Is it or is it not multiple sclerosis?

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Since my posts on multiple sclerosis are getting many hits from readers, I thought that I would in this post describe how a definitive diagnosis of MS is made.

First and foremost, a definitive diagnosis of MS can be made just clinically without any other imaging studies like MRI or the need for invasive tests like lumbar puncture (spinal tap). How you may ask?

Well if by history you have had two attacks suggestive of MS which are disseminated in time and space, then a definitive diagnosis of MS can be made. Let me explain this in simple language. Lets assume you go to your doctor because you have been having numbness in your right arm. Your doctor examines you and finds that apart from sensory loss in the right arm, you have other examination findings such as you have ataxia (your gait is off and unsteady), you have incoordination and tremor in your right arm, your eyes do not move well and you have what we call internuclear opthalmoplegia. Hmm sorry for all that medical jargon, let me try to make it more simple. What I am trying to say that your examination findings are suggestive of not one but multiple sites of pathology in your brain.

Numbness right arm localizes to the sensory cortex on the left side of your brain.

Ataxia might be due to midline cerebellar problem

Right arm tremor localizes to the right cerebellum (cerebellar pathways are double crossed in the brain)

The eye findings and internuclear opthalmoplegia localizes to the midbrain.

So you have signs that whatever your disease is it is disseminated in space (SPACE AS IN DISSEMINATED IN DIFFERENT  PARTS OF THE BRAIN). Your findings cannot be explained by one single lesion rather by multiple small lesions.

So you have met the first criteria to make a definitive diagnosis of MS-dissemination in space. (OF COURSE DISSEMINATION IN SPACE SHALL ALSO BE CLEARLY SHOWN IF YOU DO A MRI SCAN)

 Now how do we prove you have dissemination in time?  Well that is done by history. Lets assume your doctor now asks you ” Miss Smith have you ever had a problem with your eye before? Did you ever lose vision in one eye?”

Miss Smith: ” Now that you ask doctor Sethi, yes. When I was 18, I had an episode where I had pain in my left eye and lost vision rather abruptly. By the time I saw my doctor, it had started to improve by itself and I did not think much of it.”

Viola!!! here the history is telling you that Miss Smith has in fact had dissemination in time. Likely she had an attack of optic neuritis when she was 18 which had resolved by itself.

So as a doctor examining Miss Smith, I now know that her disease is disseminated in time (she has had attacks in the past) and also in space (from my examination findings I know that she likely has multiple lesions in the brain, only then I can explain all her findings).

I DO NOT NEED ANY ADDITIONAL TESTS TO MAKE A DIAGNOSIS OF MS. SHE HAS HAD 2 ATTACKS DISSEMINATED IN TIME AND SPACE.

Of course as part of her management I would do a MRI study of the brain and some doctors might still do a lumbar puncture. 

 Additional tests like MRI brain, spinal tap and evoked potentials (visual and somatosensory evoked potential) are needed when either of the above 2 is missing. Either Miss Smith has had just one clinical attack or her examination finding are suggestive of one lesion.

Nitin Sethi, MD

Cannabis use in patients with multiple sclerosis

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Just read a study in Neurology about the effects of marijuana in patients with multiple sclerosis. It seems that MS patients who smoke marijuana have more cognitive dysfunction and mood disorders as compared to MS patients that do not. MS patients may be smoking marijuana recreationally or they may be using it to get rid of tingling and other paraesthesias.

Multiple sclerosis itself causes cognitive problems and if patients smoke marijuana it seems they compound them. With the limited data available to us currently, it is probably wise that patients with multiple sclerosis avoid smoking marijuana.

Nitin Sethi, MD

Foot drop: making sense of its causes

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A common problem for which patients consult neurologists like me is foot drop. As the name says, they have foot drop and hence are unable to dorsiflex their foot. As a result they are likely to catch their foot on the ground while walking and thus are prone to falls and this brings them to medical attention. Foot drop should be differentiated from frail foot. In foot drop, patients are unable to dorsiflex their foot while those who have a frail foot are unable to dorsiflex as well as unable to planter flex the foot (that is they are unable to pull their foot up or push down their foot as when you press down on a gas pedal).

Foot drop might occur suddenly (acutely) or may be more insidious and the causes for both vary. Before we discuss the causes of foot drop, it is helpful to know a little about the relevant anatomy. The muscle which helps to dorsiflex the foot is called tibialis anterior and it is supplied by a nerve called the peroneal nerve. The peroneal nerve is a branch of the sciatic nerve. The sciatic nerve is formed by the lower lumbar and sacral nerve roots and forms a part of the lumbosacral plexus. The peroneal nerve in the knee area is quite superficial as it cross the neck of the fibula (fibula is one of the bones in the lower leg along with the larger tibia). As the nerve is superficial it is prone to compression across the neck of the fibula.

