2) This program is intended for an audience of healthcare providers and is supported by educational grants from Sanofi Genzyme and from GW Pharmaceuticals.
— MultipleSclerosis_CME (@ms_cme) August 24, 2021
4) #Multiplesclerosis keeps clinicians humble, because it remains unpredictable, because no two people with MS are the same, and because our science keeps evolving and revising how we think about this disease. @mssociety @mscare @MSViewsandNews
— MultipleSclerosis_CME (@ms_cme) August 24, 2021
6) Loss of reserve is increasingly recognized as essential to MS disease course. See https://t.co/a8pufJ01bn pic.twitter.com/INrfHsdq3n
— MultipleSclerosis_CME (@ms_cme) August 24, 2021
8) The topographical model of MS pulls together many of these aspects of MS into one dynamic visualization — The “Leaky Pool” (h/t @AaronBosterMD @BretStetka, co-author extraordinaire @kcooknyc)
— MultipleSclerosis_CME (@ms_cme) August 24, 2021
10) Periventricular lesions are crucial for MS diagnosis (and the McDonald Criteria) but are often asymptomatic, like the “sed rate” of MS: an indicator of inflammatory activity but not very specific. The brain compensates through functional reserve (Neurol Clin 2018;36:13-25).
— MultipleSclerosis_CME (@ms_cme) August 24, 2021
12) But it’s really not so paradoxical: Location (of lesions) matters — those in areas of least reserve, the spinal cord and optic nerve, are more apt to cause relapses. These lesions “cross the threshold” when they form.
— MultipleSclerosis_CME (@ms_cme) August 24, 2021
14) MS lesions in areas of greater reserve (the cerebral hemispheres) are more likely to remain hidden “beneath the surface.” Sidebar: for an incredible short documentary film 🎬 on MS by this name see: https://t.co/8vtN5n12Lv
— MultipleSclerosis_CME (@ms_cme) August 24, 2021
16) Over time the brain can age and atrophy faster for those with MS than for those without it — this is the leaking of reserve which gradually exposes symptoms from lesions that formed many years earlier, under the threshold (https://t.co/IWBJbb1sBI) pic.twitter.com/w4fvbpIAtd
— MultipleSclerosis_CME (@ms_cme) August 24, 2021
18) Tomorrow we’ll look at data that supports this model and some implications for patient care and treatment. First, a polling question:
— MultipleSclerosis_CME (@ms_cme) August 24, 2021
20) Mark your answer and return tomorrow for more education and discussion! @GavinGiovannoni @AaronBosterMD @KlausSchmierer @myelinMD @DrJNicholas @JennyFengMD @DanOntaneda @Brandon_Beaber @DocforMS @DrJim4MS @drbarrysinger @NerdyNeuroMD
— MultipleSclerosis_CME (@ms_cme) August 24, 2021
22) What data are there to support the topographical model? We mapped the disease journey for 10 people with MS followed >20 years, and showed that their progression comprised the same symptoms as those they’d experienced during relapses…
— MultipleSclerosis_CME (@ms_cme) August 25, 2021
24) Other work also supports the importance of lesion topography — landmark studies from @cemcat_em @MarTintore @J_SastreGarriga @XMontalban have shown that lesions in regions of low reserve like the spinal cord predict MS disability outcomes . . .
— MultipleSclerosis_CME (@ms_cme) August 25, 2021
26) Keegan and colleagues proved even one critically-located MS lesion (usually cervical cord or cervico-medullary junction) can yield progressive motor symptoms.
Lesions like these: pic.twitter.com/3Xo8Txi6jE— MultipleSclerosis_CME (@ms_cme) August 25, 2021
28) What about CNS reserve? Sumowski and colleagues found that higher brain volume was protective against decline, for both cognitive and physical symptoms of MS (https://t.co/fJb6yIaA5U).
— MultipleSclerosis_CME (@ms_cme) August 25, 2021
30) What are some implications of reserve and the topographical model concept? It isn’t always obvious in practice what phenotype a person with MS has. There can be *years* of diagnostic uncertainty as one gradually transitions from RRMS to SPMS (Mult Scler. 2014;20(12):1654-7).
— MultipleSclerosis_CME (@ms_cme) August 25, 2021
32) If MS is one disease with great individual variability, and it’s not always easy to identify someone’s correct phenotype. FDA’s use of different MS phenotype labels for approved medications can be confusing! See this written point-counterpoint debate in Practical Neurology:
— MultipleSclerosis_CME (@ms_cme) August 25, 2021
34) The topographical model emphasizes the prognostic importance of spinal cord and infratentorial lesions — these factors may inform treatment selection. Consider obtaining cervical spine MRIs as part of the annual approach to disease monitoring!
— MultipleSclerosis_CME (@ms_cme) August 25, 2021
36) Implications of this model are foundational in Vollmer’s recent paper in @greenjournal: groundbreaking when first published by Sumowski in 2013 and in the topographical model in 2016 . . .
— MultipleSclerosis_CME (@ms_cme) August 25, 2021
38) And finally: brain reserve is a dynamic and “fluid” concept; there are many things people with MS can do to “keep the tank full”: smoking cessation, PT/OT, exercise, diet, social engagement, cognitive enrichment.
— MultipleSclerosis_CME (@ms_cme) August 25, 2021
40) So you made it! For more info on the topographical model, see https://t.co/OpuMX3eavJ or https://t.co/v017AUtMsr, and if you want an interactive video version, download the free MSTopography app for iPad (not iPhone, unfortunately!)
— MultipleSclerosis_CME (@ms_cme) August 25, 2021
41) Now for your free CE/#CME! Go to https://t.co/LVq2Abd3V7 and claim your credit! I’m @SKriegerMD. Follow @MS_CME for more tweetorials, @ visit https://t.co/DvhVMSUOJf for unrolled programs where credit opportunity is still active! #neurotwitter. #FOAMed
— MultipleSclerosis_CME (@ms_cme) August 25, 2021
