INO question

Question for Quix.

From the Merck manual:  Internuclear opthalmoplegia results from a lesion in the MLF.  In young people, the disorder is commonly caused by MS and may be bilateral.  In the elderly, it is typically caused by stroke and is unilateral.  Occasionally, the cause is neurosyphillis, Lyme disease, tumor, or drug intoxication (e.g., with tricyclic antidepressants).  I was diagnosed with bilateral INO.  My neurology workup has ruled out stroke and the other causes, which in my mind leads me to conclude MS.  The neuro states my "documented history and neuro exam(s) are highly consistent with a dx of MS".  But since I am not imaging plaques on MRI, the neuro says probable MS.  What am I missing here? Just a little frustrated this morning!  Thanks, SDSAM

[doublevision1]

Hi, thought I would just chime in to say that I did have INO which presented as diplopia and nystagmus.  I do have a visible lesion on my brainstem which is where the lesion causing the INO is located.  I had persistent double vision for about a year, it is now probably 95% better which is as good as it's going to get.   Follow up MRI's indicated that the brainstem lesion is still visible and unchanged, despite the improvement in my symptoms.  My neuro explained that the improvement is more likely due to other undamaged nerves taking over function from the damaged nerves, ie: brain plasticity.

I know this doesn't answer your question but thought I'd just share my experience with INO.  BTW, it was onset of the double vision plus a vast array of other clinical symptoms, an MRI showing lesions on brainstrem and c-spine, and an abnormal LP  (no O-bands though) which led to my MS dx in 2007.

How does your INO present clinically?  Do you have double vision?

[sdsam]

Exactly.  Eleven weeks ago yesterday woke up with double vision and ataxia, was hospitalized for the IV Solumedrol and left with a dx of MS.  After getting home and having the steroids wear off, noticed numbness and tingling on the left side, including my face and tongue, causing some speech difficulties.  Now the neuro has backed off the MS dx since none of my MRI's show plaques, and says probable MS due to my documented history and neuro exam.  He states the INO is causing my double vision, and can find no evidence of a stroke, major or minor.  "Given your age (60), we need to rule out a stroke".  Done!  So, what is it if not MS?  Guess I will have to ask that question when I return for followup.  Thanks for chiming in, any opinion appreciated!  SDSAM  

[Quixotic1]

Well, you are caught in the conundrum of the normal MRI with an abnormal CNS.

If you have INO or BINO then you have lesions in the brain stem involving the nuclei (transit hubs) where the cranial nerves that control eye movements communicate.  Period.  We KNOW you have lesions.  These count for one clinical lesion in the McDonald Criteria.  You are PROOF positive that the MRI is imperfect and that lesions can well be invisible to it.

I don't remember all of your story, but if you have had two or more episodes of symptoms that are very suggestive of demyelination AND you have findings on exam that show evidence of two or more lesions (damage) in the central nervous system  which are separated in space AND have had a thorough "rule out" of the MS mimics -- Then you fulfill the McDonald Criteria for the diagnosis of RRMS.  PERIOD.

At this point if someone has had two clear episodes and has two lesions as seen on exam or other testing, they look at the MRI for corraborating evidence.  The real experts in MS will tell you that MRI evidence is desirable and that it need only be "consistent" with MS.  A lone, measly lesion somewhere (consistent) will do.  The reality is that few will stand up and make the diagnosis.  Weenies!

Well, that is the reality.  But, for example, hyperreflexia and INO prove that the spinal cord and brainstem lesions are present.  Those should be able to stand in for a category of KBNYV - Known, but not yet visible, lesions.

In my never-so-humble opinion.

Quix

[sdsam]

Thanks for the input.  This episode was my second major one, the first was similar to this one, but this time had a significant prob with ataxia.  Followed by numbness and tingling, leaden left foot feeling, etc.  In between had several episodes of numbness and tingling, and even a "probable MS" opinion several years ago.  On followup exam I was also found to have hyperreflexia of the lower extremities, so I would have involvement of both the brain stem and the spinal cord, correct?  I can see why some are so frustrated on this forum!  Thanks again!  SDSAM

[Quixotic1]

Well, you make criteria for the Diagnosis.  Since your neuro is so sure of the likelihood of MS, he should have you on a med.  Are you?  If not we can formulate some questions to put his way.  Im MY mind (and remember I am not a neurologist, but I read alot and am a physician.  And I stay in a Holiday Express once with a bunch of neurologists - as if!)  you qulaify in full for the Dx and should be on treatment.

Quix

[sdsam]

They started me on Avonex while in the hospital in Dec, been doing my shot weekly.  On followup in late Jan was prescribed Baclofen for the muscle spasms in my left calf and foot.  So I am definitely being treated for MS, but they are waffling on calling it MS.  While I was in the hospital I asked the doc what it was that put me in the hospital, he in turn asked me what I thought it was.  I said MS, and he said "me too", now he writes probable MS.  Don't make any sense to me, but I am a black and white thinker I guess!