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A patient with multiple sclerosis is reported in whom neck flexion produced a reversible deterioration in gait and an increase in the degree of pyramidal weakness of the lower limbs. The name McArdle's sign is proposed.
Many patients with multiple sclerosis and their relatives view the illness as untreatable and inevitably bringing progressive immobility and loss of independence. The optimistic theme of this article is that something can be done for most patients with the disease if disability and expectations are assessed individually.
A patient resembling one with progressive multiple sclerosis in clinical presentation and by magnetic resonance imaging was studied in detail. Some features atypical for multiple sclerosis prompted a persistent search for an alternative cause. The diagnosis of a non-Langerhans systemic histiocytosis involving brain and bone was established and showed a partial response to radiation therapy. This patient illustrates the continued importance of a broad approach to the evaluation of possible multiple sclerosis, with particular attention to atypical features.
A case of multiple sclerosis presenting during anti-tumor necrosis factor treatment for rheumatoid arthritis is discussed. This association has been reported in the nonradiological literature, but is an important association for radiologists to be aware of, as they may be in a position to first suggest the diagnosis.
Urinary and sexual symptoms in patients with multiple sclerosis (MS) are frequent, although this question has scarcely been addressed in our country. The aim of this study is to prospectively evaluate the presence of such symptoms in 77 MS patients. We have valued the neurological involvement and the degree of functional disability through the Minimum Dossier of Disability for Multiple Sclerosis. The urinary and sexual symptoms were collected through a directed survey. We have performed an urodynamic study in order to evaluate the bladder function. Urinary symptoms wire observed in 81.8% of patients, with predominance of the mixed syndrome (52%). Males show greater neurological affectation and functional disability, as well as greater urinary symptoms frequency (91%). The most frequent symptoms have been urgency (66.6%), frequency (60.3%) and dysuria (53.8%). The complications have been scarce, of infectious type (14.28%) and with female predominance. The most frequent urodynamic finding has been the detrusor hyperreflexia (60%). The minimum dossier of Disability for Multiple Sclerosis is useful to establish comparative parameters with other studies and with more specific urologic data. The presence of urinary symptoms in multiple sclerosis correlated with the degree of neurological (pyramidal and cerebellar) involvement and of functional disability in the Dysfunction Status Escale.
The mortality for multiple sclerosis in Italy was analyzed for the period 1969-1987. The age-adjusted (to Italian 1981 population) death rates decreased slightly during these years for both sexes. The average national female/male ratio of the age-adjusted rates is 1.33 and shows a north-south gradient, with values < 1 in the South-Islands area where multiple sclerosis cases are probably heavily underreported on the death certificates. A positive, significant correlation between the age-adjusted death rates and latitude of the 20 Italian regions exists for the period 1969-1975; in recent years (1981-1987), these parameters show a weaker, but not statistically significant positive correlation. Moreover, the 95% confidence intervals of the death rates in the 20 regions overlapped extensively in both periods studied (1969-1975 and 1981-1987). Death rates for multiple sclerosis are a weak index of the frequency of the disease and their utility is restricted to national surveys. The descriptive epidemiological data (incidence, prevalence, mortality) available at present in Italy do not seem to support a link between multiple sclerosis and latitude.
The etiology of multiple sclerosis (MS) is still unexplained. Epidemiological studies indicate that environmental agents are involved, and MS shares both clinical and histopathological features with retrovirus-mediated neurological diseases in animals and humans. Thus, combining the fields of microbiology and epidemiology may throw new light on the many unanswered questions posed by MS.
Most patients with multiple sclerosis who have vesical dysfunction will have some variety of uninhibited bladder that generally will progress toward a hyperreflexic state. Management of these patients requires, primarily, control of the infection ahd the use of a variety of techniques and pharmacologic agents in many combinations to achieve a socially acceptable state.
A case of multiple sclerosis was diagnosed as paranoid schizophrenia 10 years earlier. The schizophrenic disorder, severe and almost nonremittent for 10 years, failed to respond to adequate drug therapy. The computerized axial tomography scan revealed moderate atrophy of the anterior cerebellar vermis, a finding of interest in view of studies which have implicated anterior vermis pathology in the pathogenesis of schizophrenia.
Seventy four patients with clinically definite multiple sclerosis were studied by using polyacrylamide gel electrophoresis of cerebrospinal fluid to assess blood-brain barrier function. Blood-brain barrier impairment was associated with recent clinical relapses of multiple sclerosis and worsened across a spectrum from the relapsing-remitting type of multiple sclerosis to secondary and primary progressive disease. The association between blood-brain barrier impairment and primary progressive disease is particularly interesting in the light of recent evidence that focal gadolinium enhancement on MRI is relatively unusual in patients with this disease.
