Natural Multiple Sclerosis Treatment Book

Reverse MS Now

Heres just a few things youll learn about how to get back into health. and conquer Multiple Sclerosis. Those not-so innocent yet everyday substances that are currently attacking your body, perpetuating and aggravating your Multiple Sclerosis. What to do and what Not to do to overcome your Multiple Sclerosis effectively and permanently. How to create the energy you need to be able to work full time and feel confident you will be able to take care of your loved ones. How the pharmaceutical and food industry are conspiring to poison you and make you sick (Hint: American medical system is now the leading cause of death in the US). Read more here...

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Multiple Sclerosis A Nervous Situation

About 350,000 people in the United States have been diagnosed with MS, with approximately 200 new cases every week. Women are affected twice as often as men. Caucasians are diagnosed more frequently than African Americans or Asians. Heavy ' stiff ' numb ' and tingling are words that patients with multiple sclerosis often use to describe the way their muscles feel, especially the muscles in their legs.

What is multiple sclerosis

Multiple sclerosis is a common disorder in which the myelin sheath within the central nervous system is destroyed by a poorly understood inflammatory process. Genetic and environmental factors have been implicated as triggers for the disease. Diagnosis is challenging and requires documentation of damage in at least two separate areas of the central nervous system and ruling out other possible diagnoses through careful medical history, neurologic examination, MRI, visual evoked potentials and CSF analysis. Symptoms associated with multiple sclerosis are variable and wide-ranging. These may include numbness, fatigue, gait problems, ataxia, bowel bladder dysfunction, cognitive dysfunction, and spasticity. No cure is available, but a variety of medications are used in an attempt to limit disease activity and progression.

Multiple Sclerosis

The partial remissions after exacerbations of multiple sclerosis (MS) and the progression over long periods of time lead to the speculation that partial restitution and substitution may evolve from lesion-induced and practice-related network and representational plasticity, improved axonal conduction,146 remyelination, and of course, recovery from the effects of local inflammation. By the same logic, exhaustion of reorganizational plasticity as the burden of axonal lesions grows may contribute to functional declines.

Network Emotional Regulatory Network Spatial Awareness Network Language Network Summary

Tem, from behavioral systems to interregional and local circuits, to neurons and their dendritic trees and spines, to microcircuits on axons and dendrites, and most importantly, to synapses and their molecules and ions. Experience and practice lead to adaptations at all levels. Knowledge of mechanisms of this activity-dependent plasticity may lead to the design of better sensorimotor, cognitive, phar-macologic, and biologic interventions to enhance gains after stroke, traumatic brain and spinal cord injury, multiple sclerosis, and other diseases.

Evaluation Guidelines Table31

Electroencephalography (EEG) is helpful in the evaluation of seizure disorders and metabolic encephalopathy and, to a lesser extent, for documentation of regional physiological malfunctions. In patients with psychosis, the EEG should be normal, whereas metabolic disorders can cause disorganization and generalized slowing. The EEG can reveal physiological abnormalities that may not be reflected on structural imaging studies. Old trauma, a postictal state, or migraine headache may be associated with behavioral abnormalities and may cause focal EEG findings when the mRi is normal. Rarely, disorders of emotion, mood, or thought with subclinical seizures or complex partial status epilepticus may be diagnosed only with EEG. The use of evoked responses in neuropsychiatric disorders remains a research tool except when organic explanations such as multiple sclerosis are being actively considered.

Associated Neurological Findings

Attention to ataxia, apraxia for orolingual movements, oculomotor abnormalities, coordination problems, gait disturbances, tremor, bradykinesia, and rigidity is critical, since alterations in the ability to smell are present in some patients with Huntington's chorea and multiple sclerosis, and in approximately 90 percent of patients with early-stage Parkinson's disease. In Korsakoff's syndrome, ataxia of the trunk but not of the limbs is frequently present, as are signs of acute alcohol withdrawal (e.g., tremor, delirium, and tachycardia).

Emotional Regulatory Network

Prefrontal and orbitofrontal cortex often bear the brunt of damage in traumatic brain injuries. Also, the system may degrade in patients with stroke, multiple sclerosis, the cortical and subcortical dementias, and other cerebral disorders. Behavioral and mood syndromes caused by frontal lobe injury are recapitulated by lesions in subcortical structures of the circuits.

Evaluation Guidelines Table95

Cerebrospinal fluid (CSF) examination is often a critical part of investigation for dysfunction of cranial nerves III, IV, and VI because these nerves are often affected selectively in meningeal infections, as well as in inflammatory and neoplastic infiltrating disorders. In addition, patients with multiple sclerosis (see Chapter48 ) may present a typical profile of CSF abnormalities, and patients with this disease often present with ocular motility disturbance from central lesions (gaze palsy, INO) and less frequently with ophthalmoplegia from plaques affecting the intramedullary portion of cranial nerves III, IV, or VI.

In Neurology And Ophthalmology

The classical application of VEP measurements for clinical purposes is its contribution to the diagnosis of multiple sclerosis (MS). The main characteristic of this disease is the patchy demyelination of afferent and efferent nerve fibers distributed all over the nervous system, and the patients have neurological symptoms that cannot be explained by a single lesion. Myelin is an insulating sheath, found on most axons, that increases conduction velocity (cf. Kandel et al., 2000), thus, electrophysiologically, latency prolongations are expected when demyelination occurs. In many patients the visual system is affected at an early state of the disease, and one finds patients with pathological VEP results who, however, do not display any subjective visual symptoms (i.e., they have normal visual acuity and visual fields). An optic neuritis occurs frequently at a very early stage of the disease, which in general is followed by a recovery after several weeks, whereas other symptoms...

Future Investigations

Vercellino M, Votta B, Condello C, Piacentino C, Romagnolo A, Merola A, Capello E, Mancardi GL, Mutani R, Giordana MT, Cavalla P (2008) Involvement of the choroid plexus in multiple sclerosis autoimmune inflammation a neuropathological study. J Neuroimmunol 199 133-141

Demyelinating Diseases

Precursors exist in normal adult humans and around the plaques of multiple sclerosis lesions.178 The number of oligodendrocyte precursors declines as the plaque ages and few precursors appear to migrate into a plaque from normal adjacent tissue.179 Strategies for re-myelination in patients with MS will require methods to stimulate proliferation and differentiation of precursors. Implanted OECs and Schwann cells may also remyelinate CNS axons. Human trials have been initiated using OECs.

Magnetic Resonance Imaging

The MRI findings of GC are not unique other diseases may produce similar findings and must be considered. The differential diagnosis includes ischemic or infectious diseases, demyelinating diseases such as leukoencephalopathy or multiple sclerosis, and other tumor processes, including diffusely infiltrating astrocytomas or multicentric glioblastoma multiforme. The acuity of onset of clinical symptoms generally enables differentiation of ischemic disease from GC, whereas it may be very difficult, if not impossible, to distinguish some infectious diseases, such as viral encephalitis. As a general rule, leukoencephalopathy is uncommon in the setting of deep or superficial gray matter involvement. Multiple sclerosis plaques are typically more circumscribed than the signal abnormalities of GC. It can be difficult to differentiate GC from a multicen-tric glioma, although the latter tends to demonstrate a different MRI pattern, including necrosis, heterogeneous contrast enhancement,...

Brainstem the bridge to the outside world

This is the point at which the large outbound motor pathways, the corticospinal tracts, merge into the brainstem, one column from each side. It is also the location of the substantia nigra (see page 57). There is also a very important group of nerve cells, which are the final stage of the system controlling eye movements. We have already discussed the importance of eye movement co-ordination with other systems but, crucially, the eyes must co-ordinate with each other otherwise double vision will ensue. Specific nerve pathways link the movements of the two eyeballs together and these can become disrupted in certain diseases of the brainstem such as strokes, multiple sclerosis and brain tumours.

Nervous About Nerve Pain

Beat Bell's palsy with Oriental Medicine Aid for limping limbs of multiple sclerosis This chapter will help you check out your wiring and see how Oriental Medicine deals with some potentially devastating conditions such as Bell's palsy, multiple sclerosis, and strokes. We also will look at the nerve pains of shingles and trigeminal neuralgia. All of these conditions involve damage to the nervous system.

