Meltem Demirkiran

Multiple sclerosis patients with and without sexual dysfunction: are there any differences?

Objective Sexual dysfunction (SD) severely affects the quality of life in patients with multiple sclerosis (MS). The aim of this study is to investigate the type and frequency of sexual complaints in MS patients, to analyse their relationship to various clinical and psychosocial variables and to clarify the differences between MS patients with and without SD. Methods Thirty-five relapsing-remitting (RR), nine secondary progressive and seven primary progressive MS patients were included in this study. A structured face-to-face interview regarding sexual function and other physical problems which may interfere with sexual functioning was administered to each patient. They also filled out Multiple Sclerosis Intimacy and Sexuality Questionnaire-19 (MSISQ-19), which includes items for primary (direct physical), secondary (indirect physical) and tertiary (psychosocial) causes of SD. Disability, cognitive functions and psychological functioning were also evaluated. Results Forty-one patients (80.4%) reported primary SD; decreased libido was the most frequent complaint (80.5%). These patients were older and more disabled, however 39% had low disability scores. SD was a common problem for both men and women. Patients with RRMS were affected less in all items of primary SD. Several items of secondary SD-problems with memory and concentration, bladder symptoms, bowel symptoms-showed correlation with different items of primary SD; these were altered genital sensation, decreased libido, increased time for arousal, decreased lubrication/difficulties with erection. Total MSISQ-19 scores were correlated with disease duration, age, disability, disease course, Beck depression scale, temporary and long-standing anxiety and low level of education. Conclusion SD is an underestimated, common symptom of MS. It may occur in MS even in the absence of severe disability. Physicians’ awareness of this problem may help to bring about appropriate treatments and management, and improve the quality of life for these patients.

Vascular parkinsonism: a distinct, heterogeneous clinical entity.

Objectives– The aim of this study was to define the symptoms and signs of suspected vascular parkinsonism (VP) which is still a debatable concept. Material and methods– Patients with parkinsonism were grouped into patients with suspected VP and Parkinsons disease (PD) after other causes for secondary parkinsonism, and parkinsonism‐plus syndromes were excluded. The clinical features of 16 patients with suspected VP to those of 50 diagnosed with PD were compared. All patients were assessed using unified Parkinsons disease rating scale (UPDRS) and all had cerebral MRIs. Results– Patients with VP had significantly older onset age and shorter duration of disease with gait disorder as the most frequent initial symptom. All PD patients had satisfactory response to levodopa treatment, whereas only 38% VP patients had satisfactory response to levodopa treatment. Vascular risk factors were more common in VP (81%) than PD (32%). Postural instability, freezing, gait disturbance, pyramidal signs, and postural tremor were significantly more prevalent in patients with VP than in PD. In VP patients these features were more prominent in the lower limbs. Twenty‐five percent had acute onset VP. All patients with VP had ischemic lesions, mainly in subcortical white matter, to a lesser extent basal ganglia and brainstem, in their cerebral MRIs, while 70% of PD patients had normal MRIs. Conclusion– The differences in the clinical features support the concept that VP is a distinct clinical entity with heterogeneous clinical, MRI, and possibly pathophysiological features.

Evaluation of Choroidal Vascular Changes in Patients with Multiple Sclerosis Using Enhanced Depth Imaging Optical Coherence Tomography

Objective: To evaluate the choroidal thickness in patients with multiple sclerosis (MS) using enhanced depth imaging optical coherence tomography (EDI-OCT). Methods: In this observational comparative study, 68 eyes of 34 MS patients and 60 eyes of 30 healthy subjects were evaluated. All participants underwent complete ophthalmologic examination and OCT scanning. Choroidal thickness measurements were performed at seven points. Results: The mean subfoveal choroidal thickness was reduced significantly in MS patients (310.71 ± 61.85 μm) versus healthy controls (364.85 ± 41.81 μm) (p < 0.001). The difference was also significant at all six measurement points (p < 0.001 for all). Choroidal thickness measurements revealed no significant difference between MS eyes with a prior optic neuritis (ON) history (MS ON) and those without ON history (MS non-ON). Subfoveal choroidal thickness did not correlate with retinal nerve fiber layer and Expanded Disability Status Scale score, but reduced choroidal thickness was associated with longer disease duration (r = -0.28, p = 0.019) in MS patients. Conclusion: In MS patients, choroidal structural changes occur both in MS ON and MS non-ON eyes. The decreased choroidal thickness might provide evidence to support a potential role of vascular dysregulation in the pathophysiology of MS.

