Bulbar-onset amyotrophic lateral sclerosis in a patient with Chiari I malformation

Amyotrophic Lateral Sclerosis Mimic Syndrome in a 24-Year-Old Man with Chiari 1 Malformation and Syringomyelia: A Clinical Case

Chiari 1 Malformation (CM1) is classically defined as a caudal displacement of the cerebellar tonsils through the foramen magnum into the spinal cord. Modern imaging techniques and experimental studies disclose a different etiology for the development of CM1, but the main etiology factor is a structural defect in the skull as a deformity or partial reduction, which push down the lower part of the brain and cause the cerebellum to compress into the spinal canal. CM1 is classified as a rare disease. CM1 can present with a wide variety of symptoms, also non-specific, with consequent controversies on diagnosis and surgical decision-making, particularly in asymptomatic or minimally symptomatic. Other disorders, such as syringomyelia (Syr), hydrocephalus, and craniocervical instability can be associated at the time of the diagnosis or appear secondarily. Therefore, CM1-related Syr is defined as a single or multiple fluid-filled cavities within the spinal cord and/or the bulb. A rare CM1-related disorder is syndrome of lateral amyotrophic sclerosis (ALS mimic syndrome). We present a unique clinical case of ALS mimic syndrome in a young man with CM1 and a huge singular syringomyelic cyst with a length from segment C2 to Th12. At the same time, the clinical picture showed upper hypotonic-atrophic paraparesis in the absence of motor disorders in the lower extremities. Interestingly, this patient did not have a disorder of superficial and deep types of sensitivity. This made it difficult to diagnose CM1. For a long time, the patient's symptoms were regarded as a manifestation of ALS, as an independent neurological disease, and not as a related disorder of CM1. Surgical treatment for CM1 was not effective, but it allowed to stabilize the course of CM1-related ALS mimic syndrome over the next two years.

Diagnostic accuracy and clinical utility of non-English versions of Edinburgh Post-Natal Depression Scale for screening post-natal depression in India: A meta-analysis

BACKGROUND

The prevalence of post-natal depression (PND) is high in India, as it is in many other low to middle income countries. There is an urgent need to identify PND and treat the mother as early as possible. Among the many paper and pencil tests available to identify PND, the Edinburgh Postnatal Depression Scale (EPDS) is a widely used and validated measure in India. However, the summary diagnostic accuracy and clinical utility data are not available for this measure.

AIM

To establish summary data for the global diagnostic accuracy parameter as well as the clinical utility of the non-English versions of the EPDS in India.

METHODS

Two researchers independently searched the PubMed, EMBASE, MEDKNOW and IndMED databases for published papers, governmental publications, conference proceedings and grey literature from 2000-2018. Seven studies that evaluated the diagnostic accuracy of EPDS in five Indian languages against DSM/ICD were included in the final analysis. Two other investigators extracted the Participants’ details, Index measures, Comparative reference measures, and Outcomes of diagnostic accuracy data, and appraised the study quality using QUADS-2. Deek’s plots were used to evaluate publication bias. We used the area under the curve of the hierarchical summary area under the receiver operating characteristic curve, with the random effect model, to summarize the global diagnostic accuracy of EPDS. Using the 2 × 2 table, we calculated positive and negative likelihood ratios. From the likelihood ratios, the Fagan’s nomogram was built for evaluating clinical utility using the Bayesian approach. We calculated the 95% confidence interval (95%CI) whenever indicated. STATA (version 15) with MIDAS and METANDI modules were used.

RESULTS

There was no publication bias. The area under the curve for EPDS was 0.97 (95%CI: 0.95-0.98). The pre-test probability for the nomogram was 22%. For a positive likelihood ratio of 9, the positive post-test probability was 72% (95%CI: 68%, 76%) and for a negative LR of 0.08, the negative post-test probability was 2% (95%CI: 1%, 3%).

