Tereza Gabelić

The vestibular evoked myogenic potentials (VEMP) score: a promising tool for evaluation of brainstem involvement in multiple sclerosis

Concerning the great importance of brainstem involvement in multiple sclerosis (MS), the aim of this study was to explore the role of the newly developed vestibular evoked myogenic potentials (VEMP) score as a possible marker of brainstem involvement in MS patients.

Ocular and Cervical Vestibular Evoked Myogenic Potentials in Patients With Multiple Sclerosis

Objectives: The aim of this study was to evaluate latencies and corrected p13-n23 cervical vestibular evoked myogenic potentials (cVEMP) and n10-p13 ocular vestibular evoked myogenic potentials (oVEMP) amplitudes in patients with relapsing remitting multiple sclerosis (MS). Methods: This was a prospective, case-control study. Thirty patients with MS and 15 healthy controls were included. Cervical vestibular evoked myogenic potentials and oVEMP in response to acoustic clicks of 1 ms duration at the intensity of 130 dB SPL and the stimulation frequency of 1 Hz were studied. Signals were divided in segments of 120 ms duration (20 ms before the stimulus and 100 ms after the stimulus) and averaged. Results: In MS group, there was significant latencies prolongation of all sternocleidomastoid responses (p13 and n23) and n10 response of the ocular muscles. The sternocleidomastoid p13-n23 normalized amplitude was significantly higher in MS patients. Prolonged latencies were found in 57% and conduction block in 7% of patients in at least one sternocleidomastoid response in the MS group. Prolonged latencies were found in 30% and conduction block in 40% of patients in at least one ocular response in the MS group. When cVEMP and oVEMP are combined, 80% had pathological finding. When correlating brainstem clinical, brainstem MRI, and cVEMP findings, there was no statistical significance (brainstem clinical vs. cVEMP P = 0.1; brainstem MRI vs. cVEMP P = 0.82). When correlating brainstem clinical, brainstem MRI and oVEMP findings, there was a statistical significant correlation between brainstem clinical versus oVEMP, P = 0.02, whereas there was no statistical significance between brainstem MRI versus oVEMP (P = 0.38). Conclusions: Combination of cVEMP and oVEMP in MS patients allows better estimation of brainstem lesions.

Auditory evoked potentials and vestibular evoked myogenic potentials in evaluation of brainstem lesions in multiple sclerosis

OBJECTIVE The aim of this study was to determine the roles of magnetic resonance imaging (MRI), auditory evoked potentials (AEP) and vestibular evoked myogenic potentials (VEMP) in the evaluation of brainstem involvement in multiple sclerosis (MS). PATIENTS AND METHODS Altogether 32 patients with the diagnosis of MS participated in the study. The following data was collected from all patients: age, gender, Expanded Disability Status Scale (EDSS) score, brainstem functional system score (BSFS) (part of the EDSS evaluating brainstem symptomatology), and involvement of the brainstem on the brain MRI. AEP and ocular VEMP (oVEMP) and cervical VEMP (cVEMP) were studied in all patients. RESULTS BSFS, MRI, AEP, oVEMP and cVEMP involvement of the brainstem was evident in 9 (28.1%), 14 (43.8%), 7 (21.9%), 12 (37.5%) and 10 (31.0%) patients, respectively. None of the tests used showed statistically significant advantage in the detection of brainstem lesions. When combining oVEMP and cVEMP 18 (56.3%) patients showed brainstem involvement. This combination showed brainstem involvement in greater percentage than BSFS or AEP, with statistical significance (p=0.035 and p=0.007, respectively). CONCLUSION VEMP is a reliable method in detection of brainstem involvement in MS. It is comparable with MRI, but superior to clinical examination or AEP.

Primary position upbeat nystagmus

Primary position upbeat nystagmus is a rare clinical finding. We report a patient with clinically isolated syndrome suggestive of multiple sclerosis who presented with primary position upbeat nystagmus. MRI revealed a demyelinating lesion in the lower medulla, which affected the nucleus intercalatus; this type of lesion inhibits the flocculovestibular inhibitory pathway, thereby causing upbeat nystagmus. Nystagmus still persisted after pulsed corticosteroid therapy. This could be due to a loss of central adaptation of the vestibulo-ocular system in our patient, because of more diffuse brainstem damage, shown on vestibular-evoked myogenic potentials as delayed latencies on both sternocleidomastoid muscles and a conduction block for the left extraocular muscles.

The Role of Cervical and Ocular Vestibular- Evoked Myogenic Potentials in the Follow-Up of Vestibular Neuritis

This study evaluates the recovery of vestibular nerve function after vestibular neuritis (VN) by vestibular-evoked myogenic potentials (VEMPs). Twenty-six patients with the diagnosis of VN were included. All patients underwent ocular VEMP (oVEMP) and cervical VEMP (cVEMP) recordings, at 6 days and 6 months from the onset of the symptoms. Of the 26 patients, 14 showed improvement on oVEMP at month 6 (group 1), and 12 showed no change or worsening on oVEMP at 6 months (group 2). At the same time, there was no change in the amplitudes of the cVEMP on either healthy or affected sides in both groups. Inability to perform the Fukuda test, and chronic white matter supratentorial lesions present on brain magnetic resonance imaging (MRI) were more frequent in patients with worse outcome on oVEMP (P = 0.044 and 0.045, respectively). Although involvement of the inferior branch of the vestibular nerve was not associated with oVEMP outcome, oVEMP latencies (N10 and P13) were associated with improvement or worsening in oVEMP amplitudes, showing that prolonged latencies correlate with 6-month improvement in oVEMP amplitudes (Pearson correlation −0.472, P = 0.041 and −0.580, P = 0.009, respectively). This study identified clinical, MRI and neurophysiological predictors of recovery in patients with superior VN, and offers additional insight into, and better understanding of, the role of VEMP in diagnosis and prognosis of patients with VN. Further studies are needed to validate this diagnostic procedure and to assess its clinical usefulness in VN management.

Treatment of facial myokymia in multiple sclerosis with botulinum toxin

Myokymia is frequent symptom in subjects with multiple sclerosis. This paper describes case report of subject with MS and brings review of literature about myokymia treatment.

Electroencephalographic Response to Different Odors in Healthy Individuals: A Promising Tool for Objective Assessment of Olfactory Disorders.

The aim of the present study was to examine human central nervous system response to three different odors. Electrophysiological activity was recorded in the baseline state and for 3 odors, lemon, peppermint, and vanilla, in 16 healthy participants. Electrodes were separated into groups according to the spatial position on the head. Fast Fourier transformation was performed on every set, and mean value of activity in theta was exported. As theta showed statistically significant results, further analysis was based only on the theta frequency band. On electrodes FP1, F3, Fz, F4, F8, T7, C3, Cz, C4, T8, TP9, CP5, CP1, CP2, CP6, P7, P3, Pz, P4, P8, PO9, and PO10 there was statistically significant difference in the electrical activity of the brain between four conditions. For peppermint and lemon, there was statistically significant difference in activity between different regions—F(1.576, 23.637) = 16.030, P = .000 and F(1.362, 20.425) = 4.54, P = .035, respectively—where the activity in the central area was significantly reduced compared with the activity in the other 4 areas and in the left and right anterior and left posterior area, respectively. There was no statistically significant difference for vanilla between specific areas, F(1.217, 18.257) = 1.155, P = .309. The results indicate that olfactory stimuli can affect the frequency characteristics of the electrical activity of the brain.

Psychotic reaction as a manifestation of multiple sclerosis relapse treated with plasma exchange

We present a patient with a clinically isolated syndrome suggestive of multiple sclerosis, who developed a full-blown picture of paranoid psychosis with suicidal attempt. Four new lesions were observed on brain MRI, one in the left and one in the right temporal lobe, one subcortically in the cingulate gyrus and one centrally in the tegmentum of the midbrain. The patient was treated with plasma exchange and recovered completely. Psychosis is not so rare symptom of multiple sclerosis as previously reported, and poses a major treatment challenge. A combination of lesions at strategic locations was a presumed mechanism of psychosis in this patient.

Do we need broad immunological work-up in all patients with CIS?☆

BACKGROUND The aim of this study was to determine the prevalence of altered immunological tests and their clinical significance in patients with clinically isolated syndrome (CIS) suggestive of multiple sclerosis (MS). PATIENTS AND METHODS The information was gathered from medical records of patients hospitalized in the Referral Center for Demyelinating Diseases in the 2008-2010 period. All patients had ANA, ENA profile, ANCA, aCl IgG and IgM, C3, C4, CH50, anti-TPO, AST and RF antibodies tested. RESULTS From 726 patients with CIS that were reviewed, the complete battery of immunological tests was performed in 418 of them (57.6%), representing our cohort. Altered tests were found in 235 patients (56.2%); 73 (17.4%) had positive antinuclear antibodies, 14 (3.3%) had positive ENA, 47 (11.2%) had positive aCl IgG, 83 (19.8%) had positive aCl IgM, and 13 (3.1%) had anti TPO antibodies. We found no correlation between ANA, aCl IgG or IgM positivity (ANA vs aCL IgG p=0.554; ANA vs aCL IgM p=0.19; aCL IgG vs aCL IgM, p=0.155). None of the patients had any clinical manifestations other than MS symptoms. CONCLUSION These results indicate that significant number of patients with CIS have altered immunological tests but nevertheless none of them had clinical expression of any other autoimmune disease making them clinically insignificant. In conclusion there is no need to perform extensive immunological work-up in all patients with CIS. Contrary, our results argue for more focused testing rather than a battery of screening tests.

Postural Orthostatic Tachycardia Predicts Early Conversion to Multiple Sclerosis after Clinically Isolated Syndrome

Background/Aims: There have been suggestions that interactions exist between the autonomic nervous system (ANS) and the immune system functions in multiple sclerosis (MS). We aimed to evaluate the ANS dysfunction, more specifically postural orthostatic tachycardia syndrome (POTS), as a possible predictor of conversion to MS in patients with clinically isolated syndrome (CIS). Methods: In this observational, prospective, longitudinal study, 84 patients were enrolled (56 females, mean age 32.9 ± 8.9 years). Disease activity during a 6-month period was monitored (relapses and/or MRI disease activity indicated by new T2 or T1 enhancing lesions), and the following predictors analyzed: age, Expanded Disability Status Scale, MRI midbrain, pontine or medulla oblongata lesions, and POTS on the head up tilt test. Results: POTS was identified in 8 (9.5%) patients. Of 84 patients, 62 (73.8%) completed the 6-month follow-up, and 28 (45.2%) patients converted to MS. Results of the multivariate regression analysis revealed age (10-year increase) and POTS as significant predictors of early conversion to MS (OR 2.34, 95% CI 1.15-4.78, p = 0.019 and OR 12.40, 95% CI 1.13-136.62, p = 0.040). The logistic model was statistically significant, χ2 (6) = 13.885, p = 0.031. Conclusion: POTS may be an indicator of a more active disease course in CIS patients and possibly be used as a prognostic factor.