Association between limbic system lesions and anxiety in persons with multiple sclerosis.

BACKGROUND: Persons with Multiple Sclerosis (PwMS) have a higher rate of anxiety and depression than the general population. Depression has been associated with clinical relapses; temporal lesions were shown to predict depression severity. Anxiety is considerably understudied. The role of MS lesions in the limbic system is also understudied, partly due to difficulties identifying limbic lesions on standard 1.5 and 3 Tesla MRI. METHODS: This is a retrospective study of 23 PwMS who underwent 7T MRI on the same day as completing the Hospital Anxiety and Depression Scale (HADS). MRI was performed on a Siemens 7T MRI Plus and an 8-channel transmit coil with 32 receiver channels operating in pTx mode. MP2RAGE and DIR-SPACE sequences were analyzed to determine the number of lesions within the limbic system. RESULTS: The median number of lesions in the limbic system was 2.0 (range 0-7). When comparing the presence or absence of lesions in the limbic system, there was a significant relationship with anxiety (X2 (1, N = 23)=4.44, p = 0.035), but not for depression. CONCLUSION: Although only a small sample size, this study provides preliminary evidence that lesions in the limbic system are associated with the presence of anxiety in PwMS. This relationship warrants further investigation.

Depression and hypomania symptoms are associated with high dose corticosteroids treatment for MS relapses.

BACKGROUND: Psychiatric side effects are known to occur with low dose corticosteroids. Standard of care for Multiple Sclerosis (MS) relapses is high dose corticosteroids (HDC), at least 1g/day for 3-5 days, and yet the relationship between this treatment and mood is not known. We sought to determine the frequency and potential predictors of (hypo)manic and depressive symptoms with HDC treatment for MS relapses. METHODS: Consecutive MS subjects requiring HDC treatment were identified. The Mood Disorders Questionnaire (MDQ) and the Beck Depression Inventory-Fast Screen (BDIFS) were administered for (hypo)manic and depressive symptoms, respectively, prior to HDC, 3 days and one month post-HDC. RESULTS: Eighty eight subjects completed the study. At relapse diagnosis, the mean BDIFS score was 4.2 (SD 3.1); the mean number of (hypo)manic symptoms endorsed on the MDQ was 4.3 (SD 3.5). Three days after completing HDC, 22.5% had an increase on the BDIFS and 38.2% endorsed more symptoms on the MDQ. A history of depression (p=0.006) and low reported quality of life (p=0.029) predicted an increase on the MDQ; the odds of an increase in (hypo)manic symptoms was 5.6 times higher with a history of any psychiatric disease/substance abuse (p=0.005). No predictors for worsening on the BDIFS were found. LIMITATIONS: Self-reported measures were used, anxiety was not evaluated and 17 subjects were lost to follow up. CONCLUSION: Depressive and hypo(manic) symptoms are commonly associated with HDC for MS relapses. It is important for clinicians and MS patients to be aware of this risk.

Autonomic dysfunction in multiple sclerosis.

Autonomic dysfunction is a prevalent and significant cause of disability among patients with multiple sclerosis. Autonomic dysfunction in multiple sclerosis is usually explained by lesions within central nervous system regions responsible for autonomic regulation, but novel evidence suggests that other factors may be involved as well. Additionally, the interactions between the autonomic nervous system and the immune system have generated increased interest about the role of autonomic dysfunction in the pathogenesis of multiple sclerosis. In this paper we analyze systematically the most relevant signs and symptoms of autonomic dysfunction in MS, considering separately their potential causes and implications.

Limb ataxia originating from peri-central sulcus demyelinating lesion in multiple sclerosis.

BACKGROUND: To report the development of limb ataxia/intention tremor (LA/IT) associated with inflammatory demyelinating cortical peri-central sulcus lesions. METHODS: We describe a case series of five multiple sclerosis (MS) patients followed at the Jacobs Neurological Institute who developed LA/IT associated with contralateral cortical lesions without visible subtentorial MRI pathology. Demographics, MRI findings and tremor evolution in relation to specific therapies were recorded. RESULTS: Five patients (M=1/F=4), age range 29-51 that developed LA/IT associated with a contralateral cortical MRI lesion were identified. LA/IT developed after an average of 3.1years (range 0-8years) from disease onset. The contralateral cortical MRI lesion became visible on average 23.2months before the development of limb ataxia/intention tremor. Central sulcus widening was noted suggesting local atrophy. Median nerve somatosensory evoked potentials revealed asymmetric reductions in N20 amplitudes. Abnormalities in latencies and amplitudes were also noted in the posterior tibial somatosensory evoked potentials, ipsilateral to the lesion. Symptomatic therapeutic interventions were only partially beneficial. CONCLUSION: Limb ataxia/intention tremor can be associated with a demyelinating lesion involving cortical and adjacent subcortical white matter, in the absence of rubro-cerebellar lesions. Aggressive therapeutic intervention to control the cortical inflammatory process is recommended.

Selective abolition of the vestibular-ocular reflex by sedative drugs.

INTRODUCTION: The vestibulo-ocular reflex (VOR) is an important part of the neurological examination of the patient with coma when determining brainstem function. VOR is tested via the oculocephalic reflex (OCR) and the oculovestibular reflex (OVR), or cold calorics. It has been noted that sedative medications, such as opioids and benzodiazepines, can diminish or abolish the VOR. METHODS: We performed a chart review on three patients noted to have absent VOR at initial neurological assessment as an isolated finding. RESULTS: The three patients ranged in age from 45-74 years. Two patients presented with intentional drug overdoses, whereas the third patient had a complicated course postcardiac surgery and received sedative drugs. All three patients initially had absent responses to OCR and cold calorics bilaterally. However, all other brainstem functions were normal at the initial examination. All three patients regained both OCR and OVR within 24 hours after sedative medication had been removed. CONCLUSION: Sedatives may selectively and transiently abolish the VOR, altering the clinical examination; this is to be considered in the examination of a patient with coma.