CONCLUSION

In this meta-analysis, we established the summary global diagnostic parameter and clinical utility of the non-English versions of the EPDS in India. This work demonstrates that these non-English versions are accurate in their diagnosis of PND and can help clinicians in their diagnostic reasoning.

A case report of amyotrophic lateral sclerosis in a patient with Klippel-Feil syndrome—a familial occurrence: a potential role of TGF-β signaling pathway

The rationale for this article is a description of a unique, familial case of a patient with amyotrophic lateral sclerosis (ALS), a progressive neurodegenerative disorder of unknown etiology coexisting with Klippel-Feil syndrome (KFS), a congenital malformation of cervical vertebrae, characterized by a fusion of minimum 2 cervical vertebrae. We report a 68-year-old man with moderate dysarthria, fasciculations, short neck, hearing deficit, and low posterior hairline. Definite ALS was diagnosed based on neurological abnormalities and electromyography results. Magnetic resonance imaging and computed tomography showed bony abnormalities of the craniocervical junction, fusion of 2 cervical vertebrae, and syringomyelia at the level of C6-C7. KFS phenotype was noted in 2 more family members, and patient's stepsister with KFS phenotype died due to ALS. The pedigree of our family suggests an autosomal-dominant inheritance of both syndromes. Cosegregation of ALS and KFS with an autosomal-dominant trait suggests an impairment of transforming growth factor β signaling pathway, and its potential role is discussed. Further evaluation of patients with autosomal-dominant and sporadic KFS by genetic testing, biochemical measurements, such as plasma transforming growth factor β1, and systematic follow-up electromyography seems warranted.

Imaging diagnosis of upper motor neuron compromising in a patient with Chiari 1 malformation

We report a case of a typical MRI from a patient with bulbar-onset sporadic amyotrophic lateral sclerosis associated with Chiari type 1 malformation. Our report reinforces the conventional neuroimaging appearance associated with each condition and the associated abnormalities on a clinical and advanced imaging techniques basis. The MRI signal intensity was useful for detecting upper motor neuron degeneration based on corticospinal tract signal intensity, while diffusion tensor imaging parameters were limited to this purpose. Our description reinforces the relevance of the T1 magnetisation transfer sequence to demonstrate corticospinal tract degeneration and corroborate an amyotrophic lateral sclerosis diagnosis in an individual participant, when there is a potential concurrent 'amyotrophic lateral sclerosis mimic syndrome'. To our knowledge, this is the first description of the non-conventional MR techniques applicability to distinguish the impact of amyotrophic lateral sclerosis from Chiari 1 malformation.

Amyotrophic lateral sclerosis (ALS) and mirror movements in a patient with polymicrogyria

We report on a case of polymicrogyria with benign childhood epilepsy and amyotrophic lateral sclerosis (ALS). While performing dexterity tasks with either hand, strong unsustained mirror movements of the unintended hand were observed. The patient was seen over a period of three years and, as often seen in ALS, there was a moderate progress of the motor neuron disease affecting the upper and lower motor neuron in an asymmetrical manner. In addition, more rapidly progressive bulbar symptoms could be observed by the clinical and neurophysiological examination. MRI revealed polymicrogyria of the right frontal lobe with irregular bumpy inner and outer surface and abnormally thick and smooth cortex, dysplastic insular cortex and asymmetrically widened Sylvial fissure. No signs of atrophy, especially of the motorcortex and corticospinal tract were observed. The corpus callosum was completely developed and of normal size. We hypothesize an enrolment of the dysplastic right frontal lobe pathophysiology of the observed mirror movements.

Amyotrophic lateral sclerosis and primary lateral sclerosis: evidence-based diagnostic evaluation of the upper motor neuron

Magnetic resonance imaging and MR spectroscopy are important tools in the diagnostic evaluation of patients with suspected motor neuron disease. Further investigation is needed to determine and to compare the utility of various neuroimaging markers for diagnosis and disease progression [112]. Newer MR tools, such as diffusion tensor imaging, magnetization transfer imaging, and functional MR imaging, have substantial promise as scientific and clinical tools in this ongoing endeavor.