Multiple Sclerosis: Diagnosis and Treatment

by Carlo Raj, MD

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    00:02 How are we going to diagnose it? How are you going to diagnose it? CSF, mildly elevated protein, gamma globulin is increased, and most importantly, oligoclonal bands.

    00:14 What does oligo mean? Little.

    00:17 So here, I want you to think of your clonal bands or the bands, in general.

    00:21 And as you’re interpreting a band, you have these little bands called oligoclonal bands, and those are quite indicative of multiple sclerosis if found by investigating your cerebrospinal fluid.

    00:35 Visual evoked potentials.

    00:36 Remember, you do have vision issues.

    00:39 Useful in demonstrating evidence of prior optic neuritis, but keep in mind though, frequently, the visual evoked potentials are found and there’s no history of the visual loss.

    00:51 Just keep that in mind as well.

    00:53 So you could have such abnormalities taking place but there is no history of optic neuritis.

    00:57 So these are things that you want to put everything together.

    01:00 Obviously, they’re not just going to give you one fact and expect you to know what’s going on.

    01:04 They’ll give you multiple clues and then you have to make sure that you use your clinical judgment to come to the proper diagnosis.

    01:12 What about treatment and such? If it’s acute relapse, you’re thinking about high dose IV corticosteroids.

    01:18 And then you have disease modifying agents.

    01:22 These include your beta interferons, beta interferons, beta interferons.

    01:28 I repeat that multiple times here because you don’t want to confuse this with alpha interferons or gamma interferons.

    01:35 These are beta.

    01:38 Then you have something called glatiramer acetate, and you have one of the monoclonal antibodies, natalizumab, is something that you want to keep in mind.

    01:47 In the parenthesis here are the trade names, but more importantly, you want to know about the generic names, obviously.

    01:54 In refractory cases, you’re not really left with much of an option except to start using chemotherapeutic drugs, in other words, immunosuppressants, and that of course has its own host at adverse effects.

    02:06 At this point, I'd really like for you to focus on acute relapses and the disease modifying agents such as your monoclonal antibodies and the beta interferons.

    02:16 And we also have, as I said, the glatiramer type of acetate.

    02:21 To summarize the multiple sclerosis: Risk factors: Caucasian, female population, the genetic predisposition I told you about family history that increase 15-fold risks.

    02:32 Preventative medicine; really, we don’t know of any, really difficult, unless there’s a family history already.

    02:38 Signs and symptoms: We’ve talked about this quite a bit.

    02:41 We talked about the blurred vision, the optic neuritis.

    02:44 We talked about internuclear ophthalmoplegia, the conjugate gaze type of issue, and then also medial longitudinal fasciculus.

    02:50 In addition to that, there might be ataxia, numbness, remember, CNS types of issues.

    02:55 Differential diagnoses includes infections, maybe vasculitides.

    02:59 And I showed you an imaging study where I showed you these plaques around your ventricles.

    03:04 Ventricles.

    03:05 What do those plaques represent, please? Good.

    03:08 White matter degeneration.

    03:10 And we talked about the treatment.

    03:11 What kind of interferon? Beta interferon and glatiramer acetate.

    03:17 And if it’s an acute type of relapse, then you’re thinking about high dose IV corticosteroids.

    03:22 So, once we’ve done -- You’ve noticed now over and over again in neuropathology that I have these topics in these pages in which I’ve summarized the pinpoint information or details that you want to take out of each one of these diseases These are important.

    03:39 Now, the variants, just very quickly.

    03:41 I don’t want to spend too much time here.

    03:42 Rarely, if ever asked, but just to make sure that you’re clear, you can have neuromyelitis or Devic’s disease.

    03:49 It’s a bilateral optic neuritis, very rare but variant nonetheless, just to make sure that we’re clear.

    03:55 Rapid progressive.

    03:57 Then you have acute, this is called Marburg form in which this is in young individuals, maybe even lesser or younger than 20.

    04:05 Fulminate course during the period of several months.

    04:08 What does that mean? Remember, it usually takes years and decades and decades and decades for this to use your most common clinical course, my goodness, this is rapidly acting, months.

    04:19 Large and numerous plaques, widespread destruction of myelin.

    04:23 It’s the variants that are extremely difficult in terms of deriving a diagnosis quickly, but nonetheless, they exist for multiple sclerosis.

    About the Lecture

    The lecture Multiple Sclerosis: Diagnosis and Treatment by Carlo Raj, MD is from the course Multiple Sclerosis. It contains the following chapters:

    • Multiple Sclerosis: Diagnose and Treatment
    • Multiple Sclerosis: Summary
    • Multiple Sclerosis: Variants

    Included Quiz Questions

    1. Gamma globulin
    2. Alpha globulin
    3. Beta globulin
    4. Zeta globulin
    5. Delta globulin
    1. Oligoclonal bands
    2. Lymphocytic pleocytosis
    3. Increased cell count
    4. Decreased glucose
    5. Increased opening pressure
    1. Visual evoked potentials
    2. CSF analysis
    3. Consensual and direct light reflex
    4. Indirect ophthalmoscopy
    5. CT scan
    1. High-dose corticosteroids
    2. Glatiramer acetate
    3. Beta interferon
    4. Natalizumab
    5. Immunosuppressant
    1. Bilateral optic neuritis
    2. Unilateral optic neuritis
    3. Intranuclear ophthalmoplegia
    4. Retrobulbar neuritis
    5. Peripheral neuropathy
    1. Patient presents with bilateral optic neuritis.
    2. It usually has a fulminant course.
    3. The presence of large numerous plaques.
    4. There is a widespread myelin destruction with axonal loss.
    5. It usually affects the young.

    Author of lecture Multiple Sclerosis: Diagnosis and Treatment

     Carlo Raj, MD

    Carlo Raj, MD

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    By Hamed S. on 18. March 2017 for Multiple Sclerosis: Diagnosis and Treatment

    Good summary of the topic but would have been also good further discuss some of the immunosuppresive agents and fingolimod. In the dx workup section the use of MRI was also omitted