Magnetic Resonance Spectroscopy

Volumes of interest can be compared to regions that are not involved in the pathological process. The extent or reversibility of axonal injury can be compared to changes in regional activation by fMRI with the same MR equipment. For example, in a patient with multiple sclerosis who had an exacerbation with a hemi-paresis, serial MRS revealed a reversible decrease in the NAA concentration. The change from presumed greater to lesser tissue injury was associated with a decrease in the number of pixels activated in primary sensorimotor cortex during an fMRI study of finger tapping and by less disability.50 In normal appearing frontal lobe white matter, based on MRI after cerebral trauma, proton MRS abnormalities such as a low NAA suggest diffuse axonal injury.51 Magnetic resonance spectroscopy has been combined with MEG and MRI to relate physiology to chemistry in ischemic brain.52

Functional Abnormalities

Positron emission tomography (PET) and single-photon emission tomography (SPECT) studies of both primary depression (unipolar, bipolar) and depression associated with specific neurological conditions (focal lesions, degenerative diseases, epilepsy, multiple sclerosis) identify many common regional abnormalities (reviewed in Mayberg, 1994 Ketter et al., 1996). For example, in depressed patients with one of three prototypical basal ganglia disorders Parkinson's disease, Huntington's disease, and left caudate stroke resting-state paralimbic hypometabolism (ventral prefrontal cortex, anterior cingulate, anterior temporal cortex) was found to differentiate depressed from nondepressed patients within each group, as well as depressed from nondepressed patients, independent of disease etiology (Mayberg, 1994). These regional findings, replicated in other neurological disorders (Bromfield et al., 1992 Hirono et al., 1998 Starkstein et al., 1990c), suggests involvement of...

Lymphomas And Hemopoietic Neoplasms

Possibility is that a B cell attracted to a CNS inflammatory lesion becomes transformed within the CNS and proliferates there, giving rise to a neoplasm. This is similar to the development of mucosa-associated lymphoid tissue (MALT) lymphoma in the context of Helicobacter pylori gastritis.49 In this situation, chronic antigenic stimulation leads to malignant transformation of B cells targeting the organism. However, the incidence of PCNSL is not increased in inflammatory disease states of the CNS such as multiple sclerosis, encephalitis, or bacterial infections, and no source of chronic antigenic stimulation has been identified in the CNS of PCNSL patients.

Approaches for Walking

Ambulation is often the highest immediate rehabilitative priority for patients following a stroke, the Guillain-Barre syndrome, and brain or spinal cord injury. Patients with progressive diseases such as multiple sclerosis, Parkinson's disease, and myopathies, as well as the elderly who develop proximal weakness and imbalance associated with deconditioning, arthritic pain, contractures or a spinal stenosis aim for continued independent walking, in part to lessen the burden of care they may pose for significant others.

Measures Of Impairment

Combinations of impairment measures may be especially valuable for the goal of measuring changes across several neurologic domains for a disease over time. For example, the Multiple Sclerosis Functional Composite (MSFC) assesses the arm with the 9-Hole Peg Test, the leg with the 25-Foot Timed Walk, and cognition with the Paced Auditory Serial Addition Test (PASAT).10 The tests are operationalized in a manual and results have been correlated with impairment, disability, and QOL.11-13 This effort to reliably quantify impairments in patients with MS with valid tests grew out of over 30 years of frustrating attempts to capture clinically important declines and reveal clini

Abnormal Findings and Clinical Uses of the SEP

Figure 24-14 Median-elicited somatosensory evoked potential elicited 4, a normal subject by right-sided stimulation, anB, a patient with multiple sclerosis by left-sided stimulation. Two trials are superimposed to show the replicability of the findings. In the responses recorded in the patient, an Erb's point potential is present but responses over the cervical spine and scalp are absent. EP, Erb's point CV5, 5th cervical spine i, ipsilateral c, contralateral other abbreviations as in earlier illustrations. In patients with multiple sclerosis, SEP abnormalities may indicate the presence of subclinical lesions, thereby helping to establish the diagnosis. y The presence of such abnormalities may also suggest that vague sensory complaints have an organic basis when this is hard to determine clinically. The SEP is abnormal in about 80 percent of patients with multiple sclerosis (see Figs 24-1ii4i and 2.4z15.), but SEP abnormalities are found in only about 30 percent of patients when this...

Nonsteroidal Anti Inflammatory Drugs

Taneous injections, the cost, and the availability of insurance coverage. ' In general, biologic DMARDs should be avoided in patients with serious infections, demyelinat-ing disorders (e.g., multiple sclerosis or optic neuritis) or hepatitis. TNF antagonists should be avoided in patients with heart failure.18

Peroxisomal Leukodystrophies Adrenoleukodystrophy

In the adolescent cerebral ALD syndrome, signs and symptoms of cerebral involvement are manifest, yet the onset of disease usually occurs between the ages of 10 and 21. The adult form usually presents with dementia, psychiatric disturbances, seizures, and spastic paraparesis with onset at some time after the age of 21. Such patients have presentations similar to those of other problems such as multiple sclerosis, schizophrenia, and brain tumor. They show a reasonably rapid regression.

Differential Diagnosis

Spinal tumors must be differentiated from other disorders of the spinal cord. A complete differential list is extensive and can include the following transverse myelitis, multiple sclerosis, syringomyelia, combined system disease, syphilis, amy-otrophic lateral sclerosis (ALS), anomalies of the cervical spine and base of the skull, spondylosis, adhesive arachnoiditis, radiculitis of the cauda equina, hypertrophic arthritis, ruptured intervertebral discs, and vascular anomalies. Multiple sclerosis (MS), with a complete or incomplete transverse lesion of the cord, can usually be differentiated from spinal cord tumors by the relapsing and remitting course. The signs and symptoms of lesions in more than one anatomic location as well as evoked potential studies, cranial magnetic resonance imaging (MRI), and presence of CSF oligoclonal bands are consistent with MS. Acute transverse myelitis may occasionally enlarge the cord to simulate an intramedullary tumor.33

Concluding Comments

The gut has its own intrinsic nervous system and is in active communication with the brain and central nervous system. Therefore, it is not especially surprising to note that disorders of gastrointestinal function exist in the absence of evidence of tissue damage, with the relationship between FGIDs and gastrointestinal diseases such as Crohn's disease perhaps being analogous to that between common psychiatric disorders such as anxiety or mood disorders and neurological diseases such as multiple sclerosis. FGIDs are indeed common, impairing, and strongly associated with anxiety and depressive disorders new treatments share common features with treatment regimens that are successful in the management of emotional disorders and migraine headache. Psychiatric symptoms and disorders, particularly depression, are also commonly comorbid with gastrointestinal diseases such as IBD and hepatitis C, sometimes in relation to associated treatments such as corticosteroids and interferon alpha.

Inflammatory Diseases

In addition to degenerative diseases or disturbances of blood supply, the brain may be damaged by inflammation. Meningoencephalitis is an acute, possibly life-threatening event caused by bacteria or viruses. ERP studies on meningo-encephalitis have been conducted primarily on patients with damage to the temporal lobe and the hippocampal system the lesions in these patients have served as models to study ERP generators. As stated previously, this will not be discussed in detail here. The research discussed here is on the chronic, potentially deteriorating damage caused by multiple sclerosis and by the human immunodeficiency virus.

Epidemiology and Pathogenesis

Autoimmune diseases are chronic disabling disorders in which immune dysregulation leads the body to attack its own organs and tissues. More than 80 autoimmune diseases have been identified. The most common of these diseases include systemic lupus erythematosus (SLE), multiple sclerosis, type 1 diabetes, autoimmune thyroid diseases, myasthenia gravis, and rheumatoid arthritis (RA). Collectively, autoimmune diseases are thought to affect approximately 14-22 million people in the U.S. and represent a significant physical, emotional, social, and fiscal burden to the country's health care system. For reasons that are not clear, the prevalence of autoimmune diseases appears to be rising. Further, the development of effective therapies has lagged behind the growing prominence of these diseases.

