Thread by @CrystalYeoMDPhD

Let’s do a quick one on #clinicaldecisionmaking and #neuroimaging. See bright spot on MRI T2 Brain just means increased water -could be any insult to the brain - #infection #inflammation #ischemia #neoplasm are the top 4 you gotta have in your brain. Pun intended. #MedTwitter

Then you think - active or inactive process? If it’s actively destroying the BBB, it’ll enhance on contrast enhancement. So get MRI with and without contrast. Why without? T2 shine-through - but that’s for another time. #MedStudentTwitter #neurology #neurologyresident

Now the important question here is what you do - remember that nice poem on #theroadnottaken by #robertfrost? 2 widely diverging choices - to immunosuppress or not to immunosuppress. #tobeornottobe #hamlet #MedTwitter #AcademicTwitter #MedStudentChat

Now bonus points for those who quote #RobertFrost line. For the purpose of this #tweetorial, let’s focus on MS Vs. Not MS. I’ll take you through what how I think. #MedTwitter #MedStudentTwitter disclaimer: many roads lead to Rome so take the useful bits as you will. #Doubledoc

Look at the #location and #shape of the lesions. Use #MIMICS to decide if it’s NOT MS - Meningeal enhancement, Indistinct lesions, Microbleeds, Infarct, Complete ring enhancement, Sparing U fibers and Spinal cord extensive lesions. Obviously many more can fit but I like these.

But you see infarction on MRI too. So you look at DWI, ADC and T2 - one tip is that ADC is only partially hypodense with demyelination but completely black with infarct. #strokeornot #MedEd #MedTwitter #MedStudentTwitter #neurologyresident

Say it looks like MS. That also means you got the typical lesions by shape and location: Dawson’s fingers, juxtacortical lesions, incomplete ring enhancement, corpus callosum, thalamus, MCP, trigeminal, <3 segment spinal cord - affects peripheral cord, has central venule. #MedEd

Then make doubly sure it’s not the related much rarer #NMOSD cuz the treatment and prognosis is different. #rituximab for #NMOSD not #MS. In NMOSD, lesions are atypically large and multifocal, more than 4 segments of spinal cord affected - more central. Why? Where do Ab bind?

#CSF is useful as #OCB present in #MS and not #NMO. #Antibodies also helpful - anti-MOG and aquaporin for NMO.

So if the lesions are typical for MS, do they meet #Macdonaldscriteria for dissemination in time and space? Space is easy. Time you can infer from #enhancement - if you got active and inactive lesions, #enhancing and #nonenhancing - or 2 or more #OCB - cuz that takes time to make

If there’s just one MS typical lesion you see on brain and whole spine MRI, make doubly sure there isn’t a #subclinical lesion - cuz the risk of developing MS is much greater with another lesion. #MedTwitter #MedEd #AcademicTwitter

What other tools besides #MRI do #neurologists have? Check #VEP or #SSEP. If these are abnormal with single MRI lesion consider #DMARDS after acute management with #steroids. #MedEd #MedTwitter #MedStudentTwitter #neurologyresident so there you have it - hope it’s useful!

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