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What are the differential diagnoses for a brain MRI that shows both juxtacortical and periventricular lesions? Answer: There are a wide variety of vascular and inflammatory diseases that are associated with juxtacortical and periventricular “lesions” or, to use a more accurate label, T2 hyperintensities. It is important to correctly define these lesions or T2 hyperintensities as follows: 1. A periventricular lesion must abut the ventricular surface. This means there can not be even a small gap between the lesion edge and the ventricular surface. The ventricule is the space in the middle of the brain where spinal fluid is formed and circulates. 2. The most specific juxtacortical lesion is a leukocortical lesion with a U or hook shape that follows the contour of a cortical gyrus. Leukocortical means that the lesion involves both the cortex and the underlying white matter. To be truly juxtacortical the lesion must be immediately adjacent to (touching) or involving the cortex. Otherwise the lesion is better referred to as a subcortical white matter lesion. Subcortical white matter lesions are not very specific for any disorder. Even though this MRI criteria is more specific, it is not diagnositc. The diagnosis is only assured in the correct clinical setting. Hope this helps Revere (Rip) Kinkel MD Professor of Clinical Neurosciences Director of the Multiple Sclerosis Program Clinical Neurosciences Director University of California San Diego
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I am being put under general anesthesia tomorrow to remove my wisdom teeth but am unsure if I should take my Extavia shot tonight or wait until after the surgery. Answer: It makes little difference if you take the Extavia tonight or wait until after you recover. If a person experiences side effects with interferon injections, I usually suggest that they hold their injection until after they recover from surgery. Check with your physician and I suspect he or she will agree. Good luck. Revere (Rip) Kinkel MD Professor of Clinical Neurosciences Director of the Multiple Sclerosis Program Clinical Neurosciences Director University of California San Diego Here is My Question:
There is a device called the Biocharger; https://biocharger.com/persona/alternative-therapies/ Could this help manage MS symptoms? Answer #1: There is no real scientific evidence that this biocharger helps with disease or symptoms of disease. In fact, the disclaimer on the website states it does not diagnose or mitigate any disease. The research presented on the website is hypotheses (over 100 years old) without any practical data to support its use in the management of disease. They do reference recipes to be used but it remains unclear to me if these incorporate herbs. This device is being marketed as a product that emits electromagnetic energy within a radius of ~3-5 feet and that somehow treats people for a myriad of different (and unrelated) diseases. I would recommend a “buyers beware” caution to anyone with MS thinking about shelling out $14,000 for this. A. Scott Nielsen MD MMSc Neurologist and MS Specialist at Kaiser Permanente Answer #2: Thanks for the question. I checked out the website thoroughly. There are comments about “proven benefits” and even “testimonials” (whatever they are worth), but the company provides no peer reviewed references and I can find no references on the BioCharger in PubMed or any other search engine; this and the cost, which is $14,000, should make anyone pause and move on. Unless you are a millionaire with money free to throw around, do not even think twice. Revere (Rip) Kinkel MD Professor of Clinical Neurosciences Director of the Multiple Sclerosis Program Clinical Neurosciences Director University of California San Diego Here is My Question:
Does spasticity hurt? Can the pain in my hamstrings be due to spasticity? Answer: Patients tend to report painful spasticity but there are exceptions. Spasticity can present in any muscle or muscle group, but also tend to follow other signs of central nervous system involvement that your neurologist can confirm on the neurological exam. If spasticity is the cause of symptoms, various medicines could be used, but I typically recommend deep stretching of the affected muscles frequently first as this can be helpful while avoiding medication side effects. A. Scott Nielsen MD MMSc Neurologist and MS Specialist at Kaiser Permanente Here is My Question:
I think my SPMS is being made more uncomfortable by arthritic changes and I'm wondering what meds will help? Answer: This is a really good question. MS never exists in a vacuum; instead it co-exists with everything else life throws at you, including old age and arthritis. In most cases your joint problems are a result of osteoarthritis, especially if the pain involves knees, hips, shoulders and/or spine. You can think of this as a form of wear and tear arthritis that can be accelerated by the muscle weakness and sensory alterations associated with Multiple Sclerosis. There is no single treatment for osteoarthritis . You need to take an integrated approach that involves exercise (especially Tai Chi and Yoga), mindfulness/meditation and relief of pain with non-steroidal anti-inflammatory medications (think motrin). Additional approaches may include corticosteroid injections in several different types of joints for short term relief of pain and injections of the knee joint with hyaluronic acid for more long term pain reduction. Glucosamine and chondroitin sulfate may also be beneficial for knee pain in some people. More recently, platelet rich plasma injections have been used to treat joint, tendon and ligament injuries. For patients with more advanced osteoarthritis involving the hip and knee and, in some cases, the shoulder, your doctor may recommend total joint replacement surgery even if you have more advanced progressive disease. This type of surgery done in the right hands in well selected patients can dramatically improve function and quality of life In my experience it is best to be evaluated by specialists in sports medicine and pain medicine for relief of joint, bursa (the lining around the joint), ligament and tendon pain. The correct diagnosis is of utmost importance. They will refer you to an orthopedic surgeon if they believe surgery is a good option Good luck Revere (Rip) Kinkel MD Professor of Clinical Neurosciences Director of the Multiple Sclerosis Program Clinical Neurosciences Director University of California San Diego Here is My Question:
Can MS cause a low grade fever? My doctor can’t seem to find a reason for why I keep having one. Answer: Fever is not a known issue in MS, in fact, on average patients can have a slightly lower body temperature Benjamin M. Greenberg, MD, MHS Vice Chair of Translational Research and Strategic Initiatives Cain Denius Scholar of Mobility Disorders Distinguished Teaching Professor Department of Neurology and Neurotherapeutics Department of Pediatrics UT Southwestern Medical Center Dallas, Texas Here is My Question:
As my MS advances, (RRMS 17 years-on glatopa daily shots) my gut seems to get worse. Especially since I had C-Diff a couple of years ago. I have had 2 short courses of flagyl for tooth abcesses recently. It was really awful then. But now it won't go away even when not on antibiotics. Is nausea and vomiting now an MS symptom that will not go away? Answer: In general those symptoms are usually not due to MS inflammation, although we do see constipation that can cause symptoms. Benjamin M. Greenberg, MD, MHS Vice Chair of Translational Research and Strategic Initiatives Cain Denius Scholar of Mobility Disorders Distinguished Teaching Professor Department of Neurology and Neurotherapeutics Department of Pediatrics UT Southwestern Medical Center Dallas, Texas Here is My Question:
Has Siponimod been FDA approved? Answer: Siponimod has not been approved by the FDA yet but they are supposed to announce their decision sometime this month (March 2019) Revere (Rip) Kinkel MD Professor of Clinical Neurosciences Director of the Multiple Sclerosis Program Clinical Neurosciences Director University of California San Diego Here is My Question:
Can Copaxone be used to treat PPMS? Answer: Copaxone has been FDA approved for RRMS and does not for PPMS (no evidence for effectiveness in PPMS). The b-cell biologicals do have data to support use in PPMS. A. Scott Nielsen MD MMSc Neurologist and MS Specialist at Kaiser Permanente Here is My Question:
Is SPMS worse than PPMS? I’m feeling I’m better off with PPMS because I have sudden things occur. Answer: The general course of PPMS and SPMS are very similar and the rate of progressive disability are also similar. SPMS is different in that it is preceded by a relapsing-remitting course while PPMS does not. The individual’s experience with MS can vary. A. Scott Nielsen MD MMSc Neurologist and MS Specialist at Kaiser Permanente Here is My Question:
I was recently diagnosed with relapsing-remitting MS my doctor gave me the choice of medicine and I decided to go with Ocrevus. Being JC virus positive should I be concerned about PML? Answer: Risk of PML has been observed in MS patients on b-cell biological when there is combined or overlapping immunotherapy (ie, coming off Tysabri and onto Ocrevus or Rituximab for instance). Since you were recently diagnosed I assume you are not on another therapy but this would be your first exposure to an immunotherapy. A. Scott Nielsen MD MMSc Neurologist and MS Specialist at Kaiser Permanente PLEASE NOTE: The information/opinions on this site should be used as an information resource only. This information does not create any patient-HCP relationship, and should not be used as a substitute for professional diagnosis and treatment. Please consult your health care provider before making any healthcare decisions or for guidance about a specific medical condition. Here is My Question:
I have a paralyzed right diaphragm with resulting atelectasis of the right lower lobe and part of middle lobe. My last MRI in 8/18 didn't show any disease C3-5. I have been off Aubagio since 7/18 due to side effects (abnormal low WBC) and will be restarting it this month. Will be repeating MRI to assess for new disease. How often does MS cause phrenic nerve damage? Answer: Unilateral paralysis of a diaphragm is relatively rare in MS, although studies performed years ago suggested subclinical involvement of diaphragm function in a larger number of patients. This paralysis does not require involvement of the cord segments with the anterior horn cells supplying innervation to the diaphragm through the phrenic nerve (C3,4 and 5). This can also be the result of involvement of central motor pathways above this level in the brainstem. Good luck Revere (Rip) Kinkel MD Professor of Clinical Neurosciences Director of the Multiple Sclerosis Program Clinical Neurosciences Director University of California San Diego Here is My Question:
I'd like your opinion about the findings from my latest MRI. These are from the radiologist at the hospital, not my neurologist. I'd like to know how concerned I should be about the level of atrophy (I am a 52 yr old female) and whether I can interpret the note about imaging stability to indicate that my DMT (Ocrevus, started 2 yrs ago, about 9 months post diagnosis) is working. Also, does the location of the subtle T2 signal indicate what functions might be / become impaired? Here are the findings: FINDINGS: The brain is mildly atrophic. There is no diffusion abnormality indicative of no acute ischemic infarct. Redemonstrated is subtle asymmetric hyperintense T2-FLAIR signal in the periventricular white matter of the left frontal lobe. There is no new signal abnormality. There is no evidence of acute or chronic extravascular blood products. There is no mass and no mass effect. Corpus callosum and pituitary gland have a normal appearance. Following gadolinium administration, there are no areas of abnormal enhancement. There is no cerebellar tonsillar ectopia with the craniovertebral junction normal. Orbital structures are unremarkable. Paranasal sinuses and mastoid air cells are clear. IMPRESSION: MR imaging of the brain shows no acute neuroimaging finding with imaging stability when compared to the exam 26 months ago. Answer: It is hard to provide an opinion about an MRI based on a radiologists report. I can however provide some explanations 1. The radiologist could see no changes since the last scan 26 months ago. This is a qualitative judgement and generally means there has not been a big enough change for the eye to perceive. 2. The comment about mild atrophy is meaningless without quantitative measurement; mild compared to what? 3. The report does not provide enough information about the location of “lesions” to make any comment regarding associated symptoms. Generally speaking there is little if any relationship between the location of “lesions” in the cerebrum (main part of the brain) and symptoms or exam findings I would emphasize the lack of change over 26 months as good news. Revere (Rip) Kinkel MD Professor of Clinical Neurosciences Director of the Multiple Sclerosis Program Clinical Neurosciences Director University of California San Diego PLEASE NOTE: The information/opinions on this site should be used as an information resource only. This information does not create any patient-HCP relationship, and should not be used as a substitute for professional diagnosis and treatment. Please consult your health care provider before making any healthcare decisions or for guidance about a specific medical condition. Here is my question:
Can I take Ocrevus without steroid administration? Answer: That is a personalized decision with each clinician based on a person's experience with the drug and location of drug infusion. While this can be done, there can be risks of infusion reactions. Benjamin M. Greenberg, MD, MHS Vice Chair of Translational Research and Strategic Initiatives Cain Denius Scholar of Mobility Disorders Distinguished Teaching Professor Department of Neurology and Neurotherapeutics Department of Pediatrics UT Southwestern Medical Center Dallas, Texas Hi to those who have utilized RadConnect on our website to store their MRI images. Please note this message we have received from them below:
Dear RadConnect Customer, NucleusHealth is excited to announce that we have a new image exchange service for you called Nucleus.io! By upgrading from RadConnect you will benefit from a new user-friendly interface, sleek new look, and improved connectivity. We have two options for Patients to move their images from RadConnect to Nucleus.io. You will need to take action before March 31, 2019 as RadConnect will no longer be in service after that date. All of our Organizations and Professionals will be moved and sharing studies to patients solely from Nucleus.io. OPTION 1 Manual Account Migration You can manually download your exams from RadConnect at your earliest convenience and wait to create a Nucleus.io account and upload your exams there on April 1st.
OPTION 2 Automated Migration Service Our team will create a Nucleus.ioPatient Account for you and transfer all of your existing exams from RadConnect to your new Nucleus.io account for a fee of $20.00.
