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Cerebrospinal fluid analysis
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Peripheral blood antibody titers
Non-contrast head CT
Contrast head CT
Head and spinal cord MR with contrast
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The patient in this vignette most likely has multiple sclerosis, with the best diagnostic modality being MR imaging (Answer 5). Multiple sclerosis (MS) is an autoimmune demyelinating condition involving multiple neurologic deficits separated in space and time. The exact etiology of the disease is unknown, although it is believed to have an autoimmune component. Classic findings on MR imaging include multiple focal demyelination throughout the brain and spinal cord and asymmetric periventricular plaques. CSF may also be studied, but is more invasive. Findings on CSF include mononuclear pleocytosis, elevated IgG and oligoclonal bands on electrophoresis. Calabresi discusses the diagnosis and management of MS. He notes that the pathophysiology of MS includes autoimmune-mediated demyelination and subsequent neuronal destruction. Diagnosis must include a presentation of two or more neurological conditions localized to the brain or spine that can be separated in time and space. Srivastava et al. investigate the antigen targets of IgG in patients with MS. Using a proteomics approach, they find that many patients with MS overproduce antibodies that bind to a specific potassium channel that is found in oligodendrocytes. They conclude that this many be a major pathophysiological mechanism in MS. Illustration A displays a head MRI classic for MS. Note the numerous enhancing lesions bilaterally. Incorrect Answers: Answers 1-4: These test are not preferred to MR imaging in the initial diagnosis of suspected MS due to their lower sensitivity and/or invasive nature.
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