What is anorgasmia and how is it treated

Anorgasmia, the inability to achieve an orgasm, may be congenital or acquired. It is estimated that about 90 of anorgasmia problems are related to psychological issues. Surveys point to performance anxiety as a common psychological problem. There is a relationship between anorgasmia and childhood or adult sexual abuse or rape. Marital strife, boredom with a relationship, coupled with a monotonous sex life are other contributing factors. Some drugs, such as alcohol and the selective serotonin reuptake inhibitors may impair orgasmic response. Certain medical conditions such as spinal cord injury, multiple sclerosis, hormone conditions and diabetes have been implicated. Treatment of anorgasmia

Experiments and Results

The SBD contains simulated brain MRI data based on two anatomical models nonnal and multiple sclerosis (MS). For both data sets, full 3D datasets have been simulated using three sequences (Tl-, T2-, and proton-density- (PD-) weighted) and a variety of slice thicknesses, noise levels, and levels of intensity non-unifonnity. These data are available for viewing in three orthogonal views (transversal, sagittal, and coronal).

Clinical Manifestations

Stage II of Lyme borreliosis may involve the neurological system. Of patients, 10 to 15 percent may have this involvement and present with a meningitis-type picture or have cranial nerve palsies. The most commonly involved cranial nerve is the seventh (facial) nerve, which results in an inability to control properly the facial musculature. In individuals with meningeal irritation, episodic headaches, neck pain, and stiffness may occur. Cerebrospinal fluid analysis frequently shows a predominance of mononuclear white blood cells. Occasional patients with stroke syndromes including hemiparesis as well as cases mimicking multiple sclerosis or encephalitis have been reported. Individuals may have associated confusion, agitation and disorientation, and memory loss. The symptoms and signs may wax and wane over weeks and months.

Geography and Epidemiology

There are two relevant geographic aspects the distribution of the disease and the distribution of its genetic associations. Among Caucasoids the prevalence of multiple sclerosis is generally higher in higher latitudes. In the United Kingdom, for example, the prevalence in the Orkney and Shetland Islands is 309 per 100,000, in northern Scotland 178 per 100,000, and in the south of England 100 per 100,000. It must be pointed out, however, that these prevalence studies have been conducted at different times, and the reliability of ascertainment varies. Nevertheless, data from other regions suggest that the trends are real Multiple sclerosis is more common in the northern United States and Canada than in the southern United States, and in the more temperate south of New Zealand and Australia than in their northern portions. migration from low-risk to high-risk zones (Vietnam to Paris, New British Commonwealth to the Old) are based on even smaller numbers, though they have yielded...

Evoked potentials recording nerve activity

Evoked potential (EP) recording is a bit like testing the resistance across a circuit. The basic principle is to stimulate on one side and record, using sticky electrode pads on the head, on the opposite side. The tests are carried out in three directions first, front to back, by stimulating the eyes (with a chequered pattern, for example) and recording the activity over the visual cortex second, in an approximately horizontal direction across the brain, via the brainstem, by providing a stimulus to the ear and recording activity from the auditory nerve and, finally, by stimulating the nerves in the limbs and recording the response from the top of the head. Evoked potential detects delays in the responses of nerves to such stimuli, which can help in the diagnosis of certain inflammatory diseases, such as multiple sclerosis, where the insulating myelin sheath of the nerves is damaged and the speed of nerve conduction becomes markedly slower.

Neurological examination

Electric pain along the spine irradiating to the extremities during maximal flexion and extension of the cervical spine has been described in patients with multiple sclerosis as the Lhermitte sign, but it is also generally observed in patients suffering from compression of the cervical spinal cord 20 . Radicular arm pain during ipsilateral sidebending rotation and manual compression of the head is described as the Spurling test, and expresses itself as a motion-induced radicular irritation compression radiating pain along the involved dermatoma.

Neurophysiological investigation of the cervical spine

The increased latency of MEPs is a sensitive sign however, the specificity is low. The increased CML can be found in not only degenerative but also inflammatory diseases of the central nervous system, such as multiple sclerosis. Kameyama examined 67 patients with clinically relevant cervical myelopathy, and 24 patients with cervical canal stenosis without myelopathy 15 . A positive correlation was found for the group of myelopathy patients. De Mattei found sensitivity of MEPs in patients with cervical compression myelopathy to be 70 for upper extremity muscles, and 95 for lower extremity muscles 10 .

Medical Overview and Epidemiology

White matter provides for information transfer in the brain, whereas gray matter is involved in information processing. Myelination in the brain continues past the second decade, in contrast to the development of other brain neurons, and normal development is affected by pediatric illness and injury. The development of myelin may be related to the appearance of more mature aspects of personality like motivation, comportment, and executive functioning. All of these skills are related to the frontal lobe, which leads to the hypothesis that white matter tracts connect the frontal lobes to other regions of the brain and are therefore responsible for the development of adult behavior. There are more than 100 cerebral white matter disorders that can be classified as genetic, demyelinative, infectious, inflammatory, toxic, metabolic, vascular, traumatic, neoplastic, and hydrocephalic. Characteristic patterns of neurobehavioral dysfunction are evident in all of these disorders regardless of...

Psychosocial Adjustment

Behavioral and emotional problems may precede other signs and symptoms of white matter disease. Affected patients with gliomatosis cerebri and multiple sclerosis, for example, experience apathy and fatigue before signs of cognitive deficits and functional decline. Psychiatric presentations vary by disease and the subsequent cognitive and functional level of the child. The diagnosis of psychiatric disorder in these patients is complicated by the emotional impact of the disabilities. It is difficult to determine whether the patient has a primary psychiatric diagnosis or an adjustment disorder. There is no direct correlation between white matter dysfunction and the etiology of psychiatric disorder. This implies that the relationship is indirect at best. However, in studies of multiple sclerosis patients, negative thoughts that are associated with depressive syndromes are predictive of cognitive difficulties. The clinician should assume that the origins of the psychiatric symptoms are...

Cognitive Effects

Cognitive dysfunction is the most common neuro-behavioral syndrome that develops as a consequence of white matter disease. The deficits are generalized rather than focal and, as in the case of multiple sclerosis, severe enough to be classified as a dementia. The range of possible neuropsychological symptoms in these cases includes the following sus tained, divided, and selective attention deficits executive dysfunction confusion memory retrieval deficits visuospatial impairment personality change depression somnolence lassitude and fatigue. Occasionally, young patients are given DSM psychiatric diagnoses as the primary cause of the clinical presentation, and there are cases that initially present with psychiatric symptoms before cognitive impairment is identified. Affected patients with gliomatosis cerebri and multiple sclerosis, for example, experience apathy and fatigue before signs of cognitive deficits and functional decline. Apathy is typically associated with medial frontal...

Arteriovenous Malformations

Clinical Features and Associated Disorders. As AVMs enlarge, symptoms are related to a number of mechanisms. They can cause bleeding, seizures, vascular headache, and chronic ischemia. Bleeding is most likely due to fragility of the abnormal vessels. The angiomas that most frequently rupture are of the AV type. Symptoms and signs depend on the location of hemorrhage. There are usually signs of meningeal irritation due to bleeding into the CSF. Not all ruptures are symptomatic but evidence of previous bleeding is often observed at necropsy. About one half of the patients present with epilepsy. Progressive neurological signs may develop secondary to a mechanism called intracerebral steal or compression of adjacent brain tissue by the pulsating blood vessels. Chronic migrainous headaches are also a frequent complaint in patients with vascular malformations. Patients with unruptured AVMs may present with increased ICP and papilledema. Angiomas in the brain stem may cause serious bleeding...

Pharmacological Management

Oxcarbazepine, a prodrug of carbamazepine, as noted, has a better side effect profile than carbamazepine. Gabapentin has also been shown to be effective in the treatment of TN, particularly in patients with multiple sclerosis. The younger the patient, the more likely the TN is multiple sclerosis

Surgical Treatment of Trigeminal Neuralgia

The most widely used procedure for TN is the microvascular decompression procedure developed by Dr. Peter Jannetta. This procedure is based on the concept that a blood vessel (artery or vein) can put pressure on the adjacent trigeminal nerve. Identifying the aberrant vessel and placing a small pad between the nerve and the vessel has been quite successful in abolishing TN symptoms. This procedure tends to be less effective in TN from multiple sclerosis.

