Event-related potentials (P300) in primary headache in childhood and adolescence

There is strong evidence for a loss of habituation during cognitive processing in migraine as measured by P300 and contingent negative variation in adults. Event-related potentials evoked by an oddball paradigm have not yet been studied in children and adolescents suffering from different primary headache types. We recorded visually evoked event-related potentials (two consecutive trials, 200 stimuli each) in 48 children and adolescents suffering from migraine without or with aura, from episodic tension-type headache, and from ergotamine-induced headache and analyzed the latencies, amplitudes, and reaction times. No statistically significant differences were noted between all headache types and healthy controls analyzing the averaged parameters for the whole measurement. However, a highly significant loss of cortical habituation as measured by P300 amplitude and latency could be observed in migraine without and with aura by analyzing the first and the second trial of measurement separately. This phenomenon increased with age and could not be seen in healthy controls, or patients with tension-type headache or ergotamine-induced headache. Our data suggest a specific cognitive processing in migraine even in children and adolescents. Measurement of the habituation effect in P300 latency and amplitude provides a specific method to differentiate between primary headache types in childhood and adolescence.     

Monoclonal gammopathy (IgA: lambda) after autologous T-cell-depleted bone marrow transplantation in a patient with non-Hodgkin''s lymphoma

We present an unusual case of sphenoid sinus mucocele with severe intracranial extension, which was diagnosed and treated at the AHEPA General Hospital, University of Thessaloniki, Greece. The patient was a 54-year-old female who presented with endocrine, nasal and ophthalmological symptoms, and headache. She was successfully treated by surgery using an intranasal approach. While presenting this case, we briefly review the literature on the subject of sphenoid sinus mucoceles.     

Coexistence of migraine and idiopathic intracranial hypertension without papilledema

Eighty-five patients with refractory transformed migraine type of chronic daily headache (CDH) had spinal tap as a part of diagnostic work-up. Twelve had increased intracranial pressure without papilledema, transient visual obscurations, or visual field defects. The headache profile of these 12 patients was not different from that of transformed migraine type of CDH. Acute headache exacerbations responded to specific antimigraine agents such as ergotamine, dihydroergotamine (DHE), and sumatriptan, whereas prophylactic antimigraine medications were only partially helpful. Addition of agents such as acetazolamide and furosemide, after the diagnosis of increased intracranial pressure, resulted in better control of symptoms. These observations suggest a link between migraine and idiopathic intracranial hypertension that needs further research. In refractory CDH with migrainous features, a spinal tap to exclude coexistent idiopathic intracranial hypertension without papilledema may be indicated.     

Alteration of central excitation circuits in chronic headache and analgesic misuse

Central excitatory circuits could be involved in the pathophysiology of pain; particularly, the genesis of chronic pain. The "second pain" is the sensation that follows the initial pain after an appropriate nociceptive stimulus. The second pain is amplified by repeating the stimulus after brief intervals (temporal summation). This phenomenon is the psychophysical correlate of the excitatory pain circuits. The temporal summation of the second pain was evaluated in four groups of subjects; one group affected by migraine without aura, one by episodic tension headache, one by chronic daily headache, and a group of healthy subjects. A percutaneous electrical shock was used as the nociceptive stimulus. The intensity of the second pain was significantly greater in the group of patients with chronic headache in comparison with the other groups. The patients with chronic headache were subdivided into three groups on the basis of their clinical history: a group with transformed migraine; a group with chronic headache ab initio, a form related to the first one; (both groups suffered from chronic daily headache with a frequent superimposition of episodes of migraine attacks) and the third group consisted of patients with chronic tension headache. The temporal summation of the second pain was altered in the first two groups. The patients with chronic migraine abused ergotamine given as a symptomatic drug. Those who were able to discontinue this drug were retested and reported a decrease of the second pain in comparison to the previous measurements. The results of the present study indicate that central excitatory circuits could be involved in the mechanism leading to the development of chronic daily headache.     

Migrainelike headache in a patient with a hemorrhagic pituitary macroadenoma

A 23-year-old woman presented with a 4-day history of a severe migrainelike headache with a normal neurological examination. The headache resolved after a ketorolac injection, but recurred a few hours later. An MRI scan of the brain showed a hemorrhagic pituitary macroadenoma for which she underwent transsphenoidal removal of the tumor 1 month later. Although uncommon, pituitary hemorrhage with and without apoplexy should be considered in the differential diagnosis of acute headache. Pituitary hemorrhage can be routinely identified on an MRI scan even without pituitary views. However, the pathology can be overlooked and underimaged on a CT scan for acute headache using 10-mm and even 5-mm slices.     