So lets now discuss some of the common causes of foot drop. If suppose you suffer a fracture across the neck of the fibula, or have a gun shot wound to that area, or during knee surgery the peroneal nerve is accidently transected, you shall develop a foot drop. In all of the above the cause is injury to the peroneal nerve.

But peroneal compression may also occur due to other more subtle causes. One of the most common causes of foot drop is habitual leg crossing. This is most commonly seen in obese persons or in diabetics who lose weight.  After weight loss they can cross their legs more easily and may develop a foot drop. Why does this occur you may ask? Well the answer is simple, as I told you before the peroneal nerve is quite superficial and hence prone to compression. When you cross your leg, the nerve may get pinched against the other knee and if you do not relieve the pressure soon, you can develop a foot drop. A common scenario is that the person is sitting with his legs crossed on a long flight, or might have fallen asleep with his leg pressed against the side rails of the bed (this is common in hospitalized patients in the intensive care unit or also when patients are undergoing surgery in the OR), they wake up and find they have a foot drop. The good news is that the prognosis for this type of compression injury to the peroneal nerve is rather good. Once the pressure is released, these patients usually make a full recovery over a few days to weeks and their foot drop goes away.

They can though be other more proximal causes of foot drop. You can have compression or injury to the sciatic nerve or to the lumbosacral plexus (remember I told you, that the peroneal nerve is a branch of the sciatic nerve).  Compression of the sciatic nerve may at times be due to a tumor or mass in the pelvis or in the thigh or knee area.

Lower lumbar disc herniation may also result in a drop foot. This is commonly seen in L5 disc herniation. Patients usually present with radicular pain radiating down the leg, though sometimes this may be absent.

Diagnosis and management of foot drop: the diagnosis of foot drop is clinical and depending upon your examination findings, your doctor may or may not order other tests to confirm at what level is the problem. He may order a nerve conduction study and an EMG (needle study, electromyogram) to check for the the sciatic and peroneal nerves. If warranted an MRI of the lower back and of the plexus may be done.

The treatment depends upon the cause. If the foot drop is because of habitual leg crossing, then all what may be needed is to advise the patient not to cross his legs. The recovery is spontaneous. If a mass is the cause then well depending upon what it is, the treatment varies. Patients usually need a ankle foot orthosis or a foot drop splint. This splints the foot up and prevents fall.

I hope this is helpful to some of you.

Personal Regards,

Nitin Sethi, MD

More neurobics anyone?

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Came with a few more neurobics which can be fun and at the same time healthy for the brain. Have fun with neurobics everyone!

1) run or walk backwards (be careful not to fall though please). I tried this myself. It is amazing how your brain is more active and conscious about the task of walking or runing backwards. Compare this with when you walk or run normally forwards, the task is nearly subconsciously attempted by the brain without even thinking about it.

2) use your left hand (if you are right handed) to answer your phone. If you use a mobile phone this has the added advantage of reducing the radiofrequecy exposure to the right side of the brain as nowdays there are some reports commenting on the increased risk of brain tumors in heavy mobile phone users.

3) learn a new language (I recommend this one).

4) hear a song and commit it to your memory. Now write down the lyrics on a piece of paper.

5)commit more things to your own memory rather than the memory of your palm-pilot. Buy a palm pilot with less memory and use it less too!!!

Personal Regards,

Nitin Sethi, MD

 

Your brain on religion and spirituality

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                                     Your brain on religion and spirituality

Nitin K Sethi, MD

 

        Comprehensive Epilepsy Center, Department of Neurology, NYP-Weill Cornell Medical Center, New York, NY (U.S.A.)

Address for Correspondence:

NK Sethi, MD

Comprehensive Epilepsy Center

Department of Neurology

NYP-Weill Cornell Medical Center

525 East 68th Street, York Avenue

New York, NY 10021

Fax: 212-746-8984

Email: sethinitinmd@hotmail.com

In the Hindu philosophy (as mentioned in the Bhagavad Gita), the word yoga has different meanings at different points. The use of the word yoga is different from its common interpretation in the West where yoga commonly refers to Hatha yoga. Hatha yoga denotes the physical aspect of yoga and mostly involves stretching and toning exercises. In the Bhagavad Gita and in the Upanisads different usage of the word yoga is described.

There is Karma yoga or the yoga of selfless action (performing actions in this material world without been attached to the fruits of those actions). Mahatama Gandhi who referred to the Gita as his eternal mother and incorporated its principles into his life said Karma yoga refers to Nishkama Karma  or actions without selfish motives.

