Demyelinating Diseases: Multiple Sclerosis, Transverse Myelitis, Neuromyelitis Optica

Front 1

What is the most common demyelinating disease in humans?

Does it affect central or peripheral nervous system?

What is the pathologic lesion?

What is the most common form of the disease?

Back 1

Front 2

What is a relapse?

Back 2

New neurologic disability that lasts greater than 24 hours

Front 3

What is the clinical definition of MS?

Back 3

Two relapses that occur during two different times in a person's life.

Two different areas of the CNS.

Front 4

What is used to diagnose MS?

Back 4

MS plaques on MRI

Inflammatory profile in spinal fluid

IgG index and oligoclonal bands

Some lymphocytes but NEVER neutrophils!

Front 5

What are the bright white areas? Diagnosis?

What are they often enhanced with?

Back 5

MS plaques

Gadolinium => does not normally enter brain parenchyma, but does in the case of new acute MS plaque where active inflammation and breakdown of BBB allows gadolinium to enter brain parenchyma.

Front 6

Can MS also affect the spinal cord?

Back 6

Yes

Front 7

What is shown here?

Back 7

Oligoclonal bands of IgG

Front 8

How is the visual evoked response effected with MS?

Back 8

How quickly the occipital cortex detects light input from the retina

Front 9

Review

Back 9

Front 10

Where are plaques located?

Luxol fast blue stains normal myeline what color?

Back 10

Deep white matter and periventricular areas

Front 11

Are axons also damaged in MS?

Back 11

Front 12

What is the pathogenesis of MS?

Back 12

Unknown

Genetically susceptible individuals => triggers => leukocytes penetrate BBB and secrete inflammatory cytokines => T-cells, B-cells, and macrophages autoimmune attack against myelin antigens => demyelination and axonal loss

Front 13

More detailed pathogenesis of MS:

Back 13

TH1 activated in systemic circulation => cross BBB and initiate autoimmune response => stimulate B cells to make antibodies and macrophages to demyelinate and cause axonal damage

TH2 => regulate and reduce pro-inflammatory response of TH1

Front 14

Age of diagnosis of MS?

Sex?

Distance from equator?

Back 14

Between 20-40

2/3 female

Incidence of MS increases with distance from the equator

Front 15

What are the two types of MS?

Back 15

Relapsing

Progressive

Front 16

Relapsing or progressive?

Back 16

Relapsing

Front 17

Steady progression of disability with few or no exacerbations. Relapsing or progressive?

Back 17

Front 18

Draw the graph of benign MS. Remitting MS. Secondary progressive MS. Natural progression of primary MS.

Back 18

Front 19

What if life expectancy of MS?

What is average relapse per year?

Median time to reach EDSS?

Back 19

Front 20

What will you see evaluated in spinal tap in MS patient?

What type of evoked potentials are used?

Back 20

Front 21

What are these the symptoms of?

Back 21

MS

Front 22

What are these all symptoms of?

Acute, subacute, or chronic

Back 22

MS

Subacute

Front 23

What is the effect of increased temperature on demyelinated segments?

Back 23

Front 24

What are the two most common presenting symptoms in MS?

Back 24

Sensory symptoms in arms/legs, unilateral vision loss

Front 25

Where are MS plaques located?

Back 25

Periventricular

Front 26

Protein level in MS CSF? Normal or abnormal

Lymphocyte count? Elevated or not?

What are the markers of MS in the CSF?

Back 26

Front 27

If the optic nerve is demyelinted from MS, what will be the delay in VER?

Back 27

Front 28

What is shown here?

Back 28

Optic neuritis in MS

Front 29

Will patients with MS sometimes have an APD?

Back 29

Front 30

What is described here?

Back 30

Clinically isolated syndrome

Front 31

Patient with CIS, how do you determine if they have MS or not?

Back 31

Traditionally = wait for second attack

Now = MRI to determines lesions in time and space

Front 32

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Front 34

How many lessons on MRI do you need if patient presents with one syndrome?

Back 34

CIS = 1!

Front 35

What drugs are used for acute relapses of MS?

Back 35

Steroids

Steroids do not alter the course of the disease

Front 36

Back 36

Front 37

Diagnosis?

Back 37

Transverse myelitis

No back pack but early urinary retention = SPINAL CORD LESION!

Front 38

Neurologic exam of what?

Back 38

Transverse myelitis

Front 39

What is shown here?

Back 39

Transverse myelitis MRI

Lesion is limited within the spinal cord to only 1-2 vertebral body segments

Front 40

What is an acute neurologic condition that reflects FOCAL inflammation of the spinal cord?

What disturbances may occur? Symmetrical or asymmetrical?

May be the first sign of what condition?

What is the treatment?

Back 40

Front 41

Diagnosis?

Back 41

Severe thoracic pain

Optic neuritis

Acute paraparesis w/ urinary retention

NEUROMYELITIS OPTICA (NMO)

Front 42

What do these tests indicate?

Back 42

Neuromyelitis optic (NMO)

Front 43

How much of spine is involved with NMO?

Back 43

Can involve almost the entire spinal cord

Front 44

What distinguishes NMO from MS?

Back 44

Eosinophils, neutrophils, hyalinized vessels

Front 45

What is the mechanism of NMO?

Back 45

Antibody mediated demyelination, axonal injury, and necrosis

Front 46

Optic neuritis + a lesion or two on MRI? Does patient have MS?

Back 46

Not technically => increased risk, but need to wait for second "time" factor to be sure

Front 47

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Front 48

Optic neuritis + lesions on MRI + gadolinium enhancing lesion (new)? Does patient have MS?

Back 48

Yes, "time" factor satisfied

Front 49

What are the distinguishing factors between MS, and NMO?

Back 49

Brain MRI,

3 VB segments

PMNs

OCB more common in MS

Front 50

Review this

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Front 51

Review

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Front 52

Review

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Front 53

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Front 54

INO results from damage to what?

Where is the lesion located?

Back 54

MLF

Lesion is on the side of adduction deficit.