1. Multiple sclerosis – late onset

2. Authors: Vitalie Vacaras Vitalie Vacaras Damian Popescu Damian Popescu Radu Antonescu Radu Antonescu Anca Simu Anca Simu

3. Case history 55 years old male with history of Optic Neuritis (1996) Acute onset of paresthesia, numbness and loss of touch in the right arm and leg, followed by weakness in the right hemibody double vision, when looking towards left

4. Case history diplopia when looking towards left; internuclear ophtalmoplegia right hemiparesis, accentuated crural right dismetria and dysdiadochokinezia no abdominal reflex; slight increase of deep tendon reflexes on right body; Babinski sign in the right right body exteroceptive hypoesthesia and paresthesia

5. Case history CT scan: no focal lesions supra- or infra tentorial MRI: high intensity lesions on T2WI and FLAIR, located in the white matter, periventricular and in the brain stem, without perilesional edema; after Gadolinium i.v. one lesion shows enhanced image – demyelinating lesions with one active plaque.

6. Case history Brain stem and periventricular high intesity lesions on T2WI

7. Case history Juxtacortical (U-fibers) and corpus callosum high intensity lesions on FLAIR, respectively T2WI

8. Case history Other paraclinical examinations: - routine blood tests: normal values - CSF: elevated protein and IgG; elevated IgG index (1.12) - pulmonary X-ray: no active lesions - visual evoked potentials: low amplitude and high latency in the left eye (190ms); normal amplitude, but high latency in the right eye (152ms) – Retrobulbar Optic Neuritis

9. Case history Treatment: Solu-Medrol 1g/day i.v. for 5 days - relapse: Solu-Medrol 1g/day i.v. for 5 days simptomatical treatment simptomatical treatment - follow-up: immunomodulators: (Interferonβ, Glatiramer Acetat) - follow-up: immunomodulators: (Interferonβ, Glatiramer Acetat) - general recomandations - general recomandations

10. Multiple Sclerosis Inflammatory, demyelinating disease of the central nervous system Dynamic disease, with almost constant lesion formation and a progressive clinical course leading to physical disability Prevalence: 2-150/100000; 2.5 mil cases in the world Frequent onset between 18-50 years; women more frequent Etiology: genetics, environment, infections Diagnosis: CSF (oligoclonal bands), imaging studies, visual and sensory evoked potentials

11. Multiple Sclerosis Late onset MS – 1-6% of total cases; onset after 55 years - less specific lesions on MRI – spinal cord MRI, CSF exam and VEP are necessary to increase specificity of diagnosis - faster neurologic deterioration - worse prognosis - more frequent Primary Progressive form of the disease Risk of Multiple Sclerosis in pacients with Optic Neuritis - associated with the number of lesions on MRI - at 10 years: 22% if no lesion; 56% if lesions found on MRI - MRI is mandatory for patients with optic neuritis

12. Multiple Sclerosis Treatment: - immunomodulators - treatment of relapses: corticoids - symptomatic treatment Prognosis: according to disease evolution and complications - lower life expectancy (with 7 years) - late onset disease has more rapid evolution towards disability

13. References 1. Kis, B., Rumberg, B., & Berlit, P. (2008). Clinical characteristics of patients with late-onset multiple sclerosis. Journal of Neurology, 255, 697-702. 2.J. de Seze, S. Delalande (2005). Brain MRI in late-onset multiple sclerosis. European Journal of Neurology 12/4, 241 - 244 3.Martinelli, V., Rodegher, M., Moiola, L., & Comi, G. (2004). Late onset multiple sclerosis: clinical characteristics, prognostic factors, and differential diagnosis. Neurologic Science, 25, S350-S355. 4.Polliack, M.L., Barak, Y., & Achiron, A. (2001). Late-onset multiple sclerosis. Journal of the American Geriatric Society, 49, 168-171. 5.Allan S. Brett. (2008). Risk for Multiple Sclerosis After Optic Neuritis, Arch Neurol, 65:727 6.Jane W. Chan, (2002). Ocular Immunology and Inflammation, European Journal of Neurology, 10/3, 161-186