Diagnostic approach to ptosis MG general concept

Diagnostic flow chart to Myasthenia gravis Therapeutic flow chart to Myasthenia gravis

MG-thymus glad-thymoma-thymectomy
Surat Tanprawate, MD

Ptosis
Non-neurogenic(mechanical) ptosis

Neurologic ptosis
Congenital ptosis

Uni-bilateral Partial-complete

Pupil involvement EOM impairment

Supranuclear lesion(cerebral ptosis) Contralateral cerebral hemisphere

LMN Neuropathic(N, fascicle, CN) NMJ Myopathic

Horners syndrome

Weakness due to NMJ disorder

Distribution of weakness

Eyelid, EOM, facial muscle, bulbar

Proximal muscle weakness

Course

Fluctuating course
Fatigability

Diagnostic flow chart

Lancet Neurol. 2009 ; 8(5): 475490

MG subtypes
(1) early-onset MG: age at onset <50 years. Thymic hyperplasia (2) late-onset MG: age at onset >50 years. Thymic atrophy

(3) thymoma-associated MG
(4) MG with anti-MuSK antibodies

(5) ocular MG: symptoms only from periocular muscles

(6) MG with no detectable AChR and MuSK antibodies;

Treatment flow chart

Lancet Neurol. 2009 ; 8(5): 475490

Immunotherapy in MG

Lancet Neurol. 2009 ; 8(5): 475490

Myasthenia gravis and thymoma

About 1015% of patients with MG have a thymic epithelial tumour(thymoma)

Thymothymectomy

often completely and permanently removes the tumour symptoms of MG usually persist and require chronic immunotherapy

Thymomectomy in MG
Early onset with generalized weakness Thymoma associated MG Early debut age within this late-onset
group (<60 years) and thymic hyperplasia on MR/CT imaging favour thymectomy

Age alone should not decide thymectomy or not

NilsErik Gilhus Autoimmine disease 2011

When is not considered thymomectomy?

Pure ocular MG Higher age, symptoms for a longer time
period, atrophic thymus, and presence of non-AChR antibodies against titin and/or ryanodine receptor
NilsErik Gilhus Autoimmine disease 2011