

MS: Px

Answer 3

Optic atrophy, nystagmus, dysarthria, pyramidal, sensory, or cerebellar defects. Signs of upper motor lesion.

Question 4

CIS

Answer 4

Clinically isolated syndrome- a single MS attack.

Question 5

Relapsing-remitting MS

Answer 5

Interval of months to years between symptoms. Relapses are followed by incomplete remissions and ultimate disease progressoin. Most common type.

Question 6

Secondary progressive MS

Answer 6

Clinical course of disease in relapsing-remitting patient changes to a steady deterioration that is unrelated to relapses.

Question 7

Primary progressive MS

Answer 7

Least common. Sx are steady and progressive from a relatively early stage.

Question 8

What are some MS triggers?

Answer 8

Heat, infections. 2-3 months following pregnancy, stress.

Question 9

T1 weighted MRI of brain in MS shows…

Answer 9

hypointense black holes representing permanent damage due to lesions. Some lesions may be hyperintense.

Question 10

T2 weighted MRI of brain in MS shows…

Answer 10

Total number of lesions, cumulative burden of disease. Typically lesions appear as areas of high signal intensity.

Question 11

Gadolinium-enhanced MRI of brain in MS shows…

Answer 11

areas of active inflammation with breakdown of BBB–this indicates new/active lesions.

Question 12

Arnold-Chiari malformation

Answer 12

parts of cerebellum and the lower brainstem are displaced into cervical canal producing mixed pyramidal and cerebellar deficits in limbs.
**Always visualize foramen magnum region to r/o. Causes MS-like symptoms.

Question 13

MS: CSF findings

Answer 13

mild lymphocytosis, slightly increased protein. Elevated IgG w/ discrete oligoclonal bands. These are all non-specific.

Question 14

What is required for a diagnosis of MS?

Answer 14

1. Dissemination in space (2 or more regions of central white matter affected. In patient w/ single attack, repeat image in a few months)
2. Dissemination in time (multiple symptomatic attacks OR enhancing and non-enhancing lesions on MRI).

Question 15

What is required to diagnose primary progressive MS?

Answer 15

Minimum 1 year of progressive disease + 2/3 of:

1. at least 1 typical brain lesion
2. at least 2 spinal lesions
3. oligoclonal banding of CSF

Question 16

What should you recommend for patient with CIS?

Answer 16

Follow up MRI in 6-12 months. Refer to neurology for possible treatment with beta interferon or glatiramer acetate, which may delay progression.

Question 17

Acute MS attack: Tx

Answer 17

IV corticosteroids (methylprednisolone 1g/day * 3 days). Follow w/ oral prednisone fore 1 week (60-80mg) and a taper over next 2-3 weeks (current).

Question 18

Relapsing-remitting MS: preventative Tx (1st line)

Answer 18

IM/Subcutaneous: beta interferon (1a, 1b); glatiramer acetate;

PO: fingolimod

Question 19

Progressive MS: Tx

Answer 19

Immunosuppressive treatment:

Rituximab, cyclophosphamide, azathioprine, methotrexate.

Question 20

Treat severe relapses refractory to corticosteroids with:

Answer 20

plasmapherisis