Brazilian experience of the influence of endovascular treatment on headache in patients with ruptured intracranial aneurysms.

BACKGROUND: The characteristics of primary headaches in patients with ruptured brain aneurysm embolization have not been well understood to date. AIMS OF THE STUDY: This study was conducted to evaluate the influence of endovascular treatment (EVT) of ruptured intracranial aneurysm (RIA) and the pattern of previous primary headache. METHODS: We evaluated the pattern of headache in patients who suffered a RIA and EVT within one year before the rupture, and prospectively evaluated the characteristics of headache for up to 12 months after EVT. Sixty patients were evaluated and a questionnaire about headache was applied at the time of admission. These patients were contacted 3, 6 and 12 months after treatment to complete the study by filling out follow-up questionnaire on the headache. RESULTS: Thirty-seven patients had headache before the rupture, 16 with tension-type headache (TTH), 11 with migraine without aura, nine with migraine with aura with and one with non-specific characteristics. There was a significant reduction in the frequency of pain for up to 12 months for patients with TTH (P < 0.001) and migraine without aura (P = 0.012), but there was a reduction in pain intensity over the same period in TTH (P = 0.002), migraine with aura (P = 0.004) and migraine without aura (P < 0.001). CONCLUSION: There was a reduction of the primary headache after endovascular treatment of ruptured brain aneurysm.

A nationwide population-based study of migraine in Brazil.

The aim of this study was to estimate the 1-year prevalence of migraine and the degree of the association of migraine with some sociodemographic characteristics of a representative sample of the adult population of Brazil. This was a cross-sectional, population-based study. Telephone interviews were conducted on 3848 people, aged 18-79 years, randomly selected from the 27 States of Brazil. The estimated 1-year gender- and age-adjusted prevalence of migraine was 15.2%. Migraine was 2.2 times more prevalent in women, 1.5 times more in subjects with > 11 years of education, 1.59 times more in subjects with income of < 5 Brazilian Minimum Wages per month, and 1.43 times more in those who do not do any physical exercise. The overall prevalence of migraine in Brazil is 15.2%. Migraine is significantly more prevalent in women, subjects with higher education, with lower income, and those who do not exercise regularly, independently of their body mass index.

Chronic daily headache in Brazil: a nationwide population-based study.

The objectives of this study were to estimate the 1-year prevalence of chronic daily headache (CDH) and the degree of the association of CDH with some sociodemographic characteristics of the adult population of Brazil. This was a cross-sectional, population-based study. We conducted telephone interviews with 3848 people, aged 18-79 years, randomly selected from the 27 States of Brazil. The degree of the association was calculated through prevalence ratios, adjusted with Poisson regression by gender, age and some sociodemographic factors. The estimated 1-year gender- and age-adjusted prevalence of CDH was 6.9%. CDH was 2.4 times more prevalent in women, 1.72 times more in unemployed, 1.63 times more in subjects with high household income and two times greater in those who did not exercise. The overall prevalence of CDH in Brazil is high. CDH is significantly more prevalent in women, the unemployed, subjects with higher income, and in those who do not exercise.

Central nervous system Aspergillus fumigatus infection after near drowning.

AIMS: To report the case of a 26 year old white man, who developed chronic meningitis and intracerebral granulomata 15 days after an episode of near drowning in a swamp. METHODS: Aspergillus fumigatus was isolated from cerebrospinal fluid cultures. RESULTS: The patient died 70 days after the symptoms were first noticed, and seven days after a subarachnoid haemorrhage. Aspergillus has never been reported before as a cause of intracranial infection after near drowning. CONCLUSIONS: Physicians must be aware of this possibility when confronted with such a situation, because there are now effective therapeutic options for systemic aspergillosis.

[S.U.N.C.T. syndrome: report of a case preceded by ocular trauma]. / Síndrome de S.U.N.C.T. Relato de um caso precedido de trauma ocular.

Report case of Short lasting, Unilateral, Neuralgiform headache, associated to Conjunctival injection and Tearing (S.U.N.C.T. syndrome) preceded by ipsilateral ocular trauma. We are not aware of any other report of such association. Until the pathophysiology of the S.U.N.C.T. syndrome becomes completely clarified, the relationship between the preceding ocular trauma and the occurrence of the clinical manifestations remains speculative. Clinical, pathophysiological therapeutic aspects of the S.U.N.C.T. syndrome are reviewed.

[Can the biologic pattern of cervicogenic headache change after overuse or withdrawal of ergotamine derivatives?]. / O padrão biológico da cefaléia cervicogênica pode ser alterado pelo uso excessivo de ergotamínicos ou pela sua retirada?

