MS and Stroke?

"MS and Stroke? Can they occur together.. case report (CPC)"

Case presentation slide summary

Slide 1: 40 year old lady married + 4 children, born in Israel, with presumptive diagnosis of MS presenting with blurred vision of the right eye 2002 -Admitted with right leg weakness - Myelopathic signs on examination - MRI revealed inflammatory lesion T7-8 - LP: TP 501, no cells, OCB negative - Treated with steroids with marked improvement - No neurological symptoms until current presentation - At presentation mild sensory symptoms only AskTheNeurologist.Com

Slide 2: Current admission • 3 days prior to admission, after slight bump to head, noticed blurred vision of R eye • Vision deteriorated over following 3 days with pain on eye movement AskTheNeurologist.Com

Slide 3: Past history • No other neurological problems • No other clinical features referable to auto-immune disease ( e.g. SLE, Bechets) • No history of miscarriage • Serological abnormalities ( to be discussed) • Had traveled to New England but no history of tick bite AskTheNeurologist.Com

Slide 4: Examination • General examination unremarkable • RAPD on the right • Fundoscopy normal • Remainder of examination normal with no evidence of myelopathy • Steroids started for presumptive “ MS exacerbation” AskTheNeurologist.Com

Slide 5: Laboratory investigation prior to admission • Immunology – ATG 87, 87 ( <100) 3.2003, 1.2004 – ATPO 793, 538 ( <75)!! (TSH 3.56 - normal) – ANA +2 / 4 (2002) –ve x2 (2003,2004) – ENA +ve x1 (2002) –ve x2 – ANCA –ve x2 AskTheNeurologist.Com

Slide 6: Laboratory investigation prior to admission • Serology – CMV past infection – EBV past infection – VZV past infection – Toxoplasma neg – Brucella neg – VDRL neg – Brucella neg – Lyme +ve x2 ( 10.2003, 1.2004) AskTheNeurologist.Com MS and stroke

Slide 7: Brain MRI AskTheNeurologist.Com

Slide 8: Laboratory investigation during current admission • FBC, Bioch normal • ESR 18 • LP: - Pressure 12 cm H2O - TP 488, no cells, OCB negative • Anticardiolipin Ab’s negative • pANCA cANCA negative • ANA negative • TSH normal • Anti TPO 397 ( 0-35) • Anti TG normal • Homocysteine Pending AskTheNeurologist.Com

Slide 9: Course • Received high dose steroids • Day 4: Ceftriaxone added, steroids tapered • Day 5: improvement noted in vision • Day 6 am : - mild left hemiparesis noted, steroid dose incresed • Day 6 pm: witnessed tonic-clonic seizure. On examination, severe L hemiparesis • Brain CT unremarkable AskTheNeurologist.Com

Slide 10: Course cont. • Further seizures: Unresponsive to benzodiazepines phenytoin, phenobarbital (RSE) • Intubation, propofol IV • MRI: Right MCA infarct • Anticoagulant treatment commenced AskTheNeurologist.Com

Slide 11: Brain MRI after Seizure AskTheNeurologist.Com

Slide 12: Further Investigation • Angiograpghy - decreased perfusion in R MCA territory • TEE - no clot detected AskTheNeurologist.Com

Slide 13: Course cont. • Weaned from propofol and BZD’s • Extubated • Marked improvement of hemiparesis AskTheNeurologist.Com

Slide 19: Neurological features of chronic Lyme disease AskTheNeurologist.Com

Slide 20: CSF in Chronic Lyme In early cases of neuroborreliosis, spinal fluid findings may still be negative. In cases of chronic disease, only mild elevations of protein may persist. In these circumstances, detection of B. burgdorferi DNA by PCR may be important to establish the diagnosis. AskTheNeurologist.Com

Slide 22: Serology • Both IgG and IgM responses can persist for over 10 years, even after successful antibiotic treatment • False positive ELISA results can be caused by other bacteria (e.g. Treponema denticulata) or by a polyclonal B cell stimulation. • Positive serology alone is not sufficient to make the diagnosis • Cross-reactivities with syphilis tests do occur • Direct detection methods (PCR) diagnostic AskTheNeurologist.Com

Slide 23: Value of Serology AskTheNeurologist.Com

Slide 27: Proposed diagnostic criteria • c lo u d in g o f c o n s c io u s n e s s with re d u c e d wa ke fu ln e s s , a tte n tio n , o r c o g nitive fu n c tio n • n o C S F e vid e n c e o f b a c te ria l o r vira l infe c tio n • h ig h s e ru m c o n c e n tra tio n (o r tite r) o f a ntith yro id m ic ro s o m a l, a n tith yro id p e ro xid a s e , o r a ntith yro g lob u lin a n tib o d ie s AskTheNeurologist.Com

Slide 28: Thyroid function AskTheNeurologist.Com

Slide 29: AskTheNeurologist.Com

Slide 30: AskTheNeurologist.Com

Slide 31: MRI in Hashimoto Encephalopathy AskTheNeurologist.Com

Slide 35: Antiphospholipid syndrome as a cause of MS and stroke?• Can simulate MS – especially in patients with myelitis and optic neuritis – Especially in those without OCB’s ( Karussis et al, Annals of Neurology 1998 ) • Associated with stroke in the young • However: – Anticardiolpin negative during current hospitalisation (steroids should not cause disappearance) – Lupus anticoagulant not checked prior to heparin AskTheNeurologist.Com

Slide 36: MS • Clinical and MRI features fit both MS and stroke • Against – OCB –ve twice – Stroke ( therefore other conditions must be excluded) AskTheNeurologist.Com

Slide 41: Normal values: TPO-Ab 0–10 IU/mL; Out of 31 MS patients 5 (16%) had Anti TPO Ab’s AskTheNeurologist.Com

Slide 44: CNS Vasculitis - GANS - PAN ( but no systemic features) GANS For Against Can simulate relapsing – Optic nerve and spinal cord remitting course of MS involvement rare Stroke Clinical course typical of MS No headache MRI probably “ too severe” given mild clinical features prior to stroke CSF and angiography normal AskTheNeurologist.Com

Slide 45: Is MS associated with alteration of platelet function? “ platelet aggregation and MS” Neu et al 1982 Acta neurologica Scand. AskTheNeurologist.Com

Slide 46: • Measured in vitro platelet aggregation in 30 “ definite MS” patients and compared to 15 healthy subjects • Both spontaneous and “ agonist-induced” aggregation was measured 80 70 60 Agg % 50 40 MS 30 CONTROL 20 10 P < 0.01 0 ADP 5-HT AskTheNeurologist.Com

Slide 47: Summary 1. MS and stroke is diagnosis of exclusion 2. Lyme disease unlikely but should be excluded via PCR because of the stroke 3. Hashimoto Encephalopathy attractive diagnosis however no encephalopathy clinically or electrophysiologically. 4. APLAS clinically fits..but no lab evidence ( Lupus Anticoagulant not checked) 5. Granulomatous angiitis unlikely but cannot be ruled- out 100% without brain biopsy 6. HIV should be tested for completeness AskTheNeurologist.Com

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