S Journal of

O p s e s n Acce Neurology and Neuro Toxicology

Case Report MS Stands for Mimicking Stroke Mishaal Al khaldi, Farah Al Eisa, Abdulnasser Aboud, Eman Nasim, Khaled Darawil King Fahad Specialist Hospital, Dammam, Eastern Province, Saudi Arabia

Abstract Stroke, Multiple sclerosis and vasculitis may share the same symptoms and sometimes also the radiological findings. The similarity between these conditions make it difficult to diagnose and it is even more complicated when these conditions coexist and the patient presents with an acute attack. It becomes challenging for physicians to decide which of these diagnoses is behind the flared up symptoms. All the above diseases can cause broad symptoms which may lead to disability, and making an early diagnosis will limit the burden of the disease and improve the patient’s quality of life; we illustrated this in our case report. We are presenting a case of a young lady with a Sudden-onset pseudo stroke form of Multiple Sclerosis resulting in a left side hemiplegia; this patient with the bizarre presentation had extensive investigations before a diagnosis was confirmed. After the right diagnosis was reached, patient was put on an early intensive program rehabilitation using new assistive technology, and within two months time our patient improved magnificently from being totally dependent in bed mobility to be able to walk without assistance.

Introduction patient’s functional status upon discharge after four weeks of admission. Multiple Sclerosis (M.S) is the most common inflammatory demyelinating disease of the central nervous system (1); it is Case Scenario known to cause scarring in multifocal areas. A cross sectional A 20 year old female came to the Emergency unit complaining study conducted in Saudi Arabia in 2016 stated that the largest of three days left side weakness associated with a difficulty in prevalence of M.S in Saudi Arabia found to be in the Eastern swallowing. The weakness started with paresthesia on the left Province (34.4%) (2). thigh then it involved the entire left side including the face. M.S usually has certain clinical features, but it may come The muscle weakness of the left side reached maximum the with many atypical forms which might be a reason for M.S day she came the emergency when she was not able to move diagnosis challenge (1). However, with the development of the left upper and lower extremities. technology many diagnosing equipment have been used to confirm the clinical examinations like Magnetic Resonance The patient had no past medical history of note. However, the Imaging (MRI) or brain CT scan (1). patient described a bilateral blurred vision one month prior to her admission. This was associated with pain during eye Once a diagnosis is made, an early rehabilitation along with movements for a course of a week then it was resolved without medications should be offered. Physical therapy is a main taking any prescribed medications. Her mother had a positive element in the M.S rehabilitation program; it is vital in history of Scleroderma. managing gait problems, and in deciding the best assistive devices to assist the movement and ankle foot orthosis (AFO) On clinical examination, there is evidence of nystagmus, (1). left side face drop, flaccidity, hyper-reflexia , un-sustained clonus, positive left Babinski sign, impaired left sensation, Usually the gait disturbance happens due to fatigue, spasticity Coordination and balance assessment could not be done as the and weakness which might happen as a result of lesions in the muscle power on the left side was grossly graded as 1/5 with descending motor tracts of the brain and spinal cord, and the disturbed balance can be caused by lesions in the cerebellar pathways (1). Correspondence to: Mishaal Al khaldi, Senior Physical therapist, King In this case report, a description of a rare M.S presentation will Fahad Specialist Hospital, Dammam, Eastern Province, Saudi Arabia, Tel: 00966555404862; E-mail: Mishaal[DOT]Alkhaldi1[AT]hotmail[DOT]co[DOT]uk be discussed, used methods for diagnosis, the rehabilitation program applied for this patient and the progress made in the Received: Sep 12, 2017; Accepted: Sep 15, 2017; Published: Sep 18, 2017

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sensory impairment. Her swallowing was impaired but her speech, cognition and memory were not affected. Modi ed Ashowrth scale Investigations 4