The transformation of a primary headache into a chronic daily headache (CDH) may or may not be related to the overuse of pain-killers, as their influence on the pathophysiological mechanisms remain inconclusive. We describe three patients (female, aged 65 and 39 years, and male, 46) affected by cervicogenic headache (CH) and CDH linked to the overuse of pain-killers (ergotamine derivatives) that were submitted to the infiltration of the greater occipital nerve (GON). At the end of three days of treatment, a total improvement of the pain symptoms was recorded, which allowed for the withdrawal of the ergotamine derivatives. The CH cannot be ranked with the CDHs, since it presents an organic etiology; however, if the pain is daily and the diagnosis is belated, the indiscriminate and excessive use pain-killers may occur. In the cases described, the overuse of pain-killers did not affect the natural evolution of this headache after treatment with the infiltration of the GON, as all the patients who underwent infiltration showed a total improvement of their painful symptoms, without headache resulting from the withdrawal of pain-killers, nor did they show any pharmacological dependence. This is an evidence that the CH presents and organic etiology, not being influenced in its pathophysiology by the overuse of ergotamine derivatives.

[Neurophysiology of pain in tentorial irritation: description of a case secondary to medulloblastoma]. / Neurofisiologia álgica na irritação tentorial. Descrição de um caso secundário a meduloblastoma.

We report the case of a 32-year-old woman who complained of dull and compressing occipital pain, with unilateral radiation to the left frontal and supraorbital areas (of the sickening type). The radiological, clinical, neurosurgical and neuropathologic investigation disclosed a medulloblastoma bulging and tickening the tentorium cerebelli. This case shows how mechanical stimuli of the structures innervated by the tentorial nerve can cause pain with characteristics of trigeminal and cervical involvement.

[Headache in patients with pheochromocytoma. Influence of arterial hypertension]. / Cefaléia em pacientes com feocromocitoma. Influência da hipertensão arterial.

Headache is an important diagnostic element in pheochromocytoma and it may characterize a body reaction to pathological hormonal oscillations. We observed the pheochromocytoma instability in 20 patients during arterial hypertension and tried to correlate with headache. We found that isolate hypertension is not the only factor in headache pathogenesis. It is possible that changes in catecholamines, adrenomedullin and other neuropeptides may cause some of these symptoms.

Evaluation of headache intensity in migrainous patients with visual handicap through the tactile analogical scale (TAS).

The tactile analogue scale (TAS) was elaborated to be used in blind subjects or those who can not use the vision during their crises. The objective of this study was to characterize, from TAS, the architecture of migraine attacks in subjects with visual disability. For that, 11 migrainous with visual disturb (MVD) subjects were studied and 22 migrainous subjects with no visual disability as a control group. All patients fulfilled the criteria for migraine and the patients of the group studied showed visual acuteness less than 20/200. To evaluate the results, the patients of the group MVD were subdivide within two groups, according to their visual acuteness: subgroup A subjects with subnormal vision and subgroup B amaurotic ones. In subgroup A measurement 46 attacks with average of the migraine attacks of the 56.50 mm, in the subgroup B 45 attacks with average of the 59.58 mm and in the control group 92 attacks with average of the 49.88 mm. When subgroup B and control group were compared there was a significant statistic difference (p=0.022). Through these outcomes we can observe that the migrainous subjects with no visual afference show a higher pain intensity during the migraine crises comparing to those subjects with no visual handicap. The study suggests that, as in other forms of sensibility, the total visual loss can also interfere in the nociceptive control of the pain during the migraine attacks.

[Pseudomigraine with CSF pleocytosis: intermittent measurement of the intracranial pressure. Case report]. / Pseudomigrânea com pleocitose liquórica: monitorização intermitente da pressão intracraniana. Relato de caso.

Pseudomigraine with pleocytosis is a self-limited and rather benign disorder, characterized by recurrent bouts of migrainous headaches, associated to focal neurological symptoms and to cerebrospinal fluid abnormalities. We have submitted an individual with pseudomigraine to three lumbar punctures. The first and the third lumbar punctures, carried out during symptomatic periods, revealed a cerebrospinal fluid with aseptic lymphomonocytic pleocytosis, and an opening pressure of 400 and 440 mmH2O, respectively. The cerebrospinal fluid pressure measured during an asymptomatic period was normal (190 mmH20). Although the underlying mechanisms of this disorder remain elusive, there is some evidence that suggests an involvement of autoimmune mechanisms leading to a reduction of the cerebral blood flow, similar to that seen in the cortical spreading depression. In this report, we raise the possibility of a contributory role to be played by the elevated cerebrospinal fluid pressure on the pathophysiology of this disorder.

