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SM, NMOSD, Acute Disseminated Encephalomyelitis MULTIPLE SCLEROSIS NMOSD - Neuromyelitis optica spektrum disorders ADEM - Acute disseminated encephalomyelitis J.Szilasiová Department of Neurology LF UPJŠ Košice 11.3.2020 Multiple Sclerosis (MS) • Definition: chronic autoimmune inflammatory disease of the CNS • Damage of myeline and axons • Inflammatory infiltrates /lesions: disseminated in the white and gray matter: • Periventriculary, in the corpus callosum, brain stem, cerebellum and spinal cord Epidemiology • Occurance: young adults • Onset: 20- 40 year • F: M – 2 : 1 • Prevalency, Slovakia: 127 / 100 000 inhabitants • Disease of the middle climate regions • Geografic gradient of prevalence, higher in North America and Europe, decreases with geographic lattitude • Highest prevalency: Scandinavia, British Islands (250 /100 000 inhab.), Orkney Islands Etiopathogenesis • MS etiology is polyfactorial: genetic + external enviromental factors • Enviromental: viral and bacterial infections, smoking, obesity, vitamin D deficiency, salt, low sun exposition • „Susceptibility“ to MS - 200 genes • Familial occurance of MS and increase risk for relatives – 10-30 % Pathogenesis Trigger factor of MS onset: - Abnormal interaction between viral infection (EBV, CMV, Herpetic virus - antigen similarity, molecular mimicry) and neuronal system leads to an autoimmune attack to the CNS myelin antigens Pathogenesis activated TH1 cells admitt to the CNS = > cytokines (TNFa, IL-2, INFgama) activation of Ma, B-Ly, antibodies production = > myeline destruction => demyelinative lesion - plaque ("Sclerose en plaque") - progressive lost of axons - brain and spinal cord atrophy Ma- macrophage, TNF- tumor necrosis factor, IL- interleukin, INF- interferon, Ly- lymphycytes Pathogenesis Inflammation and loss of myelin slows down nerve impulse conduction = > exposed axons are disrupted = axon damage = > progredient degeneration and neuronal pathways atrophy = > neurodegeneration Disease progression (non treated MS patient) Mono- Secondary-progressive Subclinical symptomatic Relaps-remitting phase phase First attack Disability progressionDisability time Cognitive dysfunction Relapses Lesion accumulation- MRI New gadolinium enhancing lesions Symptoms of MS neurol. symptoms are caused by conductive block, or slowing of nerve impulses in demyelinative fibers + axonal loss - irreversible symptoms depends on localization of the lesion, the pathway in which the lesion is located summation of residual symptoms after relapses Disease course, MS clinical phenotypes /forms • Relapsing-remitting form / RRMS • 55-85%, a half of them go on to SPMS form after approx. 10 years of disease course • Primary progressive form / PPMS 15% • Secondary – progressive form / SPMS Attack, relapse • Symptoms subjected to the patient, or objective finding typical of an acute inflammatory demyelinating event of the CNS, present or past • New symptoms, or significant worsening of existing symptoms • Symptoms of an attack last at least 24 hours • Absence of fever or infection • The paroxysmal symptoms must last for at least 24 hours • The attack is followed by a period of variable improvement (full or partial) • Pseudorelapse - fluctuation of symptoms during the day, dependence on stress, body temperature and physical exertion, menstrual cycle, co-morbidities Clinical symptoms • Sensitivity and motor activity disturbances -limbs, trunk and face • Visual problems - blurred vision, scotoma, diplopia • Balance problems - ataxia (vestibular, spinal, cerebellar) • Fatigue, cognitive deficit, depression, neuropathic pain • Sfincter problems The manifestation of MS symptoms is given by the conduction block (or slowing) in the demyelinative lesion and axonal disruption (irreversible status) They depend on the site of the lesion, the pathway that is damaged CIS (Clinically Isolated Syndrome) • The first, initial symptom/syndrom • Episode of new demyelinative lesion • Episode of the brain or spinal cord lesion • The first MS attack • Acute, or subacute episode related to the demyelination location CIS - typical , monofocal symptoms- 2/3 of patients - atypical- multifocal symptoms MS onset, the first episode = Clinicaly isolated syndrome/CIS – monofocal or multifocal syndrome Optic neuritis Multifocal syndrome Myelitis Brainstem/ cerebellar syndrome CIS: Optic neuritis • Unilateral optic nerve (n.II) infammation, and focal demyelination • Unilateral, blurred vision, retrobulbar pain, central scotoma, loss of color vision • MRI shows hypersignal T2 lesion in the optic nerve • Good prognosis, partial or complete recovery CIS: Myelitis • Focal spinal cord inflammation and demyelination • Cervical segments - most often affected • Partial transverse lesion • Sense difficulties • Motor difficulties • Lhermitte sign • Sfincter problems • Sense of „belt“ • Chest numbness • Acute dystonia CIS: Brainstem- cerebellar syndrome • Oculomotor palsy (Internuclear ophthalmoplegia) - diplopia, strabism • Nystagmus • Sensitive syndromes • Vertigo, ataxia • Hemiparesis • Trigeminal neuralgia • Hemifacial spasm • Cerebellar ataxia, dyzartria • Rubral tremor MS clinical symptoms There is no symptom specific only for MS ! Vision - blurred vision, scotoma, loss of color vision, blindness, pain of eye bulb with movements Eye bulb movement disorder – diplopia, ophthalmoplegia, nystagmus V, VII, VIII, IX nn. lesion - trigeminal neuralgia, loss of sense of the face, paresthesia, vertigo, ataxia, dysarthria Sensitivity disease - tactile, vibratory, paresthesias, dysesthesias, hypesthesia, anesthesia, ... Movement disorders - spastic paresis or plegia, monoparesis, hemiparesis, quadriparesis, triparesis Cerebellar symptoms - ataxia, dysarthria, intention tremor, titubations Sfincter dysfunction - imperative urgent micturition, urine retention, stool and uronary incontinence Cognitive dysfunction - deficit of attention, memory, information processing speed Fatigue Autonomic dysfunction - arrythmia, hyperhidrosis, orthostatic hypotension, cold and cyanosis of limbs,... EDSS - Expanded Disability Status Scale Scale used in MS for scoring of the total disability Functional systems: 1. Vision 2. Brain stem 3. Motor/pyramidal system 4. Sense 5. Cerebellum 6. Sfincters 7. Mental and mood problems - fatigue, cognitive function, depression, anxiety 8. Ambulation (walking with or without aid) EDSS scale EDSS- 0 (min.) - 10 (max.) - impairment, disability Prognosis of MS • Depends on • frequency of relapses in the first 2 years • period between 1. a 2. relapses After 10 years - 50 % of pts disable to work After 25 years - 50 % of pts disable to walk • Total surviving is 7 years shorten than common population (immobility, decubits, infections, ...) Case report Mono- Subclinical Mono- RelapsRelaps-remi-rtujúcaemitting forma Secondary-progressive symptomaticsymptomatic 3/2006 – LL paraparesis, partial urinary incontinence, need 1/2004- diplopia assisstance with walking, cerebellar dyzarthria and ataxia, 3/2002 6/2004- hemiparestesias cognitive deficit in atention 6/2001 Left side fatigue Optic 12/2004- sfincter neuritis problems and lost of sense perianogenitaly 7/2005- cerebellar dyzarthria and ataxia EDSS 1,5 EDSS 2,0 EDSS 4,5 EDSS 7,0 MS diagnosis Presence of lesions disseminated in the CNS in time (DIT) and space (DIS) 1. History, typical clinical course 2. Neuroimaging – MRI (brain, spinal cord) 3. CSF - diff. diagnosis 4. Evoked potentials - VEP None of these investigations are specific for MS !!! McDonald diagnostic criteria of MS – 2017 revision • The key principle of MS diagnosis is the evidence of lesions dissemination in space (DIS) and in the time (DIT) in the CNS A) DIS- dissemination in space – 2 and more lesions in any of 4 typical localisations B) DIT - dissemination in time – damage was repeated several times • MRI protocol of brain and spinal cord evaluation in suspected MS: • T2V0 + FLAIR + T1V0 native scan and postcontrast scan (gadolinium is used as a contrast in MRI) • Hypersignal lesions in T2 weighted scan - typical shape and localization in MS – DIS - the presence at least one T2 lesion in at least 2 different localisations (there are 4 typical localizations for MS lesions: periventricular, juxtacortical, infratentorial, spinal cord) – DIT - if gadolinium enhancing lesion (Gd +) is present with gadolinium inactive (Gd-) lesions, or a new T2 lesion and / or 1 Gd + lesion at any time since MR examination is present – or CSF positive for MS https://www.news-medical.net/news/20171222/ Magnetic resonance imaging in MS • T2-weighted imaging – hyperintensive/hypersignal lesions in the white matter, most often periventriculary • T1-weighted imaging – hypointensive lesions, black holes = axonal loss which leads to progressive brain atrophy • Gd+ enhancing lesion (Gd - gadolinium) - new, active, inflammatory lesion (last 6-8 weeks) • T2 T1 Gd+T2 GD+T1 Magnetic resonance perpendicularly stored „Dawson´s fingers“ - typical perpendicularly located lesions on corpus callosum MS diagnostic McDonald criteria 2010 and 2017 - DIT and DIS • Patient with MS must meet the criteria: • DIS - 2 or more T2 lesions in typical location • DIT - new T2 lesion or Gd+ enhancing lesion, or positive OCB (ologoclonal bands) in CFS Brain atrophy in MS is accelerated in MS (0,6 - 1,35 % of brain volume/year) in contrast with heathy controls (0,1 - 0,4 % of brain volume /year) Brain atrophy can be measured using different methods of MRI MRI Volumetry (whole brain volume, white matter, gray matter volume, ...) Evoked potentials, EP •VEP: visual EP •SEP: somato - sensory EP •BAEP: auditory brainstem
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