Based on the history and clinical assessment patient was likely 3 to have one of the following diagnoses i.e. vasculitis, Behçet’s disease, multiple sclerosis, cardio embolic stroke. 2 Upon the patient’s arrival to the Emergency Unit, she had 1 a Brain CT Scan, which showed Brain hypodensed areas Flaccid Normal Normal bringing up a possibility for a stroke. Blood investigations 0 showed negative vasculitis screen, negative Hyper coagulant On admission In 2 weeks in 4 weeks In 8 weeks state screen, negative specific typing for Behçet’s disease, her Echocardiography ruled out cardiac source for thrombosis. Graph 2: Muscle Tone score during rehabilitation. The patient declined Lumbar puncture. other hand, one of the main problems was static and dynamic Magnetic resonance imagining (MRI) showed multiple standing balance with (BBS) of 35/56. (Graph 1) demyelinating lesions on both hemispheres with Dowson’s As the patient was making a quick and good progress, spasticity finger; also non enhancing lesions were found on the cervical increased mainly in Gastrocnemius, clonus has appeared with and thoracic spine. (Figure: 1, 2, 3, 4) weight bearing status, this interfered with the normal pattern Management of gait and gait training on the robotic treadmill. Clostiridium Rehabilitation intervention started on the second day of Botulinum type A neurotoxin complex injection was given admission with physical and occupational therapy; the muscle to manage the spasticity and relieve clonus, together with strength on the left side of the upper and lower extremity was Posterior Leaf Spring (PLS) to assess dorsiflexion. graded as 1/5 except for ankle dorisflexors, hand grip and wrist The injected muscles were: Posterior Tiblias, Soleus, extensors which were graded as 0/5. Gastrocnemius, Brachialis, Brachoradilias, Pronator Teres, Using Barthel index her Functional independence score was flexor carpi radialis, flexor pollicis brevis, flexor pollicis 45/100, and Berg balance scale (BBS) was not implemented longus, and Flexor digitorum superficialis. These muscles had as the patient was immobile. a Modified Ashowrth Scale of 2 to 3 pre-injection, grade 1 after injection. She was started on pulse steroid therapy along with rehabilitation. Within 5 days her paresthesia disappeared, and Functionally, our patient was made able to walk with no foot there was a mild improvement in muscle power in the lower eversion and clonus did not affect her gait anymore. (Graph 2) limb which graded as 2/5 except for hip flexors 3/5. However, no A more intensive rehabilitation plan was given to this patient improvement in the upper limb muscle strength was observed once she started to stand with assistance including one session at that stage. For that reason Plasmapharesis was prescribed of occupational therapy and two sessions of physical therapy and the patient was put on an intensive rehabilitation program. on a daily basis; Subsequently, the muscle strength of the lower limb started to The occupational therapy program included fine motor improve significantly reaching the followings; left Hip flexors relearning, upper extremity strengthening exercises, functional 4/5, knee flexors and extensors 3/5 while ankle dorsiflexors independence training and exercises on robotic hand assistive remained weak 2/5. The patient started to ambulate with device. The physical therapy program included one session of assistance of one person and showed more independence in balance and strengthening exercises, electrical stimulation for functions with Barthel index score going up to 90/100. On the the left wrist and finger extensors. The other session included one hour and 30 minutes of gait and balance training on robotic treadmill. Berg Balance Scale After spending a one month on our intensive rehabilitation 50 program, the patient’s balance improved and reached 49/56 on (BBS), and her muscle power for the left side further improved 40 reaching 4+/5 in all muscle groups except for Gluteus Medius 30 which was graded as 4-/5 causing waddling gait when the

20 patient had fatigue this was managed with home strengthening exercises program.( Graph 3) 10 N/A Our patient was discharged home walking independently 0 On admission In 2 weeks in 4 weeks In 8 weeks with no assistive devices. We needed to focus on her fine movements, and she was followed up therefore twice a week; Graph 1: BBS score before and after rehabilitation. one session for physical therapy and one for occupational

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Muscle power Left Muscle Power Left arm leg 5 5 4 4 3 3 2 2 1 1 0 0 On In 2 in 4 In 8 On In 2 in 4 weeks In 8 admission weeks weeks weeks admission weeks weeks