[Change in the biological pattern of migraine with aura after the use of tetrabenazine: case report]. / Mudança no padrão biológico da migrânea com aura após a utilização da tetrabenazina: relato de caso.

The influence of the dopaminergic system on the pathophysiology of migraine has been suggested as a result of recent genetic discoveries. A possible hyper-reactivity of the dopaminergic receptors DRD2 reinforced the evidence regarding this. We describe a 31 years-old male patient affected by a generalized dystonia secondary to perinatal hypoxia. At age 16, the patient started having headache crises that met the criteria for migraine with aura. After three years of treatment for dystonia with tetrabenazine, a clear reduction in the frequency, intensity and duration of the crises was perceived. During two periods longer than two months, the interruption of the treatment with tetrabenazine brought about an aggravation of the migraine crises. We present this case as being the first description in the literature showing the beneficial effects of tetrabenazine, a blocker of dopaminergic receptors, on the behavior of migraine with aura.

[Lipoma of the corpus callosum associated with the hypertrophy of the corpus callosum: case report]. / Lipoma do corpo caloso associado a hipertrofia do corpo caloso: relato de caso.

Despite the lipomas are the tumors that more commonly occur in the corpus callosum (CC), its incidence in the population is not common. We report on a 5-year old boy, with history of retardation in the psychomotor development and disturbs in the gait, secondary to generalized hypotony. Magnetic resonance imaging showed a curvilinear lipoma of the CC related to its hypertrophy. In the literature patients with CC lipoma usually have agenesis or hypotrophy of the CC, but in the reported case we have seen, by the first time, a hypertrophy of the CC. We made embryologic, genetic, clinical, radiographic and therapeutic considerations about the patients that have CC lipoma comparing to findings in the case we report.

[Neurotoxoplasmosis presenting as multifocal suppuration and hemorrhage. Case report]. / Neurotoxoplasmose com apresentação multifocal supurativa e hemorrágica. Relato de caso.

Neurotoxoplasmosis is one of the commonest infections in immunosuppressed patients, and rarely presented in the hemorrhagic form. We describe a case with multiple nodular hemorrhagic lesions with perilesional edema in the computed tomography. The neuropathological study showed focal lesions, necrosis and microorganisms compatible with toxoplasmosis.

Neurofibromatosis, stroke and basilar impression. Case report.

Neurofibromatosis type 1 (NF1) can virtually affect any organ, presenting most frequently with "cafe au lait" spots and neurofibromas. Vasculopathy is a known complication of NF1, but cerebrovascular disease is rare. We report the case of a 51-year-old man admitted to the hospital with a history of stroke four months before admission. On physical examination, he presented various "cafe au lait" spots and cutaneous neurofibromas. Neurologic examination demonstrated right-sided facial paralysis, right-sided hemiplegia, and aphasia. Computed tomography scan of head showed hypodense areas in the basal ganglia and centrum semiovale. Radiographs of cranium and cervical spine showed basilar impression. Angiography revealed complete occlusion of both vertebral and left internal carotid arteries, and partial stenosis of the right internal carotid artery. A large network of collateral vessels was present (moyamoya syndrome). It is an uncommon case of occlusive cerebrovascular disease associated with NF1, since most cases described in the literature are in young people, and tend to spare the posterior cerebral circulation. Basilar impression associated with this case may be considered a pure coincidence, but rare cases of basilar impression and NF1 have been described.

[Greater occipital neuralgia associated with occipital osteolytic lesion. Case report]. / Nevralgia do occipital maior associada a lesão osteolítica occipital. Relato de caso.

The anatomic distribution of the greater occipital nerve during its path permits a close relationship with muscular structures, tendons, vessels and bones. The rupture of this relationship can origin its irritation and headache. We describe an uncommon association between an osteolytic lesion on occipital bone and greater occipital nerve. The patient, female 50, has been presenting headache for two years on the right occipital region spreading to the hemicranic and ipsilateral supraorbital region. The symptoms started spontaneously or by pressure on the trapezius tendon. The pain lasted about 30 minutes, compressive, mild intensity, with no autonomic symptoms and no improvement after the infiltration in the greater occipital nerve. The total improvement of the symptoms after releasing the nerve has allowed us to associate this lesion to the presence of algic symptoms.

[Acute schistosomiasis with brain involvement. Case report]. / Esquistossomose aguda com comprometimento cerebral. Relato de caso.

