Multiple sclerosis

?

Multiple Choice

Questions Section

The Neuroscience Journal introduces this new section on multiple choice questions as part of its commitment to continuous education and learning in Neurosciences. Experts in various neuroscience specialties are invited to participate with their knowledge and expertise in this section. Neurology, neurosurgery, and other board residents are encouraged to read this section to improve their knowledge and direct their reading for written examinations.

Multiple sclerosis

Shireen Qureshi, MD. From the Department of Neurology, Dhahran Health Centre, Saudi Aramco, PO Box 12434, Dahran 31311, Kingdom of Saudi Arabia. Tel. +966 (3) 877 3524. E-mail: [email protected]

Choose the most appropriate single answer. 1. A 23-year-old female presents with right optic neuritis. She has no sensory symptoms, no motor symptoms, and no bladder symptoms. Visual evoked potentials showed P-100 = 135. An MRI of brain showed >10 discrete white matter lesions involving both cerebral hemispheres and corpus callosum. The likelihood that she develops clinically definite multiple sclerosis (MS) in 10 years is? a. 5-10% b. 20-30% c. 50-70% d. 80-90% 2. Clinically isolated syndrome is best predicted by? a. Monofocal attack b. Expanded Disability Status Scale score at presentation c. Magnetic resonance image lesions d. Age of the patient e. Combination of a. and c. above. 3. A 39-year-old woman with MS has bladder spasticity and clonus of the lower extremities. On briskly flexing her neck forward, which of the following is she most likely to report? a. Dystonic posturing of the legs b. An electrical sensation radiating down the spine or into her legs c. Bilateral wristdrop d. Spontaneous evacuation of the bladder and bilateral extensor plantar responses e. Rapidly evolving hemifacial pain 4. A 19-year-old man had an episode of left optic neuritis, which resolved over several weeks. Two years later there was a month long episode of bladder dysfunction. The patient underwent many tests and was told that he had MS. The CSF in persons with MS will typically exhibit which of the following? a. Glucose content of less than 20% of the serum content b. Persistently elevated total protein content c. Persistently elevated immunoglobulin G (IgG) content d. Mononuclear cell counts of greater than 100 cells per µL e. Erythrocyte counts of greater than 10 cells per µL 5. A 33-year-old female with clinically definite relapsing remitting MS, on interferon, had only one relapse in the year prior to her pregnancy. Which of the following are true? a. She should be continued on Interferon during pregnancy to prevent further relapses b. She has 30% increased risk of relapse in perpurium c. Breast feeding is contraindicated after delivery d. Breast feeding would more likely protect against relapses e. She should be advised against future pregnancies

58

Neurosciences 2010; Vol. 15 (1)

Multiple choice questions

Answers: 1. d Based on predictive value of baseline MRI in monosymptomatic patients, 10 year follow up was reported as 85%.1 2. e Disease burden on MRI with gadolinium-enhanced lesions along with multi regional first attacks are the most important poor prognostic indications for MS.2 3. b The peculiar sensory phenomenon in which the patient feels an electrical sensation radiating down the spine when the neck is passively flexed is called Lhermitte’s sign and is believed to signify spinal cord disease. Patients with MS who have little more than optic atrophy and no evidence of spinal cord involvement may report the sensation. Dystonic posturing may also occur in patients with MS, but the posturing is usually spontaneous. A massive Babinski response may produce bladder evacuation and extensor plantar responses as well as involuntary leg withdrawal in these same patients. This type of reflex response is usually elicited by stimuli to the feet or legs rather than by manipulation of the neck or spine.3 4. c The IgG content of the CSF remains elevated even between acute exacerbations of the MS. The IgG has a distinctive κ light chain composition. This immunoglobulin typically accounts for more than 15% of the total protein count in the CSF of the patient with MS.4 5. d The risk of relapse increases up to 2 folds 2 months after delivery but overall pregnancy does not affect MS course. Breast feeding is advisable and protective.5

References 1. Brex PA, Ciccarelli O, O’Riordan JI, Sailer M, Thompson AJ, Miller DH. A longitudinal study of abnormalities on MRI and disability from multiple sclerosis. N Engl J Med 2002; 346: 158-164. 2. Kappos L, Freedman MS, Polman CH, Edan G, Hartung HP, Miller DH, et al. Effect of early versus delayed interferon beta-1b treatment on disability after a first clinical event suggestive of multiple sclerosis: a 3-year follow-up analysis of the BENEFIT study. Lancet 2007; 370: 389-397. 3. Victor M, Ropper AH, editors. Adams and Victor’s Principles of Neurology. 7th ed. New York (NY): McGraw-Hill; 2001. p. 962. 4. Misulis KE, Bradley WG, Daroff RB, editors. Review Manual for Neurology in Clinical Practice. 4th ed. Boston (MA): Butterworth-Heineman; 2004. p. 1650-1651. 5. Langer-Gould A, Huang SM, Gupta R, Leimpeter AD, Greenwood E, Albers KB, et al. Exclusive Breastfeeding and the Risk of Postpartum Relapses in Women With Multiple Sclerosis. Arch Neurol 2009; 66: 958-963.

Neurosciences 2010; Vol. 15 (1)

59