Graph 3: Muscle power for the left side (upper and lower). therapy for a month. Following this she was re-assessed by the specialist rehabilitation therapist and she showed further improvement in muscle power of 4+/5 on the left side, with a residual light fine movement impairment which interfered with needing both hands to perform a task i.e. opening door while carrying books on the hand. Later, our patient was seen after two months post discharge; her muscle strength for the weak Gluteus Medias reached 4+ /5, she showed a very good balance as evidence by achieving a full BBS, and she was found to have a normal gait pattern. She continued to improve and when she was seen at her four months follow up appointment, she had normal muscle power, she was functionally independent and had no residual manifestations were noticed. Subjectively, she stated that she was pleased with making such an excellent recovery, that she has become Figure 1: Non-enhancing lesions in the spine. totally independent, and got rid of her impairments without having any negative impact on her social life or her studies. She was discharged as she had reached her maximal benefits and she was provided with a list of home exercises and further patient education materials. Discussion The diagnosis of M.S has been reported to be difficult to diagnose due to variability of the MRI findings and wide range of clinical symptoms. (3)However, new diagnostic criteria suggested that M.S can be diagnosed at the occurrence of first attack if the imaging at baseline scan shows evidence of

“dissemination in time and space”. (3) Dissemination in time can be confirmed by the presence of a recent T2 or gadolinium-enhancing lesion along with clinically silent enhancing or non-enhancing lesions on follow-up MRI highly recommended to use the McDonald criteria for M.S (2010). (4) Dissemination in space is proved if the MRI shows at least one T2-hyperintense lesion in more than 2 of the 4 Central Figure 2: MRI used as a baseline for the patient. Nervous System areas (CNS): juxtacortical, infratentorial, periventricular or Spinal cord. (2) The clinical diagnosis also can be a challenging in MS. Based on However, one of the MRI limitations to diagnose M.S is our patient’s symptoms acuity and hemiplegic presentation, a stroke the discordance happening between lesion location and the was the first possibility albeit her young age. CT scan is usually clinical presentation which was seen in our patient, in addition, nonspecific, but it needs to be done to rule out certain causes of the sensitivity and specificity can vary significantly depending neurologic diseases (6). Patient’s family history has positive on the number and sites of the lesions.(5) Scleroderma which increased the possibility for vasculitis (7).

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solely muscle strengthening, maintain the available range of motion (ROM), gait training, improve balance, and regain normal functions. In addition, OT focused on improving the independence using Barthel index, movement facilitation, sensory integration and enhancing fine movement. Assistive technology was a crucial part of the rehabilitation program as using devices have been proven to improve functions in many different diagnoses i.e. Robotic assisted step training (13,14) and a gravity-supporting exoskeleton apparatus upper limb assistive device. Robotic assisted step training has been showing great results with speed and endurance for M.S patient who have gait impairments; in addition to the improvement of balance.( 13,14).This was also observed in our patient i.e. balance was assessed using (BBS) before and after the Robotic assisted step training intervention. Her balance soared from 35 to full score on BBS after using Figure 3: CT scan shows hypodensed lesions. the Robotic assisted step training in line with the traditional balance exercises. Furthermore, subjectively our patient felt she is more stable with walking compared to before using Robotic assisted step training. Another used rehabilitation equipment was upper limb assistive device, which has been a very effective intervention for improving upper limb function even with M.S patients who have sever disability (15). On discharge our patient was totally independent in her activities of daily livings (ADLs) and walking using no assistive devices. Conclusion We have shed some light on some of the rare presentations of MS which did not have any significant manifestations till the