Then there is Bhakti yoga or yoga of devotional love (traditionally used to refer to love for God, the creator).

Finally there is Gyana yoga which refers to the yoga of knowledge (one who seeks to attain  spiritual knowledge).

The Indian seers contemplated deeply about the meaning of life and the important questions of why am I born? What am I supposed to achieve in this life? Is there life beyond death? The understanding was that if you meditated  deeply , withdrawing all your senses inwards (just as a tortoise withdraws its limbs, this analogy is mentioned in the Bhagavad Gita by Lord Sri Krishna), then you shall be able to reach your inner self. The self in the Gita has been equated to Brahman and Atman. The Gita believes that the inner self is God or God equivalent. When you reach the plane of inner self all dualities cease to exist. “I” and “you” are not there anymore. One sees oneself in everyone and everyone inside oneself.  I have not read much about other religions of the world and by no stretch of imagination can I claim to be a religious scholar. Still what little I know, I feel all major religions identify with this tenant of deep introspection and reflection. The need to identify with the inner consciousness. The statement that God is within each of us and we need to look inwards to find him.

Can this deep level of meditation be achieved? Are these religious beliefs compatible with neuroscience? What does our current level of understanding of the human brain tell us about this belief? Is it scientific? Well even with our current “primitive” knowledge of the human brain, yes. An eminent neuroscientist once said ” we are what our brains see and tell us”. To understand this compatibility between religion and science we need to first understand the human brain. A fundamental question that arises is what gives each of us our unique sense of identity. How does my brain know that this is my body and not someone else? How is it able to differentiate between self and non-self (such as another human being or even inanimate objects such as a table or chair).

Elegant experiments done in the lab by eminent neuroscientists like Professor Ramachandran (read “Phantoms in the brain”  by professor Ramachandran, a book I recommend everyone to read) indicate that the human brain can be tricked to view non-self objects as self (such as another person’s arm or even inanimate objects like a table or chair as extensions of one’s own body). The human brain during its development has sensory maps laid down representing the entire body. Thus the entire body is mapped in the brain and therefore the brain knows when someone touches the arm.

So is it possible that by deep meditation one can remap the brain (at least on a temporary basis). Reach that level where all dualities disappear and one is one with the universe around. Another person’s body is felt as one’s own, another’s pain as one’s own pain.

As science advances further we shall find out whether all matter which currently has a form and shape is actually just matter (electrons oscillating in space) and how the sense of individuality comes from the brain.

Religion and science shall feel compatible and not at at odds with one other. I would appreciate my readers comments on these musings of mine.

Falls in the elderly: making sense of the numerous causes

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Today I consulted on a 90-year-old lady who had been admitted to the hospital for evaluation of frequent falls. Even though she was 90, she was a young 90. Very alert and interactive and with normal strength in bed and mentation.

Since falls in elderly is a common problem, I thought why not discuss about this here. Falls are an important cause of morbidity and mortality especially in the elderly. This is a complicated topic and I shall tackle it by first discussing about how we maintain our balance.

Balance in humans is maintained due to a complex interaction of various neurological and muscular systems. There are added inputs from the visual and auditory systems which help in maintaining stability.

Hence problems with balance and stability may arise from primary neurological conditions, either problems involving the central nervous system such as the cerebellum or the peripheral nerves as in neuropathies. The peripheral nerves carry the sensation of joint sense (where the joints are with respect to space, vibration sense and position sense (suppose you are standing on a cold floor. Even with your eyes closed you are able to make out that the floor is cold, is it even or uneven, is it soft or hard. Now if you had a severe neuropathy and had no joint sense or position sense, then if your eyes were closed you shall be unstable and liable to fall).

We also need visual and auditory cues to maintain balance  (imagine trying to walk to the bathroom at night in a pitch dark room. You shall be unsteady and liable to fall and hurt yourself).

Then there can be mechanical, neuromuscular and othopedic causes of gait instability.Example you have had a stroke in the past and hence you are weak in one leg, have had a fracture of one of the long bones of the leg or you have a myopathy, all these conditions make you prone to falls.

So how does one make sense of the numerous causes of falls in the elderly? Diagnosing the etiology of falls can be one of the toughest tasks in clincal medicine. At times in a given patient the etiology is multifactorial (combination of old age and general deconditioning, poor eyesight as we age, poor hearing as we age, superimposed neuropathy etc).

You need to see an astute physician who is willing to spend time to pinpoint the problem. The workup starts with a good history and a thorough neurological examination. Is the problem confined to the central nervous system or is it coming from the peripheral nervous system? Are there any orthopedic causes contributing to the problem? Does the patient have poor eye sight?

