Inflammatory Disorders of the Central Nervous System

Question 1

What are the basic subtypes of MS?

Answer 1

1. Relapsing-Remitting (RRMS): 85% present in this manner. Multiple attacks over time.
   Evolving/worse symptoms&raquo_space; remission
2. Primary Progressive (PPMS)
   15% present this way. More common in middle age.
   Continuous progression from outset, variable rate
3. Secondary Progressive (SPMS)
   Majority of RRMS converts to progressive disease
4. Relapsing-Progressive: Elements of relapse and progression
5. Clinically Isolated Syndrome: Single, first attack of apparent demyelination
6. Radiologically Isolated Syndrome: people scanned for non-MS symptoms show MS on MRI

Question 2

What is the epidemiology of MS?

Answer 2

• 3/4 Present between 15-45, 5%

Question 3

What is the basic approaches to therapy in MS?

Answer 3

Acute attacks: High dose corticosteroids. Plasma exchange for severe myelination unresponsive to steroids

Relapsing-Remitting: Immunotherapy = ABC-R therapy

Secondary Progressive: Immunotherapy = Interferon Beta-1b

Treatment of gait/motor function: Dalfampridine (Ampyra)

Question 4

What should you expect from immunotherapy in MS?

Answer 4

• RRMS (ABC-R tx): New attacks are reduced by 1/3. Decrease in number of enhancing lesions, T2 “burden of disease,” brain atrophy, and disability progression.
• RRMS (fingolimod): 50% reduction in relapse rate and 33% reduction in progression of disability
• SPMS (ABC-R tx): Clinical outcomes yield mixed results. Most effective in younger patients with short disease duration and evidence of inflammation.

Question 5

Early clinical symptoms of MS

Answer 5

• Parasthesias
• Weakness
• Monocular loss of vision & diplopia
• Gait problems
• Lhermitte’s Sign
• Urinary urgency/frequency
• Constipation

Question 6

Late clinical symptoms of MS

Answer 6

• Early clinical symptoms remain
• Fatigue
• Sexual dysfunction
• Depression
• Cognitive dysfunction
• Pain
• Dysphagia
• Rarely: seizures + hearing loss

Question 7

Neurological exam abnormalities of MS

Answer 7

• Asymmetric upper motor neuron signs
• Decreased visual acuity
• Optic atrophy
• Afferent papillary defect
• Eye movement abnormalities
• Internuclear opthalmoplegia (adduction impairment)
• Sensory loss
• Cerebellar signs (i.e. ataxia, tremor, dysarthria)
• Labile affect
• Cognitive dysfunction

Question 8

Lab study abnormalities of MS

Answer 8

MRI: lesions in periventricular regions, corpus callosum, spinal cord, brainstem and cerebellum. T1 holes and atrophy are most predictive of disability.

CSF: Normal to mildly elevated protein. Normal to mildly elevated WBC. Glucose always normal. Abnormal IgG production

• Possible optic nerve damage
• Myelin specific protein elevated (nonspecific finding)