Transient parkinsonism: Induced by progesterone or pregnancy?

We report on the development of transient parkinsonism after progesterone injection in a pregnant patient with a risk of abortion. Etiological possibilities are discussed, including pregnancy itself, possible toxic effects of the dead fetus, and progesterone injection. Progesterone‐induced parkinsonism seems the most likely diagnosis in this case.

Evaluation of the Innermost Retinal Layers and Visual Evoked Potentials in Patients with Multiple Sclerosis

ABSTRACT Purpose: The present study was conducted to investigate alterations in the innermost layers of the retina using optical coherence tomography (OCT) and to assess potential associations of structural measures with functional markers in patients with Multiple Sclerosis (MS). Materials and Methods: Ninety-four eyes of 47 MS patients and 60 eyes of 30 healthy individuals were included in the study. All patients underwent complete ophthalmological examination and OCT imaging to analyze peripapillary retinal nerve fiber layer (RNFL) and ganglion cell-inner plexiform layer (GCIPL) thickness. Visual evoked potentials (VEPs) and expanded disability status scale (EDSS) score were assessed for MS patients. Results: The average RNFL and GCIPL thicknesses were thinner in MS patients (86.2 ± 11.9 µm and 73.6 ± 9.7 µm, respectively) when compared with those of healthy controls (96.7 ± 8.2 µm and 85.9 ± 4.6 µm, respectively, p < 0.001 for both). Within MS patients, the average RNFL and GCIPL thicknesses were lower in eyes with a prior history of optic neuritis (MS ON) than in eyes with no optic neuritis history (MS non-ON) (p = 0.012 and p < 0.001, respectively). RNFL and GCIPL thicknesses were inversely correlated with VEP latency (r = −0.40, p < 0.001 and r = −0.36, p < 0.001, respectively) in MS patient eyes. There was a correlation between GCIPL thickness and VEP amplitude in eyes with previous ON history (r = 0.34, p = 0.035). No significant correlations were found between OCT measurements and EDSS score. Conclusions: Innermost layers of the retina are highly affected by the pathophysiologic process in MS disease, manifesting as a reduction in RNFL and GCIPL thickness. The structural retinal changes show correlation with alterations in potentials showing the optic pathway function.

Global aphasia due to left thalamic hemorrhage

Global aphasia is an acquired language disorder characterized by severe impairments in all modalities of language. The specific sites of injury commonly include Wernikes and Brocas areas and result from large strokes--particularly those involving the internal carotid or middle cerebral arteries. Rarely, deep subcortical lesions may cause global aphasia. We present three cases with global aphasia due to a more rare cause: left thalamic hemorrhage. Their common feature was the large size of the hemorrhage and its extension to the third ventricule. HMPAO-SPECT in one of the cases revealed ipsilateral subcortical, frontotemporal cortical and right frontal cortical hypoperfusion. Left thalamic hemorrhage should be considered in the differential diagnosis of global aphasia.

Crossed aphasia in multiple sclerosis.

Aphasia is a rare sign of multiple sclerosis (MS). Several different forms of aphasia have been reported in MS. We report, to our knowledge, the first case of a MS patient with crossed aphasia during an attack.

Prevalence and risk factors of low bone mineral density in patients with multiple sclerosis

Abstract Objectives: To determine the prevalence and risk factors of low bone mineral density (BMD) in patients with multiple sclerosis (MS). Methods: Patients with MS who had undergone a BMD evaluation via dual-energy X-ray absorptiometry (DXA) between January 2010 and December 2013 were included in the study. Descriptive data, BMD values, and risk factors for osteoporosis along with the details regarding MS, such as age at onset, duration of disease, clinical type of MS, expanded disability status scale (EDSS) scores, and lifetime steroid intake were obtained from the medical record database and telephone interview. Results: The study group comprised 67 patients with a mean age of 41·1 ± 10·2 years. Of the patients, 20·9% revealed low BMD for chronological age. Vitamin D insufficiency (25(OH)D < 20 ng/ml) rate was 86·6%. Comorbidity and EDSS scores of patients with low BMD were significantly higher than those of the remaining patients (P = 0·000 and P = 0·015, respectively). Neck BMD was inversely correlated with comorbidity score, disease duration, relapse number, and lifetime steroid intake (r = − 0·270, r = − 0·263, r = − 0·359, and r = − 0·314, respectively). Conclusion: The current study revealed that low BMD and vitamin D insufficiency were common in patients with MS. Longer disease duration, higher comorbidity score, and severe disability level led to lower BMD values. In conclusion, it is of paramount importance for clinicians to pay more attention on bone health in MS and to tailor preventative measures meticulously.

Cystic Lesions in Spinal Astrocytoma

Astrocytoma, which originates from uncontrolled growing glial cells, is the second most common tumor of the spinal cord after ependymoma in adults (1). It is more common in males, and the most common location is the cervical spinal cord, followed by the thoracic cord (2,3,4). Astrocytoma manifests with radicular pain and sensory loss. Motor deficits, spasticity, and sphincter dysfunction present in later stages (3,5). A patient with weakness of the legs in whom neuroimaging and histopathologic findings indicated a diagnosis of anaplastic astrocytoma is reported in this article. A girl aged 17 years was admitted to our hospital with progressive weakness and numbness in the legs and urinary incontinence. The patients neurologic evaluation revealed grade 4/5 paraparesis, hyperactive reflexes of the lower extremities, loss of sensation below the level of L1, loss of vibratory sense in the lower extremities, and bilateral Babinski signs. Spinal magnetic resonance imaging (MRI) showed multiple microcystic lesions at the levels of T5-9 in the epidural space, spinal cord edema, and myelomalacia T9 through T12 (Figure 1, 2, 3). A lumbar puncture was performed with a pre-diagnosis of myelitis. Protein level was 2549 mg/dL, glucose 71 mg/dL, lactate 4.9 mg/dL, and sodium 135 mEq/L in the cerebrospinal fluid and no cells were counted. A neurosurgical consultation was then ordered with a pre-diagnosis of spinal mass lesion. The patient underwent neurosurgery and a histopathologic evaluation of the specimen indicated a diagnosis of anaplastic astrocytoma. Lesions of patients with astrocytoma in spinal MRI are hypointense or isointense in T1 and hyperintense in T2, as seen in our patient (Figure 1, 2, 3) (6). Cystic lesions are rare, and are difficult to distinguish from solid tumors because they contain high levels of protein (6,7). Our patient had multiple independent cystic lesions around the tumor. No other patients with these features have been

Reply to the Comment by Yolcu et al. on Our Paper Entitled "Evaluation of Choroidal Vascular Changes in Patients with Multiple Sclerosis Using Enhanced Depth Imaging Optical Coherence Tomography".

have been reported in the text. The authors have wondered whether there is a significant difference between the three groups (control, MS ON and MS non-ON). As we have mentioned in detail in the article, both MS ON and MS non-ON eyes had significantly reduced average-RNFL thickness measurements when compared with healthy controls, and the average-RNFL thickness measurements in MS ON eyes were significantly thinner than those in MS non-ON eyes. We believe that the measurement of RNFL thicknesses might be a useful parameter for the assessment of the axonal loss and for monitoring the effects of demyelination on visual pathway integrity as complementary tools to other functional markers in MS patients. Dear Editor We thank Yolcu and Ilhan [1] for their valuable contributions to our article entitled Evaluation of choroidal vascular changes in patients with multiple sclerosis using enhanced depth imaging optical coherence tomography [2] . In our study, we evaluated the choroidal thickness in multiple sclerosis (MS) patients with enhanced depth imaging optical coherence tomography to provide insight into the potential effects of the disease on vessel structure. We also evaluated the average retinal nerve fiber layer (RNFL) thickness and compared the measurements of MS eyes with optic neuritis (ON; MS ON), MS eyes without ON (MS non-ON) and controls. The average values and the statistical significance of differences between these three groups Received: November 20, 2015 Accepted: November 26, 2015 Published online: January 5, 2016