Delayed postoperative tethering of the cervical spinal cord

Tethering of the spinal cord in the lumbar and sacral regions of children with congenital anomalies is a well-recognized problem; however, tethering in the cervical region has rarely been reported. A search of the literature revealed no reports of symptomatic postoperative cervical spinal cord tethering. The authors present five cases of delayed postoperative cervical spinal cord tethering and discuss the benefit of detethering in these patients. All five patients were young (16 to 42 years of age) at presentation. All had done well after an initial surgical procedure but returned between 1 and 31 years postoperatively with symptoms including severe headache, upper-extremity pain, and progressive neurological deficits. In each case, magnetic resonance imaging indicated dorsal tethering of the cord in the cervical region. Surgical exploration with microscopic sharp detethering of the cervical cord was performed on each patient with favorable results. To avoid retethering, wide Tutoplast duraplasty is recommended.     

Clinical features of daily chronic headache

INTRODUCTION: Although the International Headache Society considers chronic tension headache to be a chronic headache, patients with daily chronic headache may have pain which is not only due to tension but also has migrainous features. OBJECTIVE: To evaluate the clinical differences and abuse of drugs in a group of patients with chronic daily headache who were consecutively evaluated in the Neurology Clinic. MATERIAL AND METHODS: We consider the patients to have daily chronic headache when they have had pain at least 6 days a week for the past 6 months. Using this criterion, we studied 112 patients, of whom 90 (80.4%) were women and 22 (19.6%) men. Results. Sixty nine (61.6%) had transformed migraine and 43 (38.4%) tension headache. There were no differences in their current ages but the age of onset of the headaches varied (p = 0.000,t). Unilateral pain, trigger factors and a family history were more frequent in the cases of transformed migraine. Eighty four patients (75%) abused analgesics. Although we found different pain intensities (p = 0.000, chi 2) there was no difference in the weekly consumption of analgesics (p = 0.64, t) in the mg/week of ergotamine (p = 0.96, t) nor in absence from work between the two types of headache. CONCLUSIONS: In spite of clinical differences between transformed migraine and tension headache, which may help diagnosis, in our series abuse of analgesics (including ergotamine) was a common characteristic.     

A slowly progressed case of brain metastasis and meningeal carcinomatosis from lung cancer]

We reported a case of long survival brain metastasis and meningeal carcinomatosis from lung cancer without radiochemotherapy. A 59-year-old female admitted to our hospital suffered from headache, anorexia and nausea. Papilledema was noticed, and examinations showed a brain tumor in the left parietal lobe and cancer cells in cerebrospinal fluid. Removal of the tumor and ventriculoperitoneal shunt were performed. Pathology showed adenocarcinoma. No neurological deficit was found during the postoperative course and the patient asked for home treatment. She survived for 25 months and spent a useful life in the 15 months after the onset in spite of no radiochemotherapy for meningeal carcinomatosis. In this case, because of the slow progression of the clinical symptoms, it is considered that cancer cells in the cerebrospinal fluid space grow slowly. The first CT and MRI findings of metastatic tumor of this case showed atypical for brain metastasis. Calcifications were found in plain CT and a high intensive tumor in both T1 and T2 weighted images of MRI. Enhancement due to contrast media was very slight in both CT and MRI. We considered that these findings were related to the slow growing of cancer cells.     

Acute headache

Sudden, explosive headache is rather rare. Though dramatic for the patient and the physician, it does not necessarily herald an intracranial catastrophe. Benign and dangerous thunderclap headaches cannot be distinguished from the features of headache itself, but rather on the basis of the situation, the additional symptoms and the findings. This means that every sudden headache should be considered potentially dangerous and be investigated immediately. The dangerous forms comprise intermittent hydrocephalus, acute bacterial meningitis and above all vascular complications. Subarachnoid hemorrhage frequently must be ruled out by computed tomography and lumbar puncture. Intracerebral, especially cerebellar hemorrhage, as well as hypertensive crisis require immediate treatment. Fatal cerebral embolism complicating spontaneous dissection of craniocervical arteries (carotid or vertebral arteries) can be prevented by early anticoagulant therapy. To confirm diagnosis, additional investigations such as CT, lumbar puncture or cerebrovascular ultrasound, and in rare cases MRI, should be performed early as the available time for effective therapy in many situations is short. Many of the benign forms of sudden headache can be diagnosed with a focused interview (cold or drug induced and food dependent headaches, sinusitis, glaucoma). Others, such as neuralgia, cough and coital headache, can be diagnosed as benign only when additional investigations have ruled out symptomatic forms.     