patient had a Stroke mimicking attack which lasted three days before the patient decided to come to the Emergency unit. Diagnosing such atypical form of MS can be challenging, and MRI might help with following MacDonald criteria 2010. Good response to Pulse therapy and Plasmapharesis is supporting for the M.S diagnosis. Figure 4: Dawson’s finger is shown in the MRI. There was an impressive full recovery in our patient after The significant improvement happened with Pulse therapy and receiving Plasmapheresis and intensive rehabilitation, and Plasmapharesis was a supporting evidence of the M.S diagnosis we feel more research in this area is required to identify as the Pulse therapy has been used to treat acute M.S attack which patients phenotypes, which treatment protocols for with good results (8). In our case, it helped to decrease the traditional as well as robotic assistive technology should we be paresthesia and to improve the patient’s lower limb movement implementing and at what level of intensity, and at what stage along with the physical therapy, while no improvement was of the MS patients acute presentation they should be targeted noticed in the upper limb. to maximize their recovery and minimize future handicap The patient then was opted to have a course of 5 cycles of from such disabling disease in the young patients. plasmapharesis which contributed to a significant improvement References in the patient’s case. Both of plasmapahresis and Pulse therapy 1. Diagnosis of multiple sclerosis in adults (2017) Uptodatecom. have been proven to be effective for M.S (9, 10, 11). [View Article] Intensive rehabilitation shortly post to an M.S attack has been 2. Alshanqiti M, Alotaibi F, Alahmed J, Alrehaili M, Alalwi S, et al. showing a great impact on M.S patients’ lives in the literature (2016) Prevalence Of Multiple Sclerosis In Saudi Arabia. Int J of (12).Our rehabilitation intervention included many disciplines Adv Res 4: 1581-1600. [View Article] i.e. Occupational and Physical therapy, Physiatry, social work, 3. Polman C, Reingold S, Banwell B (2011) Diagnostic criteria for and neuropsychology. multiple sclerosis: 2010 Revisions to the McDonald criteria. Ann Neurol 69: 292-302. [View Article] The physiatrist’s role was to prevent spasticity with medications and injection while physical therapy intervention goals were 4. Sadaka Y, Verhey L, Shroff M (2010) McDonald criteria for

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diagnosing pediatric multiple sclerosis. Ann Neurol 72: 211-223. 10. Keegan M, Konig F, McClelland R (2005) Relation between [View Article] humoral pathological changes in multiple sclerosis and response to therapeutic plasma exchange. Lancet 366: 579-582. [View Article] 5. Amy T Waldman (2017) Acute disseminated encephalomyelitis in adults. Uptodatecom. [View Article] 11. Rietberg MB (2017) Exercise therapy for multiple sclerosis. Cochrane Database Syst Rev 25. [View Article] 6. Pelidou SH (2007) Multiple sclerosis associated with systemic sclerosis. Rheumatol Int 27: 771-773. [View Article] 12. Beer S, Aschbacher B, Manoglou D, Gamper E, Kool J, et al. (2007) Robot-assisted gait training in multiple sclerosis: a pilot 7. Waldman A, Gorman M, Rensel M, Austin T, Hertz D, et al. (2011) randomized trial. Mult Scler 14: 231-236. [View Article] Management of Pediatric Central Nervous System Demyelinating Disorders: Consensus of United States Neurologists. J Child 13. Freeman J, Gear M, Pauli A (2010) The effect of core stability Neurol 26: 675-682. [View Article] training on balance and mobility in ambulant individuals with multiple sclerosis: A multi-centre series of single case studies. 8. Michael J Olek (2016) Treatment of acute exacerbations of Mult Scler 16: 1377-1384. [View Article] multiple sclerosis in adults. Uptodatecom. [View Article] 14. Gijbels D, Lamers I, Kerkhofs L, Alders G, Knippenberg E, et 9. Weinshenker B, O’Brien P, Petterson T (1999) A randomized trial al. (2011) The Armeo Spring as training tool to improve upper of plasma exchange in acute central nervous system inflammatory limb functionality in multiple sclerosis: a pilot study. J Neuroeng demyelinating disease. Ann Neurol 46: 878-886. [View Article] Rehabil 8: 5. [View Article]

Citation: Khaldi MA, Eisa FA, Aboud A, Nasim E, Darawil K (2017) MS Stands for Mimicking Stroke. J Neurol Neuro Toxicol 1: 001-005. Copyright: © 2017 Mishaal Al khaldi et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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