Reviews And Selected Updates

Neurol Clin 1995 13 1. Hogancamp WE, Rodriguez M, Weinshenker BG The epidemiology of multiple sclerosis. Mayo Clin Proc 1997 72 871-878. Hogancamp WE, Rodriguez M, Weinshenker BG Identification of multiple sclerosis-associated genes. Mayo Clin Proc 1997 72 965-976. Raine CS The Dale E. McFarlin Memorial Lecture The immunology of the multiple sclerosis lesion. Ann Neurol 1994 36(Suppl) S61-S72. 1. Ebers GC MS--an historical overview. In Paty DW, Ebers GC (eds) Multiple Sclerosis Contemporary Neurology Series. Philadelphia, F.A. Davis (in pres s). 2. Medaer R Does the history of multiple sclerosis go back as far as the 14th century Acta Neurol Scand 1979 60 189-192 3. Fredrikson S, Kam-Hansen S The 150-year anniversary of multiple sclerosis Does its early history give an etiological clue Perspect Biol Med 1989 32 237-243 6. Tjernlund U, Cesaro P, Tournier E, et al T-cell subsets in multiple sclerosis A comparative study between cell surface antigens and...

Incontinence and relevant pharmacology

Condition is associated with bladder outflow obstruction (and thus is common in men with benign prostatic hypertrophy), with neuronal injury (e.g. spinal lesions, multiple sclerosis, spina bifida) and can occur spontaneously (idiopathic instability). Treatment of urge incontinence is designed to suppress these spontaneous contractions. Underlying the contractions are changes in the properties of the smooth muscles, which become more easily excited and better coupled, allowing the spread of contractile activity throughout the bladder. There also appears to be an element of neuronal activity associated with the pressure rises, and current pharmacological treatment is largely by use of muscarinic antagonists, which may also have some ability to block smooth muscle Ca2+ channels, such as oxybutynin. The side-effects of muscarinic antagonists are such as to render their long-term use undesirable, and efforts are being made to develop more selective muscarinic antagonists (tolterodine and...

Guillainbarre Syndrome

Diovascular reflexes and increase vascular volume. Chapter 8 reviews other measures for treating orthostatic hypotension. Anticholinesterase inhibitors such as pyridostigmine sometimes decrease muscle fatigability. The conduction block of AIP was not reversed, nor was clinical benefit found, when a group of patients was treated with 3,4-diaminopyri-dine (see Multiple Sclerosis in this chapter).56

Epidemiology of Disability

Multiple sclerosis is the most common chronic disabling CNS disease of young adults, affecting 1 per 1000 people in Western countries. Although prevalence rates vary considerably among populations and studies, the sex and age-adjusted prevalence of probable and definite MS was 167 per 100,000 in Olmsted County, Minnesota.91 Approximately 50 of patients with MS have a progressive disease by 10-15 In the Olmstead County population, one-third of MS subjects had a marked paraparesis or quadriparesis, 25 required intermittent or continuous bladder catheterization, 4 required supervision for cognitive dysfunction, 53 worked fulltime, and 28 needed outside financial support. Fatigue was a significant problem for 43 . Table 12-1 shows the level of disability in these subjects based upon the Incapacity Status Scale of the Minimal Record of Disability for Multiple Sclerosis. Symptoms reported by clinic pa- Table 12-1. Percentage of Population with Multiple Sclerosis Needing Assistance for...

Autonomic Dysfunction Secondary to Focal Central Nervous System Disease

Inflammation (multiple sclerosis, poliomyelitis) Multiple sclerosis Other brain stem disorders associated with autonomic dysfunction include tumors, syringobulbia, Arnold-Chiari malformation type 1, multiple sclerosis, and poliomyelitis. Brain stem tumors may present with intractable vomiting, orthostatic hypotension, or paroxysmal hypertension. Syringobulbia may produce Horner's syndrome, orthostatic hypotension, cardiovagal dysfunction, lability of arterial pressure, and central hypoventilation. y Syncope, sleep apnea, and cardiorespiratory arrest have been reported in association with the Arnold-Chiari malformation type 1. Less common manifestation of brain stem dysfunction include hypertension due to involvement of the medullary reticular formation in poliomyelitis (see Chapter . ) autonomic hyperactivity, most likely due to disinhibition of preganglionic sympathetic and parasympathetic neurons in tetanus (see Chapter s ) and fulminant neurogenic pulmonary edema due to...

Why are so many more children diagnosed with ASDs today

There have been news reports of an epidemic of autism. Autism is the fastest-growing serious developmental disability in the United States. It is five times more common than Down syndrome, three times more common than juvenile diabetes, and more common than multiple sclerosis, cystic fibrosis, and childhood cancer. ASDs are not only confined to the United States there are reports of increased rates of diagnoses on a worldwide basis.

Electroconvulsive Therapy

Electroconvulsive therapy has also been administered to treat psychiatric sequelae of a number of neurological disorders including depression secondary to a cerebral vascular accident, Parkinson disease, epilepsy and status epilepticus, multiple sclerosis, Huntington disease, tardive dyskinesia, and a few others (McDonald et al., 2002). Of these other disorders, the American Psychiatric Association has approved ECT only for Parkinson's disease and epilepsy although the clinical effects may not be long lived.

Chronic Inflammatory Demyelinating Polyradiculoneuropathy

Particular, there is an increased incidence of histocompatibility locus antigens AW30, AW31, A1, B8, and DR w3. Furthermore, CIDP, GBS, and multiple sclerosis have all been associated with the presence of the M3 allele of the alpha-1 antitrypsin system located on chromosome 14. y Some patients with CIDP have abnormalities on MRI scans of the head that are considered to be consistent with multiple sclerosis. y Whether these isolated patients represent the coincidental occurrence of two disorders or whether an immune-mediated disorder of both central and peripheral myelin is operative remains unclear.

Epidemiology and etiology

The incidence of inflammatory bowel diseases, such as Crohn's and ulcerative colitis, may be 3.8 to 7.5 times higher in psoriatic patients than in the general population.6 This has been attributed to shared or closely linked genetic susceptibility traits, with individual susceptibility localized to a similar region of chromosome 16, among others.6 There may also be a link to multiple sclerosis.6

Hereditary causes of stroke single gene disorders and their clinical presentation

Narp Syndrome

Multiple lacunar lesions and extensive white matter hyperintensities (WMHs), which may be accompanied by evidence of microbleeds (MBs). A first hint for CADASIL is the presence of extensive morphological abnormalities with SVD in the absence of vascular risk factors, especially in younger patients. Not infrequently, such a constellation may lead to a false suspicion of multiple sclerosis. Further evidence comes from the distribution of WMHs. In CADASIL, WMHs are characteristically located in the white matter of the anterior temporal lobe and the external capsule as early as in the third decade 31 . Location of WMHs and age of onset are unusual for other SVDs (Figure 9.8).

Pericytes and Disease

Pericyte loss or a reduced pericyte to EC ratio may be achieved through migration of pericytes from their microvascu-lar location under pathological or physiological conditions, selective pericyte death or from reduced pericyte turnover or maintenance. Pericytes migrate naturally during the early phases of physiological angiogenesis to make way for growing sprouts (113, 114), or in response to stress or injury (21). Migration following TBI is thought to promote survival as pericytes remaining in their vascular location show signs of degenerative activity (21). However, migration is also thought to play a pathogenic role in diabetic retinopathy (115). Decreased pericyte to EC ratios have been observed following TBI (21) and stroke (116), multiple sclerosis (117-121), brain tumor (122, 123), diabetic retinopathy (124), aging (125, 126), and in a variety of angiopathies (127). Pericyte loss may also play a role in Alzheimer's disease, however enhanced pericyte coverage of some vessels...

Directed Neurological Examination

Spastic paraparesis is frequently found in patients with neurogenic bladder and detrusor-sphincter dyssynergia (e.g., as in multiple sclerosis). Areflexia in the lower extremities, which is associated with loss of the anal and bulbocavernosus reflexes, indicates a lesion of the cauda equina that produces hypotonic bladder, bowel hypomotility, and sphincter incontinence. Extrapyramidal, pyramidal, cerebellar, and autonomic deficits in varying combinations are characteristic of multiple system atrophy (i.e., the Shy-Drager syndrome), a neurodegenerative disorder of unknown etiology. Autonomic failure may also accompany Parkinson's disease with its associated resting tremor, bradykinesia, rigidity, and postural reflex impairment.

Other Pathological Findings in OPLL

In the severely damaged cord, peripheral-type myelin, which was stained dark blue by LFB plus periodic acid-Schiff (LFB + PAS) stain, was observed at the posterior and lateral column near the entrance zone of the posterior roots. Remyelination by peripheral-type myelin has been described also in cases of multiple sclerosis, spinal trauma, and vascular disorder, and is considered to consist of remyelination around the preserved axons by Schwann cells originating from the posterior roots.