Your doctor shall make you walk to see your balance, test your reflexes, test your coordination with the eyes open and then closed. Further workup may include an imaging study of the brain or spinal cord and nerve conduction studies.

So if falls are your problem or that of a loved one, please do see a doctor. You can be helped!!!

Personal Regards,

Nitin Sethi, MD

Driving with epilepsy: when to start?

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One of the big ways in which epilepsy and seizures negatively affect quality of life is by the restrictions they impose on driving. So should patients with epilepsy be allowed to drive and if so when? Is it safe from them to drive?

All these are genuine questions for which patients frequently seek answers. Well lets tackle them one by one. Normally if you have a new onset seizure (your first seizure ever) and present to the hospital, your doctor shall ask you not to drive at least till the seizure work up is complete. The seizure workup shall determine what is the cause of your seizure, do you need to be on a seizure medication, if yes for how long and what are the chances that you are going to have another seizure.

If the cause of seizure is found to be reversible, lets say for example you are diabetic and have a seizure when your blood sugar suddenly fell down as you took your insulin shot but missed a meal. Now this is a reversible cause of seizure and the patient does not have epilepsy. If his blood sugar does not fall down again, he may never have a second seizure. In this case the answer is simple and yes the patient can drive.

Lets take another example, a patient has poorly controlled epilepsy and is brought to the hospital after a seizure at work. In this case, the doctor shall rightly advise the patient not to drive. A patient like this is liable to have another seizure and may injure himself or hurt others if he is behind the wheel.

But this does not mean, that a patient with epilepsy can never drive. If your seizures have been well controlled on medication for a period of 2 years, you may discuss driving again with your doctor. Drving laws with respect to epilepsy vary from state to state in USA. In the state of New York, as a physician I am not mandated by law to report my patient with epilepsy to the DMV. It is left to the patient’s own good judgement that he or she shall surrender their driving license and not drive. In the state of New Jersy though, physicians are mandated by law to report seizure patients to the DMV.

You should be aware of the laws in your state and should discuss the same with your doctor. Most of the bylaws can be found on the DMV website and are listed for each state.

I hope you found this information useful. Its wednesday night and the clock strikes 10pm. I think my bed is calling. Have a good night everyone.

Personal Regards,

Nitin Sethi, MD

Neurobics

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Another interesting article in the Wall Street Journal by Melinda Beck where she talks about neurobics or rather mental exercises which may have a role in preventing or rather delaying the onset of neurodegenerative diseases like Alzheimer’s dementia.

As she rightly points out in her article, the etiology of Alzheimer’s dementia is thought to involve genetic and environmental factors and it is unlikely that mental exercises (neurobics) shall prevent the onset of Alzheimer’s dementia. But research and studies have shown that people who have a good neuronal reserve (higher intellect) seem to fair better when they get stricken by Alzheimer’s dementia as compared to people who are less educated and I guess with lower neuronal reserve.

So I would advise everyone to indulge in neurobics everyday. It is easy to do, has no side-effects and possible benefits.

Some neurobics I recommend:

1) If you are right handed, try brushing with your left hand (and vice versa if you are left handed).

2) If you are right handed, try eating with your left hand (and vice versa if you are left handed).

3) try writing with your non-dominant hand (now this is hard and painfully slow at times)

4) do crossword puzzles, number games

5) learn to play chess

6) learn to play a musical instrument (drums are great since they require a lot of hand coordination)

7) avoid using palm pilots and hand held devices. Commit more things to your memory. You do not need a palm pilot to remind you what you going to do during the day.

8)  Read books and newspapers instead of watching TV all the time. Remember when you are watching TV, you are doing nothing. You are just a passive spectator. When you read, you use your brain.

9) avoid using calculators. Try to balance your cheque books without the aid of calculators.

10) be Sherlock Holmes for a day. Try to memorize all the number plates you see while driving to work. (As he would say “elimentary my dear Watson” )

11) Exercise everyday. Regular exercise like walking or running is good for the brain.

12) Sleep well at night for at least 8 hours.

13) Drink alcohol in moderation.

14) learn a new skill: learn how to swim, play golf, play tennis etc.

Happy neurobics everyone.

Personal Regards,

Nitin Sethi, MD

Awake craniotomy during brain tumor surgery

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As many of you may have read by now Senator Kennedy was awake at the time of his surgery to remove the malignant tumor from his brain. What does this mean? What is awake craniotomy (been awake during the time the cranium/ skull is open?)

