Bijal Mehta

Serum lipid profiles are associated with disability and MRI outcomes in multiple sclerosis

BackgroundThe breakdown of the blood-brain-barrier vascular endothelium is critical for entry of immune cells into the MS brain. Vascular co-morbidities are associated with increased risk of progression. Dyslipidemia, elevated LDL and reduced HDL may increase progression by activating inflammatory processes at the vascular endothelium.ObjectiveTo assess the associations of serum lipid profile variables (triglycerides, high and low density lipoproteins (HDL, LDL) and total cholesterol) with disability and MRI measures in multiple sclerosis (MS).MethodsThis study included 492 MS patients (age: 47.1 ± 10.8 years; disease duration: 12.8 ± 10.1 years) with baseline and follow-up Expanded Disability Status Score (EDSS) assessments after a mean period of 2.2 ± 1.0 years. The associations of baseline lipid profile variables with disability changes were assessed. Quantitative MRI findings at baseline were available for 210 patients.ResultsEDSS worsening was associated with higher baseline LDL (p = 0.006) and total cholesterol (p = 0.001, 0.008) levels, with trends for higher triglyceride (p = 0.025); HDL was not associated. A similar pattern was found for MSSS worsening. Higher HDL levels (p < 0.001) were associated with lower contrast-enhancing lesion volume. Higher total cholesterol was associated with a trend for lower brain parenchymal fraction (p = 0.033).ConclusionsSerum lipid profile has modest effects on disease progression in MS. Worsening disability is associated with higher levels of LDL, total cholesterol and triglycerides. Higher HDL is associated with lower levels of acute inflammatory activity.

New hypotheses on sunlight and the geographic variability of multiple sclerosis prevalence

Multiple sclerosis is an autoimmune demyelinating disorder of the central nervous system. Its etiology continues to be elucidated. The debate about the environmental impact on the disease etiology and progression has focused on sun light exposure in the recent past, but mainly as it applies to vitamin D and its derivatives. This paper will discuss how sunlight stimulus may effect neuronal and microglial antigenic presentation based on sunlight-dependent neuronal activity, as well as how sunlight may alter the amount of vitamin A and melatonin levels during immune development in the central nervous system. Changes in the number of antigens presented to lymphocytes by antigen-presenting cells for self-selective removal during immune development could therefore alter the number of circulating self-recognizing B and T-lymphocytes. This situation would increase susceptibility to a significantly greater number of self-antigens, and lead to autoimmune disorders such as multiple sclerosis.

Vitamin D and multiple sclerosis.

Background:Epidemiological data support a potential relationship between vitamin D deficiency and an increased risk of developing multiple sclerosis (MS). In vitro studies have expanded the potential role of vitamin D and its receptor beyond calcium modulation, regulation, and maintenance of bone mineralization, to include immune modulation. Review Summary:Whether vitamin D immunomodulatory effects can be translated into clinical benefits in MS patients is still a matter of debate. A review of the biochemistry of vitamin D and its synthesized derivatives is discussed in the context of treating vitamin D deficiency. Animal studies, which led to some human studies, are also discussed. Future studies are pending and will likely yield conclusive results as to the benefit and possible synergistic effects of vitamin D with other disease-modifying therapies of MS. Conclusions:Further prospective studies are needed to identify vitamin D levels during the various phases of MS, including relapses, remissions and progression, and to determine whether correcting vitamin D during any or all of these phases may affect the incidence or even the course of the disease.

Blood Pressure Management and Evolution of Thrombolysis-associated Intracerebral Hemorrhage in Acute Ischemic Stroke

BACKGROUND There is limited knowledge on the radiographic features of thrombolysis-induced hemorrhage. The factors that influence early hematoma expansion have not been elucidated. METHODS Patients presenting with a symptomatic intracerebral hemorrhage (ICH) as a result of intravenous (IV) thrombolysis with tissue plasminogen activator (tPA) for acute ischemic stroke and had noncontrast computed tomographic (CT) scans of the head were included in this retrospective study. Calculation of hematoma volumes was obtained. Analysis of covariance was used to evaluate for the effect of baseline blood pressure (BP) on initial hematoma volume and further growth. RESULTS Of 267 patients who were treated with intravenous tPA for acute ischemic stroke at our facility between January 1, 2005 and December 31, 2009, 17 patients developed symptomatic ICH and were included in the final analysis. There was a positive correlation between baseline level of systolic BP after thrombolysis and initial hematoma volume (r = 0.46; P = .03) but not for the diastolic BP (r = 0.07; P = .40). There was a significant increase in mean hematoma volume expansion when comparing results between the first and second CT scans (median 9 hours, 22 minutes; 14.9 ± 19.6 cm(3) to 26.0 ± 26.7 cm(3); P = .04). There was also a negative association between the reduction of systolic BP and hematoma growth (r = -0.67; P = .02), but no correlation with change in diastolic BP (r = -0.22; P = .28). CONCLUSIONS Once diagnosed, thrombolysis-induced symptomatic ICH undergoes significant early expansion in size. Systolic BP may play a role in hematoma expansion.