Hidden Home Exercises

Ankle Exercises After Surgery

Even for the general, sedentary, non-sporty population, exercise is an essential part of well-being. Exercise is also the 'drug' prescribed for a number of major health problems such as high blood pressure, heart insufficiency, diabetes, asthma, obesity, osteoporosis, rheumatoid arthritis and multiple sclerosis. Although for each of these disorders there are exercise alternatives that may be prescribed under the close supervision of a specialist doctor, we should be wary of sending unmotivated people to gyms or fitness centres where they feel out of place and uncomfortable. We should not underestimate the negative effects of how modern society has turned many into crisp-eating, soap-watching, coach potatoes.

The Prevention And Management Of Pressure Sores

Degree Tilt Pressure Care Pictures

Reduced mobility may also be associated with neurological deficit, such as a patient with paraplegia, but this is not always so. A diabetic patient may suffer from neuropathy without loss of mobility. Neurological deficit may be associated with strokes, multiple sclerosis, diabetes, and spinal cord injury or degeneration. Loss of sensation means the patient is unaware of the need to relieve pressure, even if able to do so. Dealey (1991a) found that neurological deficit was a common factor in those patients with pressure sores found in a survey of a teaching hospital. Kaba-gambe et al. (1994) took 10 patients with spinal cord injury and compared them with 11 healthy subjects. They found an impaired reactive hyperaemia response in those with spinal cord injury.

Use Of Essential Oils Mainly As Chemical Agents And Not For Their Odor

Aromatherapy can apparently help patients with multiple sclerosis, especially for relaxation, in association with many other changes in the diet and also use of conventional medicines (Barker, 1994). French basil, black pepper, and true lavender in evening primrose oil with borage oil was used to counteract stiffness and also to stimulate this mixture was later changed to include relaxing and sedative oils such as Roman chamomile, ylang ylang, and melissa.

Neurologic and Neuromuscular Diseases

MAC has been implicated in the progression of lesions in patients with multiple sclerosis, Alzheimer's disease and neurotrauma. Increased levels of TCC are detected in the cerebrospinal fluid of patients with multiple sclerosis (Mollnes, 1987) and they seem to be higher in patients with multiple attacks (Sellebjerg, 1998) with a positive correlation between levels of TCC in the cerebrospinal fluid and neurological disability. TCC is deposited at the site of the lesion in the periventricular area (Compston, 1989) and particularly around the active plaques (Storchet, 1998). An in vivo model of antibody-mediated demyelinating experimental autoimmune encephalomyelitis resembling the human disease has recently been established in both C6-deficient and C6-sufficient rats by Mead and colleagues (2002). The interesting finding was that the C6 deficient rats, that were unable to form MAC, failed to show demyelisation, unlike the control rats and the disease had in general a mild course in the...

Degenerative Disc Disease

Multiple Sclerosis (see Ch.apte.L48 ). Age of onset, gender, and types of neurological findings do not reliably distinguish chronic spinal multiple sclerosis. Early onset of bladder symptoms, visual complaints, and mental status changes should be sought. Cranial MRI may demonstrate periventricular bright lesions on T2-weighted images in the majority of patients with multiple sclerosis. Visual evoked responses and oligoclonal bands in the CSF, if abnormal, are helpful.

Evaluation Guidelines Table173

Compared with CT scanning, MRI offers an increased capacity for demonstrating cerebellar (and brain stem) lesions because of a lack of bone artifact. MRI demonstrates cerebellar atrophy as well as spinal and brain stem involvement in degenerative cerebellar disorders. In addition, MRI is much more sensitive to white matter lesions, particularly demyelination. Therefore, MRI should be performed when multiple sclerosis is suspected. Cerebrospinal Fluid. Lumbar puncture and examination of the cerebrospinal fluid are applied when inflammatory or infectious disorders are expected. Pleocytosis, increased total protein content, and oligoclonal bands are found in patients with multiple sclerosis, viral cerebellitis, and paraneoplastic cerebellar disorders. In addition, serum and cerebrospinal fluid anti-Purkinje cell antibodies (anti-Yo, anti-Hu, and anti-Ri) are useful in the diagnosis of paraneoplastic cerebellar degeneration.y

Posterior Fossa Anomalies

With syringomyelia is broad given the protean nature of the possible clinical symptoms. Multiple sclerosis, spinal muscular atrophy, amyotrophic lateral sclerosis, spinocerebellar ataxias, mononeuropathy multiplex, cervical disc and degenerative disease, and a variety of other disorders of the spinal cord and cerebellum can be confused with the condition on clinical grounds. Imaging resolves the majority of these differential diagnostic points. The situation can be more difficult in patients with prominent neurological symptoms but only borderline abnormal findings on imaging. Alternative diagnoses have to be considered seriously in that scenario. A cavity in the spinal cord can also have a traumatic (hematomyelia), inflammatory (necrotizing myelopathy), metabolic (Leigh's disease), or neoplastic (astrocytoma and ependymoma) basis. Of the neurocutaneous disorders, neurofibromatosis type 1 and von Hippel- Lindau disease can be associated with a syrinx. Demonstration of a flow void...

Evaluation Guidelines j Table194

Somatosensory evoked potentials allow assessment of sensory impulse conduction along the entire sensory axis from peripheral nerve to sensory cortex. They have their greatest application in lesions proximal to the dorsal root ganglion. In the upper extremity the median nerve is the most frequent site of stimulation in the lower extremity it is the tibial nerve. This test is useful in patients with multiple sclerosis, brain stem structural lesions, Friedreich's ataxia, spinal cord injury, plexopathy, or radiculopathy. The brain stem auditory evoked response may be useful in identifying a subclinical focus of demyelination in multiple sclerosis, a brain stem structural lesion, or Friedreich's ataxia. Cerebrospinal Fluid. A lumbar puncture can be helpful when multiple sclerosis, myelitis, meningitis, acute inflammatory demyelinating polyneuropathy, and certain other peripheral neuropathies are suggested. Attention

Evaluation Guidelines Table211

MRI Magnetic resonance imaging EMG, electromyography NCv, nerve conduction velocity LEMS, Lambert-Eaton myasthenic syndrome ANNA, antineuronal nuclear antibody (anti-Hu) NE, norepinephnne tSt, thermoregulatory sweat test CSF, cerebrospinal fluid MS, multiple sclerosis MRI Magnetic resonance imaging EMG, electromyography NCv, nerve conduction velocity LEMS, Lambert-Eaton myasthenic syndrome ANNA, antineuronal nuclear antibody (anti-Hu) NE, norepinephnne tSt, thermoregulatory sweat test CSF, cerebrospinal fluid MS, multiple sclerosis

Ocular Misalignment Syndromes

The clinical importance of diagnosing the MLF syndrome is its exquisite localizing value for lesions deep in the substance of the brain stem tegmentum. This general area in the brain stem contains the ascending reticular activating system, which is necessary for consciousness, along with several adjacent cranial nerve nuclei, and various ascending and descending sensory and cerebellar pathways. Therefore, the isolated occurrence of an MLF syndrome in an alert individual without other brain stem signs or symptoms suggests the presence of a highly discrete lesion. In the adult, this is caused by either small demyelinating plaques of multiple sclerosis, by small infarctions due to small vessel disease, and very occasionally can be encountered in the setting of head trauma. In children, the MLF syndrome can be the first sign of a brain stem glioma. Differentiating between multiple sclerosis (see Ch.a.p e.L48 ) and small vessel infarctions (see Chapter and Chapter45. ) can be problematic,...

Lumbar Dorsal Root Ganglia

Dorsal Root Ganglia

Pain by deafferentation, postherpetic neuralgia, thalamic syndrome, multiple sclerosis, and SMP should not be treated with this procedure. The aim of this technique is to produce a well-defined lesion in the DRG while maintaining the unaltered afferent input. It is not desirable to produce dysesthesia-paresthesia in the injured zone. If dysesthesia-paresthesia is produced for a prolonged period of time, pain by deafferentation will be produced.