Presentation and management of hydromyelia in children with Chiari type-II malformation

Hydromyelia in patients with myelomeningocele and Chiari-II malformation is a relatively frequent finding on MRI studies. However, not all children develop symptoms from the hydromyelia that requires treatment. Furthermore, treatment of hydromyelia in spina bifida patients is rather complex due to the associated malformations. The authors retrospectively analyzed 231 MRI studies carried out on spina bifida patients who presented neurological deterioration. Hydromyelia was found in 48.5% of the patients. Forty-five children with severe hydromyelia required treatment. These patients were first divided into 2 groups: those with holocord hydromyelia, and those with a segmental lesion. Fifteen patients presented symptoms characteristic of symptomatic Chiari-II malformation: neck rigidity; swallowing difficulty; pain in the upper extremeties; weakness or spasticity in the upper extremeties. Eighteen patients presented symptoms typical of the tethered cord syndrome: scoliosis; worsening bladder and/or bowel function; pain in the lower extremeties; weakness or spasticity in the lower extremeties. Twelve patients presented a mixed-type symptomatology. These patients subsequently underwent posterior cervical decompression, tethered cord release or insertion of a hydromyelia-pleural shunt according to the type of presenting symptoms and to the extent of the hydromyelic lesion. A pattern of successful treatment was identified for each type of presenting clinical and radiological picture. This has allowed the authors to determine an algorithm for optimal treatment of hydromyelia associated with Chiari-II malformation and myelomeningocele, which is proposed here.     

Diffuse cerebral artery vasospasm following total resection of posterior fossa meningioma: a case report]

Diffuse cerebral artery vasospasm following brain tumor resection is a rare complication. The authors reported a case of symptomatic diffuse cerebral artery vasospasm of early phase following resection of a left posterior fossa meningioma. A 50-year-old female patient was admitted to our hospital complaining of headache. No neurological deficits were detected at the time of admission. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a large mass in the left posterior fossa. Cerebral angiography demonstrated mildly diffuse stenosis of the bilateral internal carotid artery. The tumor was resected totally. CT after operation showed a small amount of subarachnoid hematoma in the superior aspect of the cerebellum. Pathological specimen of the tumor showed fibrous meningioma. One day after this radical operation, the patient was found to have weakness in her left leg. Then she developed left hemiparesis, weakness in the right leg and left homonymous hemianopsia. MRI showed ischemic lesions in the bilateral parietal and the occipital lobe. Angiography demonstrated diffuse severe vasospasm throughout the whole cerebral artery. Ten days after the operation, angiographical findings were improved. This case indicates that vasospasm may occur even after resection of brain tumors which are localized outside the suprasellar area.     

Rapid development of the new ambulances. From emergency transports to mobile emergency care

The role of chemotherapy (CHT) in the management of low-grade astrocytoma (LGA) is still unclear. Nineteen children with nonresectable symptomatic LGA were treated with carboplatin (CBDCA) and etoposide (E). There were 15 newly diagnosed cases and 4 were relapses; 6 of the children were under 5 years old. In all children radiological evaluation by CT scan and/or MRI was performed after four courses of CHT. We observed complete response (CR)+ minor response (MR) in 37% of these cases and an improvement in neurological symptoms in 63%. Radiological evaluation performed in 6 patients who received CHT for longer periods (8-12 courses) showed major responses (CR+PR) in 67%. Local radiotherapy (40 Gy) was administered after CHT in 14 cases, but in 3 of these radiotherapy was delayed for 2 years. Five patients did not receive radiotherapy. The overall survival was 58% after an average follow-up of 60 months. All patients with brain stem tumors died of progressive disease even though 3 of these had shown clinical improvement after chemotherapy. In conclusion, in the treatment of nonresectable symptomatic LGA, CHT with CBDCA associated with E can be used to postpone radiotherapy in young children and even to avoid radiotherapy in some cases.     

Medullary infarction due to vertebral dissecting aneurysm in a patient with Beh?et's disease]

A 65-year-old man with Beh?et's disease was admitted to our hospital because of an acute left occipital headache and truncal ataxia. He had been treated with prednisolone since the age of 40. MRI showed a hyperintense lesion on T2-weighted images on the left of the medulla oblongata. Left vertebral angiogram showed findings consistent with a dissection at the V4 segment of the artery. After admission, the patient showed marked improvement and was discharged 1 month later without neurological deficits. This is a very rare case of medullary infarction due to vertebral dissecting aneurysm in a patient with Beh?et's disease.     

