A 38-year-old woman comes to the emergency department due to a week of clumsiness and shaking in her right arm. The patient also feels unsteady and has fallen twice in the past 2 days. One year ago, she had diplopia and vertigo for 2 weeks that resolved without treatment. The patient has no other medical problems. She takes oral contraceptives and occasionally acetaminophen. She does not use tobacco, alcohol, or illicit drugs. She recently started a vegan diet. Her father died of a large stroke, and her mother has diabetes mellitus. Temperature is 37 C (98.6 F), blood pressure is 140/85 mm Hg, and pulse is 84/min and regular. BMI is 34 kg/m². On physical examination, there is mild right pronator drift but no muscle weakness. The patient is unable to walk a tandem gait. MRI of the brain without contrast is shown in the image below. Which of the following is the most appropriate next step in management of this patient?

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11ec25c8_d488_1dfb_bc81_079ac390bc91_MD0003_00 This patient likely has an acute exacerbation of multiple sclerosis (MS), an autoimmune inflammatory demyelinating disorder of the central nervous system (CNS). MS typically presents in women age 15-50 with neurologic deficits (eg, ataxia, diplopia, vertigo, pronator drift) disseminated in space and time. MRI of the brain often demonstrates multifocal, ovoid hyperintense white matter lesions (arrows) in the CNS, particularly the periventricular and subpial white matter of the cerebrum (corpus callosum) and the optic nerves, brainstem, and spinal cord. Once the diagnosis is established, patients with an acute attack and disabling symptoms are typically treated with high-dose intravenous (IV) glucocorticoids (eg, methylprednisolone). Plasma exchange is indicated in those who do not respond to glucocorticoids. Other immunomodulators (eg, interferon beta, natalizumab, glatiramer) can be used for long-term disease suppression. (Choice A) Acetazolamide is a carbonic anhydrase inhibitor that can be used to treat elevated intracranial pressure in patients with pseudotumor cerebri as it reduces cerebrospinal fluid production. Patients tend to be obese and usually have headache, transient visual changes, and bilateral papilledema. Brain imaging is typically normal. (Choice B) Aspirin and statins are appropriate for primary or secondary prevention of ischemic stroke, which is more likely to present with permanent neurologic deficits in older individuals with multiple vascular risk factors. MRI normally demonstrates ischemic changes in a vascular distribution. ischemic stroke (Choice C) IV heparin can be used to treat dural sinus thrombosis, which typically occurs in patients with hypercoagulable conditions (eg, contraceptive use, pregnancy, malignancy) and presents with headache and signs/symptoms of elevated intracranial pressure (eg, papilledema, impaired consciousness, nausea/vomiting). (Choice E) Vitamin B₁₂ deficiency is typically associated with subacute combined degeneration of the spinal cord, which presents with progressive symmetric sensory loss/paresthesias, sensory ataxia, and spastic muscle weakness. It can be found in long-standing veganism but would take many years to occur. (Choice F) An echocardiogram would be appropriate when there is concern for a cardioembolic stroke (eg, due to atrial fibrillation), which tends to occur at the gray-white junction and not the periventricular location as seen in MS. Patients typically have sudden-onset neurologic deficits that may follow a stuttering course. cardioembolic stroke (Choice G) Lumbar puncture is typically performed in patients with suspected MS when the diagnosis is not completely clear. Cerebrospinal fluid typically shows oligoclonal IgG bands. It is not necessary in this patient with classic clinical and radiographic findings. Educational objective: Acute exacerbations of multiple sclerosis should be treated with high-dose intravenous glucocorticoids. Plasma exchange is reserved for patients who do not respond to high-dose glucocorticoids. References: Diagnosis and treatment of multiple sclerosis. (http://www.ncbi.nlm.nih.gov/pubmed/16513709) Relapse in multiple sclerosis. (http://www.ncbi.nlm.nih.gov/pubmed/25872511)

A 38-Year-Old Woman Comes to the Emergency Department Due to a Week