Commonest Allergenic Essential Oils and Components

There have been very few published reports on neurotoxic aromachemicals such as musk ambrette (Spencer et al., 1984), although many synthetic musks took over as perfume ingredients when public opinion turned against the exploitation of animal products. Musk ambrette was found to have neurotoxic properties in orally fed mice in 1967 and was readily absorbed through the skin. A similar story occurred with acetylethyltetramethyltetralin (AETT), another synthetic musk, also known as versalide, patented in the early 1950s. During routine tests for irritancy in 1975, it was noted that with repeated applications, the skin of the mice turned bluish and they exhibited signs of neurotoxicity. The myelin sheath was damaged irreversibly in a manner similar to that which occurs with multiple sclerosis. Musk xylene, one of the commonest fragrance materials, is found in blood samples from the general population (Kafferlein et al., 1998) and bound to human hemoglobin (Riedel et al., 1999). These musk...

Task Oriented Training

The largest randomized clinical trial of BWSTT in stroke subjects to date was carried out by Visintin and colleagues.39 This trial showed that treadmill training alone was less successful than treadmill training with partial body weight support, especially for patients who initially walked very slowly (see Chapter 9). Thus, the trial sought out any advantage of the addition of weight support to treadmill walking and did not compare a task-oriented therapy to a conventional approach for locomotor rehabilitation. Small trials of BWSTT have been carried out in patients with Parkinson's disease,40 multiple sclerosis, and cerebral palsy41 with favorable reports of at least short-term gains.

Pathophysiology Types of Pain

Neuropathic pain is defined as spontaneous pain and hypersensitivity to pain associated with damage to or pathologic changes in the peripheral nervous system as in painful diabetic peripheral neuropathy (DPN), AIDS, polyneuropathy, postherpetic neuralgia (PHN), or in the CNS, that which occurs with spinal cord injury, multiple sclerosis, and stroke. Functional pain, a relatively newer concept, is pain sensitivity due to an abnormal processing or functioning of the CNS in response to normal stim

Evaluation Guidelines Table82

The major exceptions are typical optic neuritis (although magnetic resonance imaging MRI scan may be appropriate to determine the prognosis for developing subsequent multiple sclerosis) or classic anterior ischemic optic neuropathy. Transient visual loss in the setting of migraine does not require neuroimaging when the historical features are characteristic and results of the neurological examination are normal. All patients with chiasmal and retrochiasmal patterns of visual loss should undergo imaging examination. Electrophysiology. Other diagnostic tests used in combination with the clinical examination include electrophysiologic testing such as an electroretinogram (ERG) or visual evoked potential (VEP). ERGs measure rod and cone photoreceptor function and help to distinguish the retinal degenerations and dystrophies. VEPs measure the cortical activity in response to flashes of light or checkerboard stimuli and if abnormal suggest a lesion of the afferent...

Nuclear Brain Stem Syndromes

Other pathological processes within the brain stem can produce trigeminal dysfunction. Tumors, hemorrhage (hypertensive, ruptured arteriovenous malformation), infarctions, demyelinating disease such as multiple sclerosis, infections such as brain stem abscesses and brain stem encephalitis, and inflammatory conditions such as tuberculosis or sarcoidosis affecting the lateral pons or midbrain may result in ipsilateral or contralateral facial sensory loss, respectively, as well as severe paroxysmal hemifacial pain. Facial weakness, muscle atrophy, difficulty chewing, and diminished jaw jerk reflex may be identified in amyotrophic lateral sclerosis as

Cortical Versus Subcortical Dementing Syndromes

A distinction has been noted between the cortical dementia typically seen in Alzheimer's or Pick's disease and the subcortical dementia typified by Huntington's and Parkinson's disease but noted also in progressive supranuclear palsy, multiple sclerosis, Wilson's disease, and human immunodeficiency virus (HIV) infection. 48 Dementia seen in diseases with primarily subcortical neuropathology feature slowed movement (bradykinesia) and thought (bradyphrenia), disproportionate problems in the efficient use of memory, poor planning, judgment, and reasoning, and often affective changes.

Affective Disorder Syndromes

The differential diagnosis of depression includes primary psychiatric syndromes other than major depression such as behaviors associated with schizophrenia, generalized anxiety disorder, and obsessive-compulsive neuroses. Medical and neurological disorders either associated with or mimicking depression include malignancy, infections, medications (steroids, reserpine, levodopa, benzodiazepines, propranolol, anticholinesterases), endocrinological dysfunction (Cushing's disease, hypothyroidism, apathetic hyperthyroidism, diabetes), pernicious anemia, and electrolyte and nutritional disorders (inappropriate secretion of antidiuretic hormone, hyponatremia, hypokalemia, hypercalcemia). Depression is also associated with multiple sclerosis, Parkinson's disease, head trauma, stroke (particularly of the left frontal lobe), and Huntington's disease. Interictal changes in temporal lobe epilepsy may mimic depression, particularly with right-sided epileptic foci. Patients with diencephalic and...

Lebers Hereditary Optic Neuropathy

LHON presents as loss of central visual acuity in adolescence or early adulthood, acutely or subacutely, although it rarely can occur in children. Fundoscopic examination shows telangiectatic microangiopathy and swelling of the nerve fiber layer around the optic disc in acute presentations and optic atrophy in subacute to chronic presentations. Up to almost one fourth of patients regain vision. In addition to blindness, complex neurological features include signs suggestive of multiple sclerosis, multisystem atrophy, or MELAS. Extrapyramidal features like dystonia may develop with bilateral striatal necrosis. The differential diagnosis includes other causes of optic neuritis, multiple sclerosis, MELAS, Leigh's disease, subacute combined degeneration due to vitamin B 12 deficiency, Friedreich's-like ataxia, other causes of multisystem degeneration. The general paradigm should be followed, but in leukocyte platelet analysis, for major manifestations, MTNDI*LHON4160 and MTND4*LHON11778...

Treatment Specific Factors

Proposed for the neurotoxic effects of IFN-a, including actions mediated through neuroendocrine, neurotransmitter, and cyto-kine pathways.14 Inductions of other inflammatory cytokines, such as interleukin-ip (IL-1P), tumor necrosis factor-a (TNF-a), and IL-6, are major mechanisms of immunotherapy neuro-toxicity. IL-1 and its receptors are found in many areas of the brain. IL-1 mRNA is found in abundance in the hippocampus, a critical structure for memory processes. IL-1 depresses the influx of calcium into hippocampal neurons, which may explain the preponderance of memory impairment in patients with immunotherapy toxicity. TNF is also neurotoxic and is associated with demyelination in the brain. TNF and IL-1 are synergis-tically toxic and are associated with the development of multiple sclerosis plaques and gliosis.3 Patients with Alzheimer's disease have elevated levels of IL-6. In addition to their direct effects on brain function, these cytokines also provoke a stress hormone...

Demyelination and Wallerianlike degeneration

Progressive and extensive axonal loss occurs in multiple sclerosis (MS) and other demyelinating diseases, and contributes to the neurologic deficits (Trapp et al., 1998) (see Volume II, Chapter 38). In MS and other human and experimental settings with inflammatory demyelination, axonal degeneration and loss can result from focal axonal interruption consequent to the presence of nearby inflammatory cells and inflammatory mediators. Acute intralesional axonal damage correlates with the degree of inflammation (Bjartmar et al., 2003). In experimental allergic encephalomyelitis (EAE) axonal loss increases with number of relapses (Wujek et al., 2002). Changes in axonal cytoskeletal elements, including hyperphos-phorylation and aggregation of tau, have been observed in EAE but not noninflammatory models of demyelination (Schneider et al., 2004).

Finding our way through the white and the grey

Motor Strip The Frontal Lobe

If we look at the hemispheres in cross-section, the central portion appears lighter and is referred to as white matter . It appears white because of the presence of myelin, the insulator which allows nerves to conduct signals more quickly. (In diseases like multiple sclerosis, the myelin becomes damaged, seen as multiple patches of sclerosis or scarring throughout the brain.) Covering the white matter, like the rind of an orange, is the darker grey matter or cortex.

Special precautions for certain disabled groups

Not all disabilities are static some medical conditions such as multiple sclerosis may have a variable course and others such as muscular dystrophy are progressive. The sporting activity that is possible at one stage may not be so in the future, and therefore reassessments of the individual's capacity to participate in sport may be necessary 62 . As already mentioned, training of progressive muscular dystrophy with low muscle strength may be potentially harmful.

Factor Viii Inhibitors

Acquired hemophilia is due to the development of an autoantibody to factor VIII (FVIII). The estimated incidence is approximately 1 per 1 000 000 per annum. Most cases occur in healthy individuals without discernible risk factors, but the condition is associated with autoimmune conditions such as rheumatoid arthritis and SLE, inflammatory bowel disease, multiple sclerosis and malignancies. In up to 11 of cases, the associated factor is a recent or ongoing pregnancy50.