I thought in this post I shall discuss awake craniotomy. As you know during most surgeries, patients are under deep general anaesthesia. We try to reach a plane of anaesthesia so that they feel no pain and also have no recollection of any events during the surgery. Sometimes though especially in brain surgeries we actually want them to be awake during at least a part of the surgery.

Why you may ask. Well take the case of Senator Kennedy, his tumor was in a location which is very near to eloquent areas of the brain (parts of the brain which control language/ memory/ movements of the opposite arm and leg that is his tumor was near the language and motor cortex). So in cases like these the surgeon wants you awake during a part of the procedure so that he can test that these functions are indeed intact. The patient is asked to speak, talk aloud or move the opposite arm or leg). This assures the surgeon that he is not near these vital areas of the brain and once he maps them out he can avoid them.

At times we do what is called cortical mapping. With the help of an electric probe, the surgeon touches parts of the brain near the region of interest (in this case a brain tumor), if when the probe is touched the patient has a language arrest or his hand or leg move, we know these are vitals parts of the brain. In this way we are able to map all the parts of the brain hence the name cortical mapping.

Awake craniotomy requires special type of anaesthesia and preparation. At times what is done is that the anaesthesia is turned off after the surgeon has cut open the skull and then the patient is woken up. Once the mapping has been carried out, the anaesthesia is restarted and the patient falls back asleep and then the surgeon continues with the surgery. Awake craniotomy is also carried out during deep brain stimulation (DBS) surgery for Parkinson’s disease.

I shall discuss DBS in a separate post.

 

Personal Regards,

Nitin Sethi, MD

 

 

Bells Palsy: what to expect

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Let us talk a little about Bells palsy a relatively common neurological condition affecting the function of the seventh cranial nerve (that is the facial nerve).  The muscles of the face are suplied by the facial nerve. It is this nerve which helps you to smile, frown, wrinkle up your forehead, purse your lips and all other facial expressions. The facial nerve is also the nerve which supplies taste sensation to the anterior part of the tongue. It suppiles a muscle called stapedius in the middle ear which helps in damping loud sounds and also supplies the lacrimal gland (helps in tear function).

In Bells palsy patients develop weakness of all the muscles of one half of the face (they cannot close their eye on that side, have a crooked smile as the face gets pulled to the normal healthy side when they attempt to smile, cannot puff their cheeks or purse their lips to whistle). Depending upon the site of involvement of facial nerve, they may also be unable to tear (complaint of dry eye), unable to taste food or complain of excessive loud sounds in the ear on the side of the facial nerve palsy.

In Bells palsy there is inflammation of the facial nerve somewhere along its course from the brainstem to the muscles of the face. In Bells palsy, this inflammation is idiopathic (no definite cause for inflammation is found) though inflammation by the herpes group of viruses has been implicated in its etiology. Some patients have developed Bells palsy after been exposed to cold air (this has never been proved though). Bells palsy is not life threatening but can be quite socially disabling especially if severe (you can imagine how socially disruptive it might be to have one half of your face paralysed and be unable to smile or emote with your face).

Diagnosis and management of Bells palsy: the diagnosis of Bells palsy is clinical (can be made by a clinical examination by a neurologist). In the typical case no further investigations are warranted, though in some cases if the history is atypical (slow onset with addition neurological findings) your doctor may order an MRI study of the brain. 

Most of the patients recover spontaneously from Bells palsy. All that we advise them is to cover the eye at night with an eye patch and wear sunglasses when they go out during the day (this is to protect the eye from keratitis as the eye does not shut). If you present acutely to your doctor with Bells palsy, he may recommend a course of steroids and acyclovir (antiviral drug with efficacy against herpes virus). It is thought that this hastens recovery though some studies have shown that the recovery is the same whether or not acyclovir is used or not).

Your doctor shall also recommend facial exercises (just as you undergo physical therapy if you have a stroke, in the same way we want to encourage facial exercises to hasten recovery). Facial exercises are easy to do and I usually recommend my patients to stand in front of the mirror and attempt to smile, frown, pout and whistle. I ask them to do this for at least 10 mins two times a day. Massaging the face has not been shown to be beneficial. In case the recovery is slow or incomplete your doctor might order a nerve conduction study of the facial nerve to assess the degree of damage to the nerve.

As I stated earlier most patients have a good recovery. At times when the facial nerve regenerates, it regenerates in an arbitary fashion. Patients develop crocodile tears (they start tearing when attempting to eat) or have synkinesis (all the muscles of the face contract at once when attempting to smile that is the fine control of individual facial muscles is lost). If you have these problems you should contact your doctor and ask for advise.

I hope this short post on Bells palsy shall be helpful to some of you.

Personal Regards,

Nitin Sethi, MD