Your Questions Answered

Neurology Now
May/June 2006
Volume 2(3)
p 34–35
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Q I just learned I've had a couple of mini-strokes. Is there anything specific I should be doing about this?

DR. SEEMANT CHATURVEDI ADVISES:

A If you've had a couple of mini-strokes, you should try to see a neurologist to find out the cause.

This will direct treatment to prevent a stroke in the future.

One of the most common causes for a mini-stroke — also known as a transient ischemic attack (TIA) — is a blockage of the blood vessels leading up to the brain. TIAs are also frequently the result of a blood clot traveling to the brain from somewhere else in the body, such as the heart.

If the mini-strokes result from a severe blockage of the carotid artery, you might be a good candidate for a surgery to clear out that blood vessel.

But if the cause is a blood clot that has traveled up from the heart, you may need a strong blood-thinning medication, such as warfarin (Coumadin).

In general, patients who suffer mini-strokes need to go on a blood thinner. This could be aspirin, clopidogrel (Plavix), or a drug that combines aspirin and dipyridamole (Aggrenox).

You also must pay attention to risk factors such as hypertension, high cholesterol and smoking. High cholesterol and hypertension need to be controlled. And if you are a smoker, you will need to quit.

Finally, you should educate yourself about the warning signs for a stroke. Once you've had a TIA, you have a one-in-three chance of having a stroke in the next five years. Therefore it's important to recognize stroke symptoms so you can get medical attention as soon as possible because you might be a candidate for a clot-busting drug, such as tissue plasminogen activator (TPA).

One other thing to keep in mind: You may also be at risk for future heart problems. So it would be a good idea to have tests done to evaluate your chances of having a heart attack.

Q Since being diagnosed with MS last year, I'm doing well other than occasional tiredness. Is it normal to have days when my legs feel like they weigh 100 pounds?

Figure. Seemant Chaturvedi, M.D., is director of the Stroke Program at Wayne State University and Detroit Medical Center as well as lead author of the American Academy of Neurology's new stroke-surgery guidelines.

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DR. CLYDE MARKOWITZ ADVISES:

A When it comes to fatigue and multiple sclerosis, it's not uncommon for patients to have good days and bad days.

On a bad day, you might feel sleepy or completely wiped out. And that feeling can last anywhere from a couple of hours to the whole day.

It's also not uncommon to feel like your legs don't work or to have the sensation that they weigh 100 pounds.

And that's particularly true in the case of patients who have a spinal cord lesion. The lesion is a site at which the myelin — the material coating nerve cells that acts like the insulation on an electric wire — is damaged. When myelin is damaged, the electrical signals carrying information down the nerve cell can be slowed, distorted or even stopped.

If the nerves connecting the spinal cord to the legs are affected, that could lead to the symptoms you describe.

The sensation of heaviness can last minutes, to hours, to days. Sometimes rest helps. Sometimes it doesn't. Certain things seem to make this symptom worse. For example, heat from a shower or a hot tub — or simply a hot day. Stress can also have an impact.

There are drugs to help with the fatigue. But those drugs don't seem to have much impact on the sensation of heaviness in the legs.

For this, we mostly recommend physical therapy. You can do exercises to improve endurance. If you're fatigued when you walk, improving the strength and endurance of your legs will allow you to go longer distances without that sensation of heaviness.

Q My 7-year-old daughter has petit mal seizures. What are the chances she'll grow out of them?

Figure. Clyde Markowitz, M.D., is director of the Multiple Sclerosis Center at the University of Pennsylvania in Philadelphia.

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DR. robert fisheR ADVISES:

A There's a 50 percent to 75 percent chance that a child with absence seizures — also known as petit mal seizures — will grow out of them.

In this type of seizure, children experience brief staring spells and occasionally a fluttering of the eyelids or a nodding of the head. Your doctor can diagnose these seizures with an electroencephalogram — a test that monitors electrical activity in the brain through sensors placed on your child's scalp.

While an absence seizure can last as long as many minutes, in most cases the duration is between 5 seconds and 30 seconds. The longer the seizure lasts, the more symptomatic the person is.

The biggest factor affecting whether your daughter will grow out of her epilepsy is whether she experiences only absence seizures or has other types of seizures as well. If there are only absence seizures, a condition called childhood absence epilepsy, then the prognosis is very good: two out of three children will outgrow it.

If your child has absence seizures along with grand mal seizures, in which there is a complete loss of consciousness and jerking of the whole body, then the odds aren't as good. Children grow out of this condition, juvenile absence epilepsy, about 40 percent to 50 percent of the time. A third type, juvenile myoclonic epilepsy, is typified by several kinds of seizures and usually is permanent, though generally treatable with medications.

Even if your daughter experiences only absence seizures, it's important to get them treated. That's because a child can have hundreds of these seizures a day and could be missing a lot of information in school. And this can lead to bad grades.

The good news is that most childhood absence epilepsy can be controlled with medication.

Q Myasthenia gravis limits me to about 20 minutes on my feet at a time. Is my morning walk enough exercise for me to stay healthy?

Figure. Robert Fisher, M.D., Ph.D., is director of the Stanford University Epilepsy Center and former president of the American Epilepsy Society.

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DR. GARY GRONSETH ADVISES:

A In general, a brisk walk of 20 to 30 minutes each day would be good enough to stay healthy. But this can be difficult since patients with myasthenia gravis tend to become fatigued easily. That's just the nature of the disease. It affects the ability of the nerves to communicate with the muscles. And exercise tends to make this worse, which leads to feelings of weakness.

The cause of these problems is a faulty immune system, which sends antibodies to attack the part of the muscle that receives signals from the nerves. The nerves normally send signals to the muscles with a chemical messenger called acetylcholine, which is designed to dock at a site on the muscle, known as a receptor. But when people have myasthenia gravis, antibodies attach to the receptor, blocking the acetylcholine molecules from docking.

Nobody knows why some people's immune systems go awry and start making antibodies to attack receptors on the muscles.

And while exercise is good for overall health, many people with myasthenia gravis have an exacerbation of symptoms when they work out. When this happens, rest — sometimes even bed rest — can be the best solution.

But you don't want to stop working out. That's because the fatigue is transient. There is no permanent damage from exercise. The key is to develop exercise tolerance. If you're having problems sticking with a moderate exercise program, then you might need to talk to your doctor about more-aggressive therapy for your myasthenia gravis.

There are several types of medications available to treat the condition, including ones that increase the amount of acetylcholine in your body and others that quiet the immune system.

Most patients with myasthenia gravis — about 85 percent — improve enough to resume a normal life that would include walking for exercise.

Figure. Gary Gronseth, M.D., is vice chairman of neurology at the University of Kansas Medical Center.

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