Signaling Through DAF

Several other intriguing stories implicating DAF in signaling have emerged. DAF has been identified as a ligand for CD97, a member of the seven-span transmembrane (TM7) protein family, with its extracellular domain comprising epidermal growth factor (EGF) repeats (110,111). CD97 is expressed on monocytes and granulocytes and is upregulated on activated B and T cells. The interaction between DAF and CD97 is of low affinity (Kd 90 J,M) and appears to involve the first SCR of DAF, a domain with no clear role in C regulation (112-114). The biological significance of this interaction is as yet unclear but it may be involved in cell activation, migration and or adhesion in inflammatory conditions. Upregulation of DAF concomitant with increased expression of CD97 on leukocytes at sites of inflammation has been demonstrated in inflammatory diseases, such as arthritis and multiple sclerosis (115,116).

Structural Abnormalities

Lesion deficit correlation studies demonstrate that certain disorders are more likely to be associated with a major depression than others (a) discrete brain lesions, as seen with trauma, surgery, stroke, tumors, and certain types of epilepsy (b) neurodegenerative diseases with regionally confined pathologies such as Parkinson's, Huntington's, and Alzheimer's diseases (c) disorders affecting diffuse or multiple random locations such as multiple sclerosis and (d) system illness with known central nervous system effects such as thyroid disease, cancer, and acquired immunodeficiency syndrome (AIDS) (Table 7.1). Multiple sclerosis Studies of systemic disorders, such as lupus erythematosus, Sjogren's syndrome, thyroid and adrenal disease, AIDS, and cancer, describe mood symptoms in subsets of patients. As with the more diffuse neurodegenerative diseases, such as Alzheimer's disease (Cummings and Victoroff, 1990), a classic lesion-deficit approach is generally...

Christopher J Jankowski

Complications from neuraxial anesthesia have been recognized since August Bier reported the first spinal anesthetic over 100 years ago.12 Fortunately, serious complications of neuraxial anesthesia remain rare but can be devastating when they occur. As morbidity and mortality from anesthesia and surgery continue to decline, the relative importance of these problems increases. Safe, effective practice of neuraxial anesthesia requires a detailed knowledge of the potential complications, their incidence, and the risk factors associated with their occurrence. This is not easy. Definitive study of the complications remains problematic. Many are so rare that it is virtually impossible to conduct controlled, prospective studies. Thus, the bulk of the existing studies are large retrospective surveys or case reports that provide valuable information about incidence and possible associations but do not necessarily demonstrate causality. Further, other factors besides neuraxial anesthesia may be...

Patient Assessment And Selection

There is no evidence that neuromuscular disorders or multiple sclerosis are adversely affected by local anaesthetic techniques, but most anaesthetists use regional anaesthesia in such patients only if there are obvious benefits to be gained any perioperative deterioration in the neurological condition is often associated by the patient with the local anaesthetic procedure. Raised intracranial pressure is a contraindication to central blockade.

Nuclear Magnetic Resonance

The brain is readily apparent, and excellent delineation is provided of pathologies such as demyelination and tumours in inaccessible sites. In the evaluation of lesions produced by multiple sclerosis or vascular lesions, findings are not pathognomonic but must be assessed, as with all ancillary investigation techniques, together with clinical signs. As with computed tomographic (CT) scanning, contrast enhancement may be used. The hazards associated with anaesthesia for NMR are discussed on (p. 607)

Clinical applications of evoked potentials

As demyelination increases, complete conduction block occurs at lower temperatures. Subclinical lesions can be detected by the combined use of auditory, visual and somatosensory EPs, which show an abnormality in 80 of patients with a definite history.

Upon completion of the chapter the reader will be able to

Identify risk factors for multiple sclerosis (MS). O Multiple sclerosis (MS) symptoms are a function of the location of lesions within the CNS. Multiple sclerosis (MS) is an inflammatory disease of the CNS, variable in symptoms and presentation. Multiple describes the number of CNS lesions, and sclerosis refers to the demyelinated lesions, today called plaques.

Overflow Urinary Incontinence Related to Urethral Overactivity andor Bladder Underactivity4

Weakened, in some cases enough to lose the ability to voluntarily contract. In this case, the bladder cannot be emptied completely and large volumes of residual urine remain after micturition. Clinically, this is most commonly seen in the setting of long-term chronic bladder outlet obstruction due to benign or malignant prostatic enlargement. However, this may also be a manifestation of neurogenic bladder, frequently being seen in patients with diabetes, lower spinal cord injury, multiple sclerosis, or following radical pelvic surgery. If due to urethral overactivity, the resistance of the urethra and or sphincters cannot be overcome by detrusor contractility. This functional or anatomic obstruction results in incomplete bladder emptying. Clinically, in males this most frequently occurs in the context of long-term chronic bladder outlet obstruction as outlined previously. In females, urethral overactivity is rare but may result from cystocele formation or surgical overcorrection...

Pathogenesis and Etiology

Much evidence has accumulated suggesting an immunologic basis for the disorder in patients with multiple sclerosis. There is abnormal synthesis of antibodies, both inside and outside the brain there are changes in the number and functional activity of peripheral blood lymphocyte subsets in active disease and there are immune-competent cells around the venules in the lesions and in the brain itself. The occurrence of such changes in the retina (where there is no myelin) is evidence that the vascular events are not secondary to myelin breakdown produced in some other way. This, combined with the results of recent functional vascular studies and other evidence, suggests that a vascular change is a critical early event in development of the new lesion. These processes provide a plausible though incomplete explanation for the development of the lesions in established multiple sclerosis. What of its initiation There is good evidence from family studies and epidemiology that an environmental...

Comparative Analysis of Open and Laparascopic Approaches

In order to define the clinical outcomes of a laparascopic approach to bladder reconstruction, we compared prospectively, our initial experience in laparoscopic augmentation cystoplasty with continent catheterizable ileal stoma to a similar cohort of patients who underwent an open approach. Eighteen consecutive cases of augmentation colocysto-plasty with continent catheterizable ileal stoma were performed at our Institute nine patients underwent the open approach (eight women and one man mean age, 45 years, range 21-56), and nine cases underwent the laparoscopic approach (eight women and one man mean age, 36 years range, 18-46). All cases were performed by the same surgical team. Indications for the operation were reduced bladder capacity and or compliance either due to a neurologic condition (mostly multiple sclerosis), or idiopathic refractory detrusor overactivity. Before the operation, all patients had urodynamically proven detrusor overactivity with incontinence that had failed...

The Specialneeds Athlete

Strapse Lackkleid

Muscular dystrophy, and multiple sclerosis. The benefits of exercise for the special-needs athlete are the same as those for other athletes. Additionally, special-needs athletes have fewer pressure ulcers, fewer infections, improved proprioception, increased proficiency using prosthetic devices, and decreased hospitalizations. The Special Olympics and the United States Paralympics require a preparticipation examination to be done within 12 months of competition. An office-based examination is preferred for these athletes. Questions on which the physician should focus are listed in Table 2-4. These questions should be asked and appropriate consultations made if needed. Special attention should be given to the vision, cardiovascular, neurologic, dermatologic, genitourinary, and musculoskeletal portions of the examination. The functional assessment with sport-specific tasks should be done on all athletes with special needs. Diagnostic imaging should be done on all athletes at risk of...

What are important points to assess on physical examination in the patient being evaluated for possible revision spine

A general neurologic assessment and regional spinal assessment are performed. The presence of nonorganic signs (Waddell signs) should be assessed. Global spinal balance in the sagittal and coronal planes should be assessed. The physical examination is tailored to the particular spinal pathology under evaluation. For cervical spine disorders, shoulder pathology, brachial plexus disorders, and conditions involving the peripheral nerves should not be overlooked. For lumbar spine problems, the hip joints, sacroiliac joints, and prior bone graft sites should be assessed. Examination of peripheral pulses is routinely performed to rule out vascular insufficiency. Consider degenerative neurologic or muscle-based problems, such as amyotrophic lateral sclerosis or multiple sclerosis.

Human TCell Lymphotrophic Virus Type

The differential diagnosis includes myelopathy due to a compressive lesion of the cord from a disk, tumor, or infection, subacute combined degeneration resulting from vitamin B12 deficiency, HIV-1 myelopathy, multiple sclerosis, and syphilis. Serological testing should be performed to detect HTLV- 1 antibodies in serum. Magnetic resonance imaging (MRI) of the brain may demonstrate hyperintense lesions in the subcortical white matter on T2-weighted scans, resembling the lesions of multiple sclerosis. yi Elevated antibody titers to HTLV-1 can be detected in blood and cerebrospinal fluid of patients with HAM-TSP.

Acoustic Schwannoma and Trigeminal Neurilemmoma

Clinical Features and Associated Disorders. Acoustic neuromas are considered slow growing, but they grow in a physiologically eloquent area, the cerebellopontine angle, thus leading to subtle complaints that may evolve slowly over many years. Symptoms may progress slowly, although sudden presentations can be seen. Patients usually present with hearing loss (especially sound discrimination), tinnitus, loss of balance, nystagmus, loss of facial sensation, or loss of function of the facial muscles or the muscles of mastication. Pain is uncommon but may sometimes mimic trigeminal neuralgia. Cerebellar findings such as ataxia and gait abnormalities may be noted when extremely large tumors have extended into the cerebellum. In patients with trigeminal pain multiple sclerosis may be diagnosed initially only with further hearing loss and a lack of involvement of other areas of the nervous system will re-evaluation be conducted. Meningiomas are occasionally confused with neuromas. Rarely,...

Trigeminal Neuralgia Tic Douloureux

Painful neuralgia of the trigeminal nerve results in the clinical syndrome of tic douloureux or trigeminal neuralgia. y The paroxysmal disorder presents as excruciating, lancinating painful spasms affecting one or more divisions of CN V. Trigeminal neuralgia is unilateral and usually affects the second or third division of CN V (3rd 2nd 1st). In less than 5 percent of cases V1 is affected, whereas V3 is affected in more than 70 percent of cases. y Rarely, pain may occur bilaterally, although simultaneous bilateral spasms are quite atypical. The pain occurs spontaneously as brief lightning-like spasms lasting seconds to minutes, or pain may be precipitated by cutaneous or auditory stimuli. In many instances, there is a demonstrable trigger point that can reproduce pain, and some patients may be unable to chew, eat, drink, shave, or brush their teeth for fear of triggering a spasm. y Paroxysms recur throughout the day and night. Between attacks, there are no symptoms, but the patient is...

Syndromes of Overactivation

This is a progressive, irregular fibrillation of individual facial muscle fibers. Usually, it begins in the frontalis and extends to involve all the ipsilateral facial muscles. Electromyographic findings include spontaneous activity of motor units at a rate of 30 to 70 per second. Common causes include pontine gliomas and multiple sclerosis.

Supranuclear Syndromes

Facial sensory loss may occur in the setting of lesions involving the trigeminothalamic pathways, corona radiata or internal capsule white matter projections from the VPM nucleus of the thalamus to primary sensory cortex, or within sensory cortex itself. Specific pathological processes affecting these pathways include ischemia, hemorrhage, neoplasm, and demyelinating diseases. All result in contralateral hemifacial and hemibody numbness. In seizures, facial tingling often occurs in association with hand numbness and suggests a lesion in the postcentral gyrus. In the cheiro-oral syndrome, ipsilateral numbness in the hand and at the corner of the mouth reflects an insult, typically vascular, at adjoining portions of the ventroposterolateral and VPM nuclei of the thalamus where the anatomical distributions of these regions are directly adjacent to one another. In contrast, a persistent deep, aching, poorly localized facial pain has been reported in patients with thalamic lesions...

Spinal Cord Myelopathy

Generally with transverse lesions of the spinal cord there is a demonstrable sensory level with bilateral loss of all modalities of sensation below a definite level. With involvement of the dorsal columns there is loss of proprioception, discriminative modalities, and vibration within a couple of levels caudad to the lesion site. With smaller lesions it is possible to selectively involve certain dorsal column modalities owing to the topographical distribution of the various modalities fibers carrying discriminative touch are most posterior, vibratory fibers are most anterior, and proprioceptive fibers are intermediate within the dorsal funiculi. There will be no significant loss of light touch however, pressure sensation may be impaired. Examples are a metastatic lesion to the spinal cord, cord infarction, and multiple sclerosis plaque.

Other Forms of Chorea

The movements are brief, usually lasting less than 3 minutes, and occur many times daily, sometimes up to 100 times a day). y Nonkinesigenic and exertional paroxysmal dyskinesias may also be transmitted as autosomal dominant disorders, and the movements in these forms tend to be more dystonic than choreic in nature. The episodes of dyskinesia are usually more prolonged (lasting 2 minutes to 4 hours) and less frequent (occurring three to five times a day). Attacks are precipitated by alcohol, coffee, fatigue, stress, or excitement. Kinesigenic dyskinesias respond well to anticonvulsant medications such as phenytoin, carbamazepine, or phenobarbital. In contrast, the nonkinesigenic dyskinesias respond poorly to most medical therapy, although some patients improve with clonazepam. y Pathophysiologically, these conditions appear to be an interface between movement disorders and epilepsy, since in some conditions assiduous electrode placement over the frontal and frontocentral regions may...

Ocular Flutter and Opsoclonus

Abnormal repetitive eye movements in which the fast phase or saccades are abnormal include ocular flutter and opsoclonus. Opsoclonus is a continuous succession of multidirectional conjugate saccadic eye movements with no intersaccadic interval. In the acute stage, it is usually associated with violent ataxia and high-amplitude tremor of all limbs. As recovery occurs, some patients go through a phase in which there are spontaneous bursts of horizontal back-to-back saccades, again without intersaccadic interval. In adults, opsoclonus usually results from brain stem encephalitis, either sporadic or as a remote effect of carcinoma. In infants and children, opsoclonus can be a remote manifestation of neuroblastoma. Ocular flutter comprises bursts of saccades in one plane, typically horizontal, during forward fixation. There are no intervals between saccades. Patients can manifest ocular flutter when developing or recovering from opsoclonus, and both disorders probably share...

Mitochondrial Encephalopathy Lactic Acidosis and Strokelike Episodes

Conditions to exclude include any other causes of stroke in childhood, infancy, or adulthood other mitochondrial multisystem disorders, such as MERRF or KSS chronic progressive external ophthalmoplegia (CPEO), or other uncharacterized disorders and any neurological disease in adulthood with an overall progressive course but relapses that leave residuals, such as multiple sclerosis or other demyelinating diseases.

Magnetic Resonance Imaging Of The Spine

MRI is uniquely sensitive in detecting the presence of intramedullary spinal cord diseases. Common primary intramedullary neoplasms that can be elucidated include astrocytoma, ependymoma, and spinal cord hemangioblastoma. Contrast medium-enhanced MRI can help differentiate tumoral cord edema, as seen in these entities from the primary tumoral masses. Other causes of abnormal signal within the spinal cord include inflammatory or demyelinating diseases such as acute disseminating encephalomyelitis, transverse myelitis, or multiple sclerosis. The evaluation of spinal cord edema, secondary to trauma, either from chronic discogenic disease or in situations of acute complex fracture injuries is becoming increasingly essential, particularly in national trauma centers.

Familial Spastic Paraplegias

Differential Diagnosis and Evaluation. The FSPs are diagnoses of exclusion. Particular care is necessary if the family history is not revealing or if there are numerous complications or atypical features. Because FSP can mimic treatable disorders, such as vitamin B12 deficiency, doparesponsive dystonia, cervical spondylosis, or multiple sclerosis, exhaustive evaluation is justified. 17

Experimental Allergic Encephalomyelitis

Another widely studied animal model is Theiler's murine encephalomyelitis virus model. Intracranial inoculation with Theiler's virus leads to chronic infection and chronic inflammatory demyelination. Studies have shown that immune suppression ameliorates the pathological damage in this model, verifying that it is the immune response and not the viral infection that is responsible for the chronic demyelination. TMEV has been particularly useful in exploring a number of possible mechanisms of inducing remyelination in the setting of chronic demyelination. As outlined earlier, both polyclonal antispinal cord immunoglobulins and monoclonal antibodies directed against several protein antigens and chemical haptens have been shown to promote extensive CNS remyelination in TMEV. This work has led to two phase II clinical trials of human immunoglobulin in patients with optic neuritis and multiple sclerosis.

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