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MS Stands for Mimicking Stroke 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 J Neurol Neuro Toxicol 1 Volume 1(1): 2017 Khaldi MA (2017) MS Stands for Mimicking Stroke sensory impairment. Her swallowing was impaired but her speech, cognition and memory were not affected. Modied 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 J Neurol Neuro Toxicol 2 Volume 1(1): 2017 Khaldi MA (2017) MS Stands for Mimicking Stroke 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.
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