Magnetic resonance (MR) techniques have had a major impact in the last 10-15 years in understanding and managing multiple sclerosis. This review summarizes the current uses of MR in multiple sclerosis, based on the proceedings of a recent international workshop, under four headings: (i) technical issues; (ii) role in diagnosis; (iii) natural history studies in understanding the disease; (iv) application in clinical trials. The theory and methodology of relevant technical issues is outlined, in order to provide a framework with which to understand the potential and limitations of MR in addressing biological and clinical questions in multiple sclerosis. The principles underlying signal-to-noise and contrast-to-noise ratio are discussed, along with the techniques and clinical results for conventional and fast spin echo T2-weighted imaging, fluid-attenuated inversion recovery, detection of blood-brain barrier break down and hypointense lesions on T1-weighted images, magnetization transfer, T2 decay-curve analysis, MR spectroscopy, spinal cord imaging, diffusion imaging, and quantification of lesion load and atrophy. MRI has an extremely valuable role in confirming the clinical diagnosis of multiple sclerosis. T2-weighted brain imaging remains the standard diagnostic tool, but in some instances it is usefully complemented with gadolinium enhancement and spinal imaging. The caveat that the diagnosis of multiple sclerosis remains primarily a clinical one cannot be over-emphasized. Serial MRI studies have added much to our understanding of the natural history and pathophysiology of the disease. Blood-brain barrier breakdown is a consistent early feature of new lesion development in relapsing-remitting and secondary progressive multiple, sclerosis, and this usually correlates with active inflammation and myelin breakdown. A number of the acute MR changes are reversible, but chronic persistent abnormalities in a number of MR parameters, such as reduced N-acetyl aspartate, low magnetization transfer ratios, atrophy and T1-hypointensity, suggest the presence of demyelination and/or axonal degeneration in many chronic lesions. The presence and extent of T2-weighted MRI abnormalities at first presentation with a clinically isolated syndrome suggestive of demyelination strongly predicts the risk of developing clinically definite multiple sclerosis in the next few years. In established multiple sclerosis, however, the correlations between T2 abnormalities and disability are modest. This poor relationship partly relates to the discrepancy between lesion site and function in attempting to correlate locomotor disability with brain MRI findings. However, the correlations between brain lesion load and cognitive dysfunction in multiple sclerosis, whilst more evident, are still modest. A more important limitation is the low pathological specificity of abnormalities seen on T2-weighted images. Stronger correlations have been found between disability and new putative MR markers for demyelination and/or axonal degeneration. Serial studies using multiple MR techniques are now needed to further clarify pathophysiological mechanisms in multiple sclerosis. Serial MR has become an important tool in monitoring treatment efficacy. It provides data which can be readily analysed in a blinded fashion and which directly inspects the pathological evolution; it also enables a rapid and sensitive measure of treatment outcome in early relapsing-remitting and secondary progressive disease. Because of the modest clinical correlations it is, however, still appropriate that the definitive determinant of treatment efficacy remains a clinical one. Further work is needed to address issues of quality control in serial studies, statistical calculation of appropriate sample sizes, and optimization of the nature and frequency of MR outcomes measured.
Seven patients with multiple sclerosis who were receiving subcutaneous injections of recombinant interferon beta had pain followed by ulceration at the injection site. An eighth patient had a pustular flare of her usually mild psoriasis. No evidence of infection or contaminated medication was found.
Sixteen women with multiple sclerosis who complained of nocturia completed a double-blind cross-over trial of Desmopressin (DDAVP) and placebo. Nocturia was reduced from a mean of 2.55 voids to 2.01 with placebo and to 1.28 with Desmopressin (p less than 0.01, for the difference between placebo and Desmopressin). Side effects were minor, and equally distributed between treatment and placebo.
A patient with multiple sclerosis (MS) who developed intractable hiccups and syncope due to a cervical cord lesion is reported. Previous case reports of intractable hiccups occurring in MS have all been located in the medulla oblongata. Our patient is the first case with the responsible lesion in the cervical cord. The pathophysiological mechanism of the syncopal attacks in this case were thought to be same as that of cough syncope.
Sixteen patients with multiple sclerosis were evaluated by magnetic resonance imaging (MRI) to determine if number of brain lesions correlated with the amount of functional disability, as described by the Incapacity Status Scale contained in the Minimal Record of Disability. Although no correlation existed, the statistical analysis did indicate a trend toward correlation, which warrants a study with a larger number of subjects.
Strategies proposed for the treatment of multiple sclerosis are numerous and sometimes contradictory. This review summarizes the most recent studies on the treatment of multiple sclerosis. Possibilities of influencing progression of the disease and the degree of disability suffered by patients are discussed. The treatment of acute relapses with high-dose intravenous glucocorticoids is now widely accepted because it has been shown that the duration of the relapse is reduced. Interval therapy between relapses and treatment of the chronic progressive variant of multiple sclerosis are still under debate. Immunosuppression, in particular with azathioprine, appears to have a positive effect on the long-term outcome. Whether other regimens, e.g., treatment with recombinant lymphokines, have a therapeutic effect, is difficult to assess at present since these substances have either never been tested in controlled double blind studies or the results of these studies are not yet available.
A patient with multiple sclerosis is described who presented with a unilateral loss of voluntary function of his lower face muscles. However, in an emotional situation, there was strong involuntary innervation of these muscles: automatic-voluntary dissociation. The subcortical afferents to the facial motor nucleus are discussed. It is hypothesized that cortical disinhibition of midbrain nuclei underlies the accentuated involuntary innervation.
The individual with multiple sclerosis (MS) experiences a severe alteration in lifestyle both physiologically and emotionally. Sexuality is an integral part of life. However, discussion of alterations in sexuality by health care workers has traditionally been viewed as taboo. Specifically, the sexual concerns in chronic debilitating disorders such as MS have been neglected. This paper will explore physical and psychological aspects of MS on a patient's sexuality. Implications for nursing practice will also be considered.