Primary/Progressive Multiple Sclerosis: CerebroSpinal Fluid Considerations
Mult Scler 2004 Jun;10 Suppl 1:S31-4; discussion S34-5
University of Ottawa, Ottawa Hospital General Campus, Department of Medicine (Neurology), 501 Smith Road, Box 601, Ottawa, Ontario K1H 8L6, Canada
Diagnosing the 'Primary/Progressive' form of Multiple Sclerosis (PPMS) requires assurance that other conditions that might cause a chronic Inflammatory NeuroDegenerative Central Nervous System (CNS) Disease have been ruled out.
Both imaging and pathological studies have shown that this form of MS tends to be less inflammatory compared with either the Relapsing/Remitting or Secondary/Progressive types.
There are therefore many conditions that cause a slowly progressive wasting of the CNS that might be confused with MS.
The new MS diagnostic scheme has made the presence of 'typical' MS abnormalities in the CerebroSpinal Fluid (CSF) a mandatory first criterion.
But, there may well be individuals that still have PPMS even in the absence of a typical MS CSF.
Here we explore what the CSF can tell about an individual's disease process and outline the current state of the art in terms of CSF analysis. Used properly, the CSF can be very helpful in clarifying a diagnosis of PPMS.
Clinical Presentation Of Primary/Progressive Multiple Sclerosis 10 Years After The Incidental Finding Of Typical Magnetic Resonance Imaging Brain Lesions: The SubClinical Stage Of Primary/Progressive Multiple Sclerosis May Last 10 Years
McDonnell GV, Cabrera-Gomez J, Calne DB, Li DK, Oger J
Mult Scler 2003 Mar;9(2):204-9
Vancouver Hospital & Health Sciences Centre at UBC Hospital, Multiple Sclerosis Clinic, Vancouver, BC, Canada
SubClinical Multiple Sclerosis (MS) has been identified incidentally at autopsy; apparently unaffected individuals with an affected twin have demonstrated Magnetic Resonance Imaging (MRI) changes consistent with MS, and 'MRI relapses' are several times more common than clinical relapses.
A 39-year-old, right-handed man underwent MRI and PET scanning in 1986 as a 'normal' control in a Parkinson's Disease study, where his father was the proband.
MRI indicated multiple areas of abnormal signal intensity in a PeriVentricular and Gray-White Matter junction distribution.
Repeated clinical evaluations over the next 10 years were unchanged until 1996, when he complained of progressive weakness of the right foot and clumsiness in the right hand.
MRI now indicated a further area of high signal intensity in the right posterior Cord at the level of C5/C6.
There was mild Pyramidal distribution weakness in the right leg with an Extensor Plantar response on the same side.
Over the next five years there has been mild progression in Weakness and Fatigue and intermittent Lhermitte's Phenomenon.
At no stage has there been a history of relapse, CerebroSpinal Fluid examination was normal and Evoked Responses (Visual and SomatoSensory) are normal.
This case demonstrates the phenomenon of SubClinical MS, unusually supported by prolonged clinical and MRI follow-up.
The patient eventually became symptomatic nine years after MRI diagnosis and is following a Primary/Progressive course.
Although MRI is known to be sensitive in identifying subclinical 'attacks', the pattern illustrated here may actually be quite typical of Primary/Progressive MS and is compatible with the later onset seen in this subgroup of patients.
Cordonnier C, de Seze J, Breteau G, Ferriby D, Michelin E, Stojkovic T, Pruvo JP, Vermersch P
J Neurol 2003 Dec;250(12):1447-52
CHRU de Lille, Dept. of Neurology, Lille, France
The clinical and radiological characteristics of Myelopathy in Multiple Sclerosis (MS) are relatively well known.
Nevertheless, it remains difficult for the clinician to ascertain conversion to MS after a first episode of Acute Partial Transverse Myelopathy (APTM).
The aims of this study were to define predictive factors for conversion to Clinically Definite MS after an APTM and to define predictive factors for disease severity.
Patients And Methods
Between 1994 and 2001, we prospectively included 55 patients presenting with a first episode of APTM. Three patients were lost during the follow-up.
We evaluated clinical signs, Spinal Cord and Brain MRI, CerebroSpinal Fluid (CSF) and Visual Evoked Potentials on admission.
After a mean followup of 35 months (range 12-86), we evaluated the diagnosis and, among the MS group, the severity of the disease.
Of the 52 APTM patients who completed the study, 30 became Clinically Definite MS.
The predictive factors for conversion to MS were: initial Sensory Symptoms, Latero-Posterior Spinal Cord lesion, abnormal Brain MRI and OligoClonal Bands in CSF.
In the MS group, the number of Spinal Cord lesions on MRI was the only predictive factor for a poor outcome, being statistically correlated with a higher number of relapses.
On the basis of our results, we propose that, in patients with APTM, Sensory Symptoms, OligoClonal Bands and Brain MRI are predictive factors.
For subsequent conversion to Clinically Definite MS and that within the latter patients the number of Spinal Cord lesions on MRI is the only predictive factor for a poor outcome.