A case of acute schistosomiasis with magnetic resonance images (MRI) of the brain suggestive of demyelinating lesions, pyramidal disorder in the lower limbs and normal cerebrospinal fluid is presented. Diagnosis could be established by detection of antibodies on blood and cerebrospinal fluid. Schistosoma mansoni involves the spinal cord more often than the brain. Praziquantel associated to prednisolone was effective in this case. There are few reports of brain involvement with S. mansoni, but its prevalence is probably greater. Due to the paucity of studies, its pathophysiology and therapeutics remain to be better clarified. The immune and MRI aspects are emphasized.

[Anesthetic blockade of the greater occipital nerve in migraine prophylaxis]. / Bloqueio anestésico do nervo occipital maior na profilaxia da migrânea.

Migraine comprises a great many encephalic structures in its pathophysiology with the trigeminal nerve (TN) type being one of the main ones. For the purpose of determining a possible influence of the greater occipital nerve (GON) on migraine behavior, 37 patients who showed this pathology were studied. Using a double blind "cross over" group and submitting those patients to a GON infiltration with bupivacaina 0.5% (BP) and physiological serum 0.9% (PS), the clinical effects were evaluated: subjectively, through a pain analytical visual scale; objectively, by determining the threshold of pain perception (algometry). The comparison between the two groups (BP-PS) and (PS-BP) has shown that the number and duration of the attacks did not show significant statistical differences during the study. The intensity of the attacks was lower in group (BP-PS) only after the second infiltration (p=0.020), in the other moments no differences have been observed between the groups. The conclusion is that the anesthetic blockage with BP on the GON does not change the number of crises and their duration, but it does provokes an intensity reduction after 60 days from the infiltration. The results shown here suggest that GON participates in the cranial nociceptive modulation during crises of migraine without aura.

[Using algometry of pressure measuring the threshold of trigeminal pain perception in normal volunteers: a new protocol of studies]. / Utilização da algometria de pressão na determinação dos limiares de percepção dolorosa trigeminal em voluntários sadios: um novo protocolo de estudos.

Algometry of pressure is a technique that measures the physiology of the nociceptive system. Acting directly on the responsive peripheral nociceptors to pressure stimuli, this technique allows the study on nociceptive integrity in normal subjects or having different algic syndromes. Utilizing 29 asymptomatic volunteers, the threshold of the painful perception was studied, measuring them in a direct way over the emergence of the supra-orbital, infra-orbital and mental nerves. The following algometric average were recorded: right mental nerve 46.2 Kg/cm2 and left 48.6 Kg/cm2; right supra-orbital nerve 47.7 Kg/cm2 and left 45.2 Kg/cm2; right infra-orbital nerve 53.9 Kg/cm2 and left 55.4 Kg/cm2. After reviewing the principles of the algometry utilization, we have validated this protocol, showing the average values obtained by measuring the trigeminal system, afterwards comparing them with an inervated region by cervical branches (major occipital nerve) and the temporal muscle.

[Prevalence and semiologic aspects of the idiopathic stabbing headache in a migraine population]. / Prevalência e características da cefaléia idiopática em punhaladas em uma população de migranosos.

Idiopathic stabbing headache is a quite unknown disorder. Its main features consist of brief stabbing pains, lasting few seconds. In most cases, idiopathic stabbing headache is underdiagnosed. We have followed up migraine patients during a period of 12 months, aiming to determine the prevalence and main features of idiopathic stabbing headache while occurring apart from migraine attacks. Two hundred and thirty-three of the 280 patients initially surveyed were included in the analysis of the results. Ninety-four patients presented idiopathic stabbing headaches (40.4%), being 72 of them females (76.5%). For migraine with idiopathic stabbing headaches, mean age, age of beginning of migraine and years with migraine were 33, 22.5 and 10.6 years, respectively. Mean duration of the idiopathic stabbing headaches was reported to be 1.42 seconds [ 1 second by 68 patients (72.4%), 2 seconds by 17 (18.1%), 3 seconds by 6 (6.3%), 4 seconds by 1 (1.05%) and 5 seconds by 2 (2.15%)]. Pain paroxysms were reported to be unilateral by 86 (91.4%) and bilateral by 8 (8.6%) of the cases. They were reported to be temporal by 56 patients (60%), occipital by 15 (15.6%), frontal by 8 (8.5%), temporo-occipital by 7 (7.4%), parietal by 5 (5.3%), fronto-temporal by 1 (1.06%), cervical by 1 (1.06%) and ocular by 1 patient (1.06%). The study confirms a high prevalence of idiopathic stabbing headaches in migraineurs. Its main clinical features could be well determined during the interval between migraine attacks.