00:01
So when we think about
clinically isolated syndromes
and patients presenting with any
of those constellation of symptoms,
what's the workup?
What is our diagnostic approach?
Well, here the goal is
to stratify the risk
of presenting with another attack
or looking for a prior attack.
00:17
Clinically isolated syndrome
is one attack.
00:20
If there have been prior episodes
of autoimmune attack on the brain,
spinal cord or optic nerve,
or risk of future attacks,
we start to worry about
a recurrent syndrome
MS, NMO, anti-MOG disease
And so our workup is to look at
other areas of the neuro axis
to look for prior episodes or
the potential for future attacks.
00:39
We can do that with
MRI of the brain, MRI of the spine,
evoked potentials.
00:44
Typically visual evoked potentials
of somatosensory evoked potentials
can also be performed
and lumbar puncture.
00:50
And in the lumbar puncture,
we're looking for signs of CNS
and CSF inflammatory changes.
00:59
First, let's talk about
typical MRI findings
that we can see in these patients.
01:03
50 to 80% of patients
will have findings on their MRI
at the time of their initial
clinically isolated syndrome.
01:10
And so these patients,
we begin to be more concerned
about the risk of
a recurrent syndrome.
01:17
The presence of these lesions
confers a 70 to 90% chance
of clinically definite MS
over the next 14 years.
01:24
And so many of these patients,
particularly those
who have pre-existing MRI findings
will go on to develop MS
or recurrent syndrome.
01:33
In many fields that number matters,
although it's unclear.
01:37
The more lesions that
are present on the brain,
the more concerned we become about
the potential for future attacks,
and the more likely we are
to treat those patients
at their presentation
with an initial clinical event.
01:51
So first, let's walk through
some of the MRI brain findings
that we can see in patients
presenting with a
clinically isolated syndrome.
02:00
Here you can see
typical MRI of the brain,
an axial FLAIR on the left
and a sagittal FLAIR on the right.
02:06
And we really like
the FLAIR sequences
when evaluating
CNS autoimmunity or MS,
or clinically isolated syndromes.
02:14
we're looking for
white matter lesions.
02:16
So those are white areas
on the T2 or FLAIR
that are in the white matter.
02:21
The white matter on
the FLAIR is darker.
02:23
And what we tend to see
is white matter lesions
around the ventricles,
periventricular
white matter lesions.
02:29
And you can see that really well
on the sagittal FLAIR,
These white matter lesions that are
emanating away from the ventricles,
they course along
the perivenular pathways
emanating away from the ventricles
and give us an appearance
of what's been termed
Dawson's fingers.
02:47
Finger like projections
away from the ventricle,
which is very commonly seen
in patients with MS
and other inflammatory disorders
of the nervous system.
02:59
How about MRI of the spine?
What are the typical findings
that we see
on the MRI of the spine?
Here we're looking at
two sagittal T2 weighted MRI
demonstrating a very typical
appearance of a lesion
that would be consistent
with a transverse myelitis.
03:14
A short segment of
T2 hyperintensity
that is suggestive of an area
of acute inflammation.
03:21
These lesions often will enhance,
there may be patchy enhancement
present in these lesions
indicative of acute
blood-brain barrier breakdown,
particularly early
in the presentation
within that first couple of weeks
from symptom onset.
03:38
How about evoked potentials?
Historically, this was a very
commonly used diagnostic tool.
03:44
And increasingly other tools are,
have higher resolution
and more specificity and sensitivity
for a diagnosis.
03:50
But occasionally, we'll will do
visual evoked potentials.
03:54
This is the presentation
of a visual stimulus
and recording of the time
it takes for that stimulus to move
through the optic pathway
and be recorded back
in the occipital cortex.
04:05
We're looking for the time
it takes to get there
and looking for an asymmetry
between the signals coming in from
the left eye and the right eye.
04:13
That would be
indicative of a lesion
somewhere along the visual pathway.
04:19
This is really an extension
of our physical exam.
04:21
It's another way of doing
that swinging flashlight test
looking for an afferent
pupillary defect.
04:28
And so this can be useful
when the patient
has a really suggestive story
of an optic neuritis,
or a clinically isolated
transverse myelitis.
04:36
And we're looking to establish
some other evidence
that there has been a CNS attack.