Please submit the Migration Form and Payment by March 15, 2019. Effective March 31, 2019 at 11:59pm PST RadConnect will no longer be in service or accessible. Please review our Frequently Asked Questions for further information. Thank you for your attention and understanding, we look forward to continue serving your medical imaging needs. - NucleusHealth Team View this email in your browser Copyright © 2019 NucleusHealth, LLC. All Rights Reserved. Here is My Question:
Why do I have days when I'm so sad and cry so much? Is it the MS or the glatopa injections? Before MS I never had this problem even during the worst days in my life. I never cried and always had control. I'm 57 and am still working and in good health. Answer: Feeling sad and not being able to control certain emotional expressions such as crying, laughing or smiling are not necessarily related in people with MS. It is definitely important to first determine if these symptoms are a sign of depression. Even if your description of sadness is felt to be a symptom of depression, you could still be having difficulty controlling the ‘release’ of your emotions because of areas of the brain affected by MS. All of these symptoms are amenable to treatment, so talk to your MS specialist. Good luck Revere (Rip) Kinkel MD Professor of Clinical Neurosciences Director of the Multiple Sclerosis Program Clinical Neurosciences Director University of California San Diego Here is My Question:
Can I switch back to Tysabri from Ocrevus? After 4+ years on Tysabri I became JCV+ with a high titer #. For the last year and a half, while on Ocrevus, my symptoms have been continuously up, without relapse. Definitely felt better when on Tysabri. Given the new extended Tysabri dosing regimen, can I consider switching back? Is there any info on switching back that would help make this kind of decision? Answer: We do not have any direct data to answer your question at this time, so there will always be unknown risks associated with this treatment decision. Remember, there may be risks other than PML that we are not even aware of at this time, since few people have been methodically switched from an anti-CD20 drug to Tysabri. If you do decide to switch back to tysabri, consider the following information: Risk factors for the development of PML on Tysabri given at every 28 day intervals include JCV index > 1.5, lower weight (Less than 60 Kg), older age (over 60) and low lymphocyte count. You can probably mitigate against all of these risks, except low lymphocyte count, by extending the interval between tysabri infusions. Therefore, it is probably important to make sure that your absolute lymphocyte count and T cell subsets are normal before restarting tysabri. If possible you may want to wait until your B Cell count is on the rise, but this could take up 6 to 18 months after your last Ocrevus infusion. Before restarting Tysabri make sure you have a new baseline MRI of the brain (only is required to monitor for PML) and then monitor with MRI every 4 to 6 months after re-starting Tysabri Make sure you have a good discussion with your MS specialist about your current disease type and stage and risk of inflammatory activity; tysabri is not very effective in well established progressive MS and the risks of treatment would not be warranted if you are in this stage of the disease Good luck Revere (Rip) Kinkel MD Professor of Clinical Neurosciences Director of the Multiple Sclerosis Program Clinical Neurosciences Director University of California San Diego Question:
I have been on Aubagio for almost two years. Is it OK to have the Shingrix vaccine? Everyone tells me it is an inactive vaccine. Thanks. Answer: Yes, it is true that Shingrix is not a live viral vaccine. Use of Shingrix while on a DMT (ie, aubagio) may be blunted due to the MS therapy. Per CDC, if you are negative for the chicken pox virus antibody (meaning you do not have immunity against the chickenpox virus), you should not get this vaccine. Your neurologist can test for this by sending for a VZV IgG antibody titer (blood test). If you are younger than 40, there is a chance that you are negative for the chicken pox antibody (those over than 40, and before the vaccine era for VZV, are likely to have memory immunity for chicken pox and could get the Shingrix vaccine). Before you pursue this vaccine, please discuss with your MS provider as there may be other considerations for this vaccine in your specific case. A. Scott Nielsen, MD MMSc Neurologist and MS Specialist at Kaiser Permanente Here is My Question:
I have RRMS but a mild form. My neurologist/MS specialist doesn’t believe a DMD will benefit me. All symptomatic medication has given me all the side effects and seem to be sensitive to them. Your thoughts?? Answer: Decision to treat or monitor off a DMT is a case specific decision. In most circumstances treating is favored as the DMTs are preventative rather than restorative. The best time to use DMTs is early in the disease course for that reason. The decision when to come off therapy is challenging given the unpredictable nature of the disease. Prolonged periods of disease quiescence may indicate that the inflammatory phase of the disease (the phase we are best able to treat) has passed and the patient is unlikely to benefit from DMTs any longer. Any decision to come off therapy with a monitoring plan should always be done in coordination of your treating physician. A. Scott Nielsen MD MMSc Neurologist and MS Specialist at Kaiser Permanente |
PLEASE NOTE: The information/opinions on this site should be used as an information resource only. This information does not create any patient-HCP relationship, and should not be used as a substitute for professional diagnosis and treatment. Please consult your health care provider before making any healthcare decisions or for guidance about a specific medical condition.
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