Acute Psychosis Associated with Subcortical Stroke: Comparison between Basal Ganglia and Mid-Brain Lesions

Acute onset of psychosis in an older or elderly individual without history of previous psychiatric disorders should prompt a thorough workup for neurologic causes of psychiatric symptoms. This report compares and contrasts clinical features of new onset of psychotic symptoms between two patients, one with an acute basal ganglia hemorrhagic stroke and another with an acute mid-brain ischemic stroke. Delusions and hallucinations due to basal ganglia lesions are theorized to develop as a result of frontal lobe dysfunction causing impairment of reality checking pathways in the brain, while visual hallucinations due to mid-brain lesions are theorized to develop due to dysregulation of inhibitory control of the ponto-geniculate-occipital system. Psychotic symptoms occurring due to stroke demonstrate varied clinical characteristics that depend on the location of the stroke within the brain. Treatment with antipsychotic medications may provide symptomatic relief.

Calcified parenchymal central nervous system cysticercosis and clinical outcomes in epilepsy

OBJECTIVE This study aimed to compare clinical outcomes including seizure frequency and psychiatric symptoms between patients with epilepsy with neuroimaging evidence of past brain parenchymal neurocysticercosis infection, patients with other structural brain lesions, and patients without structural neuroimaging abnormalities. MATERIAL AND METHODS The study included retrospective cross-sectional analysis of all patients treated for epilepsy in a community-based adult neurology clinic during a three-month period. RESULTS A total of 160 patients were included in the analysis, including 63 with neuroimaging findings consistent with past parenchymal neurocysticercosis infection, 55 with structurally normal brain neuroimaging studies, and 42 with other structural brain lesions. No significant differences were detected between groups for either seizure freedom (46.03%, 50.91%, and 47.62%, respectively; p=0.944) or mean seizure frequency per month (mean=2.50, S.D.=8.1; mean=4.83, S.D.=17.64; mean=8.55, S.D.=27.31, respectively; p=0.267). Self-reported depressive symptoms were more prevalent in those with parenchymal neurocysticercosis than in the other groups (p=0.003). No significant differences were detected for prevalence of self-reported anxiety or psychotic symptoms. CONCLUSIONS Calcified parenchymal neurocysticercosis results in refractory epilepsy about as often as other structural brain lesions. Depressive symptoms may be more common among those with epilepsy and calcified parenchymal neurocysticercosis; consequently, screening for depression may be indicated in this population.

The nervous system's potential role in multiple sclerosis associated bone loss

Osteoporosis is a degenerative bone disease that causes significant morbidity and mortality in multiple sclerosis (MS) patients; the pathogenesis of this disease being poorly understood in the context of MS. Osteoporosis is seen more frequently in MS patients than in healthy controls matched for age and sex. Extensively studied factors, including impaired ambulation and the use of steroids, do not appear to completely account for the phenomenon. This review summarizes common risk factors, physiologic and genetic, that may contribute to the etiology and progression of osteoporosis in MS patients as well as providing insight into nervous system control of bone metabolism and homeostasis.

Cost Effective Community Based Dementia Screening: A Markov Model Simulation

Background. Given the dementia epidemic and the increasing cost of healthcare, there is a need to assess the economic benefit of community based dementia screening programs. Materials and Methods. Markov model simulations were generated using data obtained from a community based dementia screening program over a one-year period. The models simulated yearly costs of caring for patients based on clinical transitions beginning in pre dementia and extending for 10 years. Results. A total of 93 individuals (74 female, 19 male) were screened for dementia and 12 meeting clinical criteria for either mild cognitive impairment (n = 7) or dementia (n = 5) were identified. Assuming early therapeutic intervention beginning during the year of dementia detection, Markov model simulations demonstrated 9.8% reduction in cost of dementia care over a ten-year simulation period, primarily through increased duration in mild stages and reduced time in more costly moderate and severe stages. Discussion. Community based dementia screening can reduce healthcare costs associated with caring for demented individuals through earlier detection and treatment, resulting in proportionately reduced time in more costly advanced stages.

Chasing the dragon--heroin-associated spongiform leukoencephalopathy.

A 21-year-old male presented with acute ataxia. For 1 week, he became increasingly unbalanced, clumsy, and severely dysarthric. He sustained multiple falls and had difficulty walking. He admitted to inhaling heated heroin vapors twice in the past, the last time was 1 week prior to admission. His symptoms started acutely 24 h after that. He denied injecting heroin in the past as he had a known “needle phobia”. On examination, his speech was severely dysarthric. He demonstrated horizontal nystagmus and positive cerebellar signs bilaterally with inability to stand without assistance and falling backwards when unsupported. Serum toxicology screen was negative. MRI revealed symmetrical white matter hyperintensities with a “C-shaped” lesion in the deep cerebellar hemispheres compatible with edema (Figs. 1 and 2). There was a loss of cerebellar folia, with inferior displacement of bilateral cerebral tonsils, compatible with developing cerebellar herniation through the foramen magnum (Fig. 2). Bilateral hypointensities involving the posterior limbs of the internal capsules were remarkable (Fig. 3).

Vitamin D and multiple sclerosis: can vitamin D prevent disease progression?

The possible link between limited sun exposure versus vitamin D deficiency and multiple sclerosis (MS) originated with the findings of geographic patterns in MS prevalence. Acheson et al. found that MS prevalence increases with increasing latitude [1] and this finding has been confirmed by several other epidemiological studies [2–8]. A complex interplay between diverse multiple environmental factors, including viral infections, hygiene, sunlight-UV exposure, smoking and nutrition acting in the context of genetic vulnerability have been implicated as potential risk factors for MS [1,9–13]. Although research interest into the relationship between vitamin D and MS risk has continued to increase [14], many key questions still remain unanswered.