04:41
In a patient who has
transverse myelitis
where there's an abnormal
visual evoked potential
that then separates
those lesions in space
and can separate them in time
to establish a diagnosis of MS.
04:53
This can also be useful in patients
who present with an atypical story
where it just doesn't sound like
the classic optic neuritis.
05:02
We don't have evidence of an
afferent pupillary defect on exam
and it's unclear whether there is
truly a lesion of the optic nerve
and visual evoked potentials
can be helpful
as objective evidence of lesions
that may be subclinical
in those patients.
05:20
And then lastly,
the lumbar puncture.
05:22
This is a critical aspect of
evaluating any immune attack
in the central nervous system
and often incorporated
into the evaluation
of patients with
clinically isolated syndrome.
05:32
When we're performing
a lumbar puncture,
we do so with a patient
in the lateral decubitus position.
05:37
You can see that here
the patient lying on their side.
05:40
We take a spinal needle and
that's inserted into the L4-L5
or occasionally L3-L4
spinous process spaces.
05:48
As you can see here and
access that thecal sac area
where we can gain access
to cerebrospinal fluid.
05:55
And typically we draw off
10 to 20 ml of spinal fluid
and we'll perform a range of
tests to look for signs of
infection, inflammation,
malignancy,
or other potential explanations
for the patient's presentation.
06:08
Routine studies performed on
essentially all spinal taps
performed in neurology includes
cell count, glucose, and protein.
06:15
The cell count guides us in
terms of whether to be concerned
for infection or for cancer.
06:20
An elevation in a cell count
is called pleocytosis.
06:23
Pleocytosis gives us concern
for a possible infectious process
or occasionally malignancy,
that when some
inflammatory conditions
we can see mildly elevated
cell count or a mild pleocytosis.
06:36
Glucose levels
should really be normal
and patients presenting with
inflammatory conditions,
but maybe abnormal in cancer or
acute bacterial or fungal processes
affecting the spine or spinal cord.
06:49
And Protein.
Protein is really important.
06:51
This is an inflammatory marker,
we see elevation in protein
in the spinal fluid
in conditions that
result in inflammation.
06:58
So normal cell count and
elevated protein is called an
albuminocytological dissociation,
and that signature
is highly suggestive
of an inflammatory process.
07:09
In addition, we can look at
some more specific markers
for evidence of CNS inflammation,
including oligoclonal bands,
IgG index,
and kappa free light chains.
07:18
And here we're comparing
the findings in the spinal fluid
to those in the blood
looking for evidence
of inflammation
that is specific
to the spinal fluid
specific to the
central nervous system.
07:29
An increase in oligoclonal bands
present in the spinal fluid
and not in the serum is suggestive
of an active inflammatory process
in the nervous system.
07:37
An increase an IgG index
and that's immunoglobulins
IgG that's increased in the
spinal fluid and not in the serum
is also supportive of
an inflammatory process,
as well as increased
kappa free light chains.
07:50
These findings should
raise strong suspicion
for a CNS autoimmune condition,
clinically isolated syndrome
MS, NMO, anti-MOG disease
but can also be seen
in other conditions
that rev up the immune system
in the nervous system,
including rarely some cancers and
rarely some infectious processes.
08:10
How do we treat
clinically isolated syndrome?
Well, we treat it the same way we do
any acute CNS inflammatory attack,
and that's with corticosteroids,
IV methylprednisolone
or solu-medrol
is typically the workhorse
in treating these patients.
08:25
Patients will receive one gram
of IV methylprednisolone daily
for anywhere between
three and five days.
08:32
There are a number of studies
looking at the length of treatment
of IV methylprednisolone,
in a famous
optic neuritis treatment trial,
three days was used
typically in clinical practice.
08:43
We may see five days
of treatment use.
08:45
The key is to treat that
acute CNS inflammatory attack
with strong and powerful
anti-inflammatories
and corticosteroids
is the treatment of choice.
08:55
Importantly,
steroids do not stop the attack,
but reduce the continued progression
of the attack and of symptoms
and reduce the nadir,
reduce the likelihood of reaching
as severe a clinical deficit,
as we would see.
09:12
Patients with
CNS autoimmune conditions
will recover spontaneously,
and the goal of steroids
is to speed that recovery.