A case of rheumatoid factor-positive pachymeningitis

We report a case of rheumatoid pachymeningitis involving the posterior fossa. A 71-year-old woman presented with headache, vertigo and dizziness. MRI demonstrated hypertrophic masses in the meninges of the left cerebellar tentorium, cerebellopontine angle and the fourth ventricle. Six months of treatment with betamethasone, prednisolone and azathioprine improved the patient's neurological status. Because an inappropriate immune process and systemic immune disease may cause idiopathic pachymeningitis, the performance of immunological studies for idiopathic cases is mandatory.     

Diagnosis and investigation of headache

BACKGROUND: Headache is one of the commonest medical complaints. It is usually benign but may be the first presentation of serious disease. OBJECTIVE: This article reviews the symptoms and signs that suggest the diagnosis of the common headaches and discusses which headache presentations require investigation. DISCUSSION: An accurate clinical history is the key to diagnosing the cause of a headache. A new headache of acute onset or progressing over days to weeks or associated with abnormal neurological signs requires investigation.     

Mucocele of the sphenoid sinus presenting as spontaneous pneumocephalus

A 60 year old woman presented with headaches and a destructive lesion in the sella turcica. She refused treatment but returned seven years later with a spontaneous pneumocephalus and dementia. A mucocele of the sphenoid sinus was discovered. Her symptoms resolved after removal of the mucocele and obliteration of the sphenoid sinus.     

Recurrent vascular headache: Home-based behavioral treatment versus abortive pharmacological treatment.

This study compared the effectiveness of a home-based behavioral intervention with an abortive pharmacological intervention for treating recurrent migraine and mixed migraine and tension headaches. Relaxation training and thermal-biofeedback training were provided to 19 patients in a home-based treatment format that required minimal therapist contact, whereas 18 patients received ergotamine tartrate accompanied by a compliance-training intervention to assist them in making optimal use of the medication. The two treatments yielded similar reductions in headache activity (Ms?=?52% and 41%, respectively), psychosomatic symptoms, and daily life stress. However, the two treatments differed in (a) the timing of improvements, (b) their impact on analgesic medication use, and (c) the variables that predicted treatment response. The results highlight the role that psychological variables may play in pharmacological treatment and provide additional evidence that behavioral treatment can be effectively administered in a home-based treatment format. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Microneurographic evidence of sudden sympathetic withdrawal in carotid sinus syncope; treatment with ergotamine

A proportion of patients with carotid sinus syncope (CSS) remain symptomatic even after pacemaker implantation because of persistence of a vasodepressor component. We report a patient with CSS whose syncopal episodes could be reproduced by carotid sinus massage and were due to profound hypotension associated with sudden sympathetic withdrawal, based on direct measurements of sympathetic nerve traffic. A double-blind trial with inhaled ergotamine provided significant symptomatic relief.     

SUNCT syndrome: forehead sweating pattern

The forehead sweating function has been assessed in SUNCT syndrome--a short-lasting, unilateral, neuralgiform headache syndrome with autonomic phenomena on the symptomatic side (conjunctival injection, lacrimation, etc.). In the three patients (of a total of six) who could be studied during paroxysms, increased evaporation was present on the symptomatic side of the forehead compared to the non-symptomatic side during attacks or to the symptomatic side between attacks. Basal sweating was generally within control limits, so long as the attack frequency was not so high as to influence the interictal level. During attacks precipitated by eating chocolate or sour apple (in the case of one of the patients), forehead sweating was also increased on the symptomatic side. The forehead sweating responses to heating and pilocarpine were without any notable or systematic asymmetries. The forehead sweating pattern in SUNCT syndrome may differ from the patterns in unilateral headaches like cluster headache, on the one hand (in which there is generally an asymmetry during heating and pilocarpine tests), and chronic paroxysmal hemicrania (CPH) and cervicogenic headache, on the other (where there is no systematic increase during attacks.     

Pure red cell aplasia associated with true thymic hyperplasia

We reported unique magnetic resonance imaging (MRI) findings of a 57-year-old Japanese man who was diagnosed as Vogt-Koyanagi-Harada disease. This patient presented with complaints of a transient severe headache followed by a bilateral loss of visual acuity and truncal ataxia. Magnetic resonance imaging revealed abnormal contrast enhancement of both the uveas and the cerebellar vermis corresponding to his neurological abnormalities. The distribution and the nature of the resolution of this unusual pattern of contrast enhancement suggested that these MRI findings might illustrate transient destruction of the blood brain barrier or vascular extravasations. Such events might be representative of pathophysiology involving the central nervous system that occurred in patients with Vogt-Koyanagi-Harada disease.