white matter disease

1. White Matter Disease
Neurology Rotation Lecture Series
Last Updated by Lindsay Pagano
Summer 2013

2. Case Presentation
The ED calls you in consultation for a 10 year old female with fever,
altered mental status and weakness.
•Normal state of health until 7 days ago when she developed cough and fever
•In the last 2 days, started acting irritable and then sleepy
•Over the last 24 hours, has developed right sided weakness
•General exam: crackles on lung exam
•Neuro exam: pertinent positives
– MS: sleepy but arousable with slightly painful stimulation
– Motor: right UE and LE with 1-2/5 strength diffusely, hypotonia
– Reflexes: brisk on the right
– Sensory: responds to painful stimulation in all 4 extremities
•Differential?

3. ADEM
• Acute disseminated encephalomyelitis
• Presents with
– Altered mental status/encephalopathy (irritability to obtunded)
– Acute/subacute onset of focal symptoms based on lesions (max neuro symptoms over
4-7 days)
– Typically still during febrile illness (typically URI)
– 1/3 with seizures
• Workup
– Labs: none are diagnostic
– CSF: pleocytosis, elevated protein, elevated IgG index; rule out infection!
– Imaging: MRIbrain with contrast
• Treatment: IV steroids (ok to start while r/o infection and prophylactic antibiotics
are on board) > IVIg > PLEX; PT
• Outcome
– Recovery over 4-6 weeks- 60-90% with no residual defecits
– Repeat MRI 6-12 months later to assess for lesion resolution

4. Guillain-Barré Syndrome
• Aka AIDP, acute inflammatory demyelinating polyneuropathy
• History: febrile illness 2-4 weeks prior to onset pain, paresthesias and ascending weakness
• Pathophysiology
– grouping of acute immune mediated polyneuropathies (cross reacting Ab to GM1 ganglioside)
– both humoral factors and cell-mediated immune phenomena that damage myelin and/or the
myelin-producing Schwann cells
– 2/3 with antecedent respiratory or diarrheal illness 2-4 weeks prior; c. jejuni most frequent (30%)
• Neuro Exam: distal > proximal weakness, hypotonia and areflexia; sensation testing may be
intact despite subjective feelings of numbness and paresthesias
• Be wary of potential autonomic involvement! Monitor on tele, q4h nifs, continuous pulse
ox
• Workup
– Labs: None
– LP: albuminocytologic dissociation
– EMG/NCV: demyelination ( slowed nerve conduction velocities)
– MRI: not indicated for diagnosis (MRIspine would show nerve root enhancement)
• Treatment: IVIg > PLEX + PT
– Treatment doesn’t change overall outcome/degree of recovery

5. Transverse Myelitis
• Focal inflammatory disease process of the spinal cord
– Affects motor, sensory and autonomic fibers
– Up to 50% with preceding febrile illness
• Highest incidence between 10-19 yo, 30-39 yo (bimodal)
• Present with
– Acute/subacute onset of pain, weakness, sensory loss,
incontinence over hours-weeks
– 80% of cases are in the thoracic spine
• Neuro exam: depends on where the lesion is!
– Typically bilateral weakness with UMN signs, but…
– If anterior horn cells are involved, may get a predominantly LMN exam
• Workup:
– Labs: none positive for this condition, but can get labs to rule out other disease processes
– CSF: pleocytosis, elevated IgG index
– Imaging: MRIspine, with and without contrast
• Treatment: IV steroids + PT
• Outcome: 1/3 no long term sequelae, 1/3 mild-moderate disability, 1/3 severe disability

6. Multiple Sclerosis
• Chronic demyelinating disease
• 5% patients present before age 18
– 95% of these have a relapsing remitting course: little to no disability inbetween flares (versus
primary progressive, secondary progressive, progressive relapsing)
• MacDonald Criteria for diagnosis: lesions separated by space and time
– Check the FLAIR and post contrast to help date lesions in 1st
presentation
• Presentation/Neuro exam: dependent on location of lesions
– No prodromal illness
– Not all lesions are symptomatic
• Workup
– Labs: none diagnostic
– CSF: pleocytosis, increased protein, elevated IgG index/oligoclonal bands present
– Imaging: MRIbrain with contrast
• Periventricular lesions
• Dawson’s fingers
– Visual evoked potentials (slowed conduction if optic nerves affected)
• Treatment
– Acute: MS trial: IV methyprednisolone + steroid taper
– Long term: interferon, glatiramir

7. Neuromyelitis Optica
• Aka NMO, Devic Disease
• Diagnostic Criteria
1. Optic neuritis AND
2. Transverse myelitis AND
3. -MRI evidence of myelitis incolving 3 or more contiguous segments OR
-NMO-IgG + (aquaporin 4, found in serum)
• The above do not have to occur simultaneously
• May also have CNS lesions and resulting symptoms
• Clinical course is primary progressive or relapsing-remitting
• Worse recovery of vision [from optic neuritis] and strength [from myelopathy]
as compared to MS
• 93% with recurrent attacks, 90% with residual disability

8. PREP question
A 12 year old girl presents with a 2 day history of progressive back pain and
difficulty walking, especially up stairs. This morning she had trouble dressing and
combing her hair.
On PE, the girls vital signs and stable and she is not short of breath. Cardiac,
pulmonary, and joint evaluation results are normal. Neurologic exam reveals normal
mental status and cranial nerves. Strength is diffusely reduced in the arms and legs,
and reflexes are absent. Her gait is slow, and she requires assistance Ato arise from
the floor. Noncontrast head CT scan results are normal. Forced vital capacity is
normal. LP reveals a CSF protein of 100 mg/dL. CSF WBC count, RBC count and
glucose are normal. You admit the girl for cardiorespiratory monitoring and
treatment.
Of the following, the treatment that is MOST likely to be beneficial in hastening this
child’s recovery is:
A. Immune globulin intravenously
B. Methotrexate intrathecally
C. Methylprednisolone intravenously
D. Neostigmine intravenously

9. A. IVIg
• GBS (Guillain-Barre syndrome) aka AIDP (acute inflammatory demyelinating
polyneuropathy)
– Localize!
– Albuminocytologic dissociation
– IVIg 2g/kg divided over 3 vs 5 days (may pretx)
– Need to monitor respiratory (NIFs, FVCs) and cardiovascular (tele) status,
ICU if needed
• Regarding the other choices:
B. Methotrexate IV: chemotherapy used for CNS malignancy
C. Methyprednisolone IV: not effective as monotherapy
D. Neostigmine IV: acetylcholinesterase inhibitor, for NMJ junction disease,
eg myasthenia gravis
E. tPA IV: given in adult acute stroke

10. A. IVIg
• GBS (Guillain-Barre syndrome) aka AIDP (acute inflammatory demyelinating
polyneuropathy)
– Localize!
– Albuminocytologic dissociation
– IVIg 2g/kg divided over 3 vs 5 days (may pretx)
– Need to monitor respiratory (NIFs, FVCs) and cardiovascular (tele) status,
ICU if needed
• Regarding the other choices:
B. Methotrexate IV: chemotherapy used for CNS malignancy
C. Methyprednisolone IV: not effective as monotherapy
D. Neostigmine IV: acetylcholinesterase inhibitor, for NMJ junction disease,
eg myasthenia gravis
E. tPA IV: given in adult acute stroke