Delayed diagnosis of cluster headache in African-American women.

The male-to-female ratio has fallen in cluster headache over the last several decades and is now 2.1:1. Unfortunately, women still are not diagnosed accurately. This lack of appropriate diagnosis appears related to the misconception that cluster headache rarely occurs in women. Compounding this misconception, there seems to be an ethnic bias. We report cluster headache in five African-American women in whom diagnosis was delayed due to gender, ethnicity, and, most importantly, an inability to make a correct diagnosis of cluster headache. Cluster headache diagnostic criteria are no different in men or women and have no ethnic boundaries. Clinical features such as disordered chronobiology and abnormal behavior often suggest the diagnosis. Migrainous features occur commonly in cluster headache and, when present, should not exclude the diagnosis. Likewise, neither race nor sex should exclude the diagnosis. The diagnosis of cluster headache is easily made by considering unilateral orbital, supraorbital or temporal location; short duration (15-180 minutes, untreated), and ipsilateral autonomic dysfunction involving the eye or nose.

Development of a spanish version of the Schwartz Outcome Scale-10: a brief mental health outcome measure.

The lack of culturally appropriate psychometric instruments for the assessment of cognitive and emotional functioning in minority populations has been a concern often discussed in the assessment literature. With the increased focus on the measurement of outcome in mental health treatment, the lack of appropriate instruments for minorities has become readily apparent in this venue as well. We report on the Spanish translation of a brief and reliable measure of psychological health and well-being that has been shown to be sensitive to treatment outcomes. The original and Spanish translated versions of this measure are highly correlated, providing clinicians and organizations with a instrument that can be used for assessment of psychological well-being and treatment outcomes with Hispanic patients.

Low doses of gabapentin may be helpful in the management of chronic daily headache.

CONTEXT: The difficult management of chronic daily headache and the lack of clinical trials for this medical condition led the authors to perform this study. Gabapentin has been successfully used for a variety of chronic pain conditions and therefore may be of use in the treatment of chronic headache. OBJECTIVE: To assess the efficacy and safety of low doses of gabapentin in cases of chronic daily headache. DESIGN: Open-label study on a series of cases of chronic daily headache. PATIENTS: Twenty-one consecutive patients with primary headache lasting 4 or more hours a day, at least 15 days per month, were invited to participate in this open trial. They were treated with low doses of gabapentin for sufficient time to lead to a headache-free period of at least 7 consecutive days. A minimum of 1 follow-up visit and 1 phone call were made in the subsequent 6-9 months. MEASUREMENTS: A simple "Patient Impression of Change" was used to evaluate the results. Patients were also invited to compare this treatment to previous ones, whenever possible. RESULTS: The efficacy of the treatment with gabapentin was rated as "excellent" by 19% of the patients, "good" by 47.6%, "fair" by 19%, and "poor" by 14.4%. CONCLUSIONS: Despite the inherent limitations of such a small open trial, the authors concluded that ratings of excellent and good by two thirds of this population of patients with chronic daily headache should encourage the setup of a large double-blind, multicentric, placebo-controlled trial of low doses of gabapentin for chronic daily headache.

Alzheimer's disease: pharmacological treatment and management.

The expected rise in prevalence rates of Alzheimer's disease over the next several decades has generated a great deal of attention at all levels of society, including governmental and scientific communities. These concerns have resulted in a vast number of research studies which have yielded medications focusing primarily on the symptomatic relief of the cognitive, neuropsychiatric and behavioral alterations felt to be pathognomic of the disease. Medical and pharmacological interventions which impact the onset or delay the progression of the illness are not yet readily available. We review and discuss the medications which are currently used for the symptomatic treatment and management of the disease, as well as discuss new pharmacological strategies which are under investigation and development.

Perioperative electroencephalographic seizures in infants undergoing repair of complex congenital cardiac defects.

Many infants with cardiac anomalies undergo repair early in life. Both commonly used support techniques, deep hypothermic circulatory arrest (DHCA) and low-flow cardiopulmonary bypass (LFB), may be associated with adverse neurological outcomes, including seizures. In a single center study, 171 infants undergoing correction for D-transposition of the great arteries were randomized to one of these support techniques. Incidence and onset times of EEG seizures during continuous EEG-video monitoring in the first 48 h postoperatively and clinical seizures in the first postoperative week were compared. EEG seizures were characterized by time, duration, and localization of onset. Incidence of EEG seizures (20%) was more than 3 times that of clinical seizures (6%). Most infants with EEG seizures had multiple seizures beginning between 13 and 36 h postoperatively. Durations ranged from 6 s to 980 min. Onset of EEG seizures occurred most commonly in frontal and central regions. Factors associated with EEG seizures included randomization to DHCA, longer duration of circulatory arrest, and diagnosis of VSD. In this study EEG seizures were common following this type of cardiac surgery, illustrating the importance of EEG monitoring in detecting seizures. This data adds insight into mechanisms of seizures in infants undergoing cardiac surgery.

Facilitation of infantile spasms by partial seizures.

We report 16 patients with infantile spasms in whom onset of the clusters of spasms appeared to be triggered by close temporal association with partial seizures. Common features included the presence of focal cerebral lesions in 12 infants (3 were classifiable as cryptogenic); all had partial seizures with EEG localization, clusters of bilateral spasms always preceded by partial seizures, and response to adrenocorticotropic hormone (ACTH) and traditional antiepileptic drugs (AEDs) generally was poor. Three had complete agenesis of the corpus callosum, which argues against interhemispheric callosal spread of focal discharges resulting in the generalized spasms. Surgical cortical resections were performed in 6 of the infants, with good outcomes. This group of patients supports a model in which the spasms, although probably generated at a subcortical level, are facilitated or possibly induced by focal discharges from cortical pathology.

Transaqueductal migration of a neurocysticercus cyst. Case report.

The clearly documented transaqueductal migration of a solitary intraventricular neurocysticercus cyst is described. The cyst was fortuitously demonstrated on magnetic resonance imaging during migration through the aqueduct. The radiological appearance and clinical significance of this condition are discussed.

Isolated oculomotor nerve palsy following apoplexy of a pituitary adenoma.

An isolated oculomotor nerve palsy is very rarely the presenting sign of a pituitary adenoma. It