Effect of Deep Brain Stimulation on Cerebellar Tremor Compared to Non-Cerebellar Tremor Using a Wearable Device in a Patient With Multiple Sclerosis: Case Report

Tremor of the upper extremity is a significant cause of disability in some patients with multiple sclerosis (MS). The MS tremor is complex because it contains an ataxic intentional tremor component due to the involvement of the cerebellum and cerebellar outflow pathways by MS plaques, which makes the MS tremor, in general, less responsive to medications or deep brain stimulation (DBS) than those associated with essential tremor or Parkinson's disease. The cerebellar component has been thought to be the main reason for making DBS less effective, although it is not clear whether it is due to the lack of suppression of the ataxic tremor by DBS or else. The goal of this study was to clarify the effect of DBS on cerebellar tremor compared to non-cerebellar tremor in a patient with MS. By wearing an accelerometer on the index finger of each hand, we were able to quantitatively characterize kinetic tremor by frequency and amplitude, with cerebellar ataxia component on one hand and that without cerebellar component on the other hand, at the beginning and end of the hand movement approaching a target at DBS Off and On status. We found that cerebellar tremor surprisingly had as good a response to DBS as the tremor without a cerebellar component, but the function control on cerebellar tremor was not as good due to its distal oscillation, which made the amplitude of tremor increasingly greater as it approached the target. This explains why cerebellar tremor or MS tremor with cerebellar component has a poor functional transformation even with a good percentage of tremor control. This case study provides a better understanding of the effect of DBS on cerebellar tremor and MS tremor by using a wearable device, which could help future studies improve patient selection and outcome prediction for DBS treatment of this disabling tremor.

A Rare Case of Adult Medulloblastoma Associated with Multiple Sclerosis: Case Report and Literature Review

Medulloblastomas are the most common primary malignant brain tumors in childhood. They are responsible for around 20–40% of all brain tumors in children. They rarely occur in adulthood, but here they only make up less than 1% of all brain tumors. The standard therapy consists of an operation in combination with radiation and chemotherapy, which are individually determined for the patient. In this article, we discuss a case of 47 years old female patient diagnosed with primary progressive multiple sclerosis since 1 year. After 3 months of the diagnosis, she deteriorated and became unable to walk. MRI showed a large patchy enhancing midline cerebellar mass with evolving hydrocephalus. Tumor expressed positive reaction with synaptophysin immunohistochemical stain rendering medulloblastoma diagnosis.

Detection of oligoclonal bands as a part of the diagnosis of multiple sclerosis – case studies

Introduction: Oligoclonal bands are the result of the synthesis of antibodies of limited heterogeneity, that is, directed against one or more specific antigens. Their detection is an important element in the diagnosis of autoimmune diseases. In multiple sclerosis, the diagnostic sensitivity of the determination of oligoclonal bands is high. Aim: The aim of this study is to answer the question whether the detection of oligoclonal bands a more valuable study is than the Tibbling-Link index and reibergram analysis in the context of the diagnosis of multiple sclerosis. Material and methods: Oligoclonal bands were tested in the cerebrospinal fluid and serum from 9 patients suspected of multiple sclerosis using the Sebia HYDRAGEL 3 CSF ISOFOCUSING kit. Results: In 7 out of 9 patients the Tibbling-Link index, reibergram analysis and oligoclonal bands detection clearly indicated intrathecal IgG synthesis. In 2 of 9 patients, detection of oligoclonal bands indicated intrathecal IgG synthesis and the value of Tibbling-Link index and reibergram analysis did not indicated intrathecal IgG production or these tests indicated limit values. Conclusions: The detection of oligoclonal bands in many cases allows for faster diagnosis and introduction of therapy. This test should be an integral part of SM diagnostics.

Central vein sign for differential diagnosis of demyelinating diseases of CNS

The search for highly sensitive and highly specific biomarkers of MS, including neuroimaging biomarkers, continues. One of such biomarkers is the central vein sign detectable on SW and T2-weighted MR images. The sensitivity and specificity of methods used for central vein sign detection vary. This article describes two clinical cases of patients with similar neurological symptoms which required making differential diagnosis between multiple sclerosis and secondary demyelination in the presence of a systemic disorder (systemic lupus erythematosus). In addition to routine MR sequences, we used SWI generated by a 3T scanner. The lesions with the central vein sign were counted; the proportion of perivenular lesions was determined. In the multiple sclerosis case, all the lesions were perivenular; the proportion of lesions with the central vein sign in the patient with secondary demyelination in the presence of systemic lupus erythematosus was 16.7%. The use of SW images improved the informative value of the analysis.

Title Immersive Virtual Reality and Vestibular Rehabilitation in Multiple Sclerosis: Case Report (Preprint)

BACKGROUND Background: Dizziness and imbalance are common and disabling symptoms in multiple sclerosis (MS) patients caused by a central, peripheral or mixed vestibulopathy. Central vestibular disorder is the most frequent report in the MS population due to demyelination. Vestibular rehabilitation ameliorates these symptoms and its repercussions in quality of life. However, immersive virtual reality (VRi) is a growing tool in this fieldwork, but no previous research has been performed studying its effects in MS. OBJECTIVE Objective: To apply a VRi vestibular training protocol in a patient with MS and assess the effects induced by the experimental intervention. METHODS Methods: Case study of a 54-year-old woman with relapsing remitting multiple sclerosis (RRMS). We developed a standardized VRi exercise protocol for vestibular rehabilitation based on the gold standard vestibular training of Cawthorne-Cooksey. The 20 session intervention is formed of 10 initial sessions and 10 advanced sessions. Each 50 minute session will be performed 3 times per week for 8 weeks. Four evaluations were carried out over the study period: at baseline (T0), between the two intervention phases (T1), at the end of the intervention and at the one month follow-up (T3). The outcomes of the research were dizziness, balance, gait, impact of fatigue, quality of life, repercussions in muscular tone and usability of HMD. RESULTS Results: The patient improved DHI (T0=62 points/T2=4), BBS (T0=47/T2=54), iTUG (T0=8.35 sec/T2=5.57 sec), muscular tone of the erector spinae, rectus femoris and soleus, MFIS (T0=61/T2=37) and MSQoL-54 (T2 physical area=67.16%; T2 mental area= 33.56%) after receiving the VRi vestibular protocol. System Usability Scale reached 90% of usability and A grade. CONCLUSIONS Conclusions: This research provided evidence of the first VRi vestibular protocol in the MS population to improve dizziness, balance, gait, impact of fatigue and quality of life and muscular tone through an exergame intervention. This study may help to set a standardized VRi protocol for vestibular rehabilitation.

Prevalence and Incidence of Multiple Sclerosis (MS) in Guilan Province

Introduction: The aim of this study was to investigate the prevalence and incidence of multiple sclerosis (MS) in Guilan Province) and to compare the standardized prevalence by the factor of age in this province. Methods: The study was a cross-sectional design that was conducted in 2018 at the Guilan MS Society (GMSS) on people with multiple sclerosis and examined the 654 people with multiple sclerosis case. In this study, the trend of MS disease was examined from 2009 to 2019 and in order to investigate the rate of cumulative incidence of the disease, new cases were defined based on the date of diagnosis of the disease from the beginning of 2018. Data collection was performed using a checklist that was collected during the GMSS registration by a registrar in the form of a structured interview. Prevalence rate was compared between different subgroups using Chi-Square and Fisher's exact tests. Field characteristics were described by using absolute and relative frequency indices or mean and standard deviation using Stata 13 and SPSS 19 statistical software. Results: The results showed that 71.4% of all patients were female. The mean age of the patients was 36.5 years and the highest frequency of MS was observed in the age group of 30-40. The MS patients lived in the urban were 81%. The highest initial manifestations of people with multiple sclerosis were reported in numbness or tingling, vision problems, weakness, other symptoms, and walking (Gait) difficulties, respectively. The highest prevalence of MS was in Lahijan and then Rasht and Astaneh-ye Ashrafiyeh citie.. Conclusion: From the results of this study, it is concluded that there is no significant difference between the prevalence rate in Guilan Province and the standardized rate with the age adjustment based on the WHO standard population, although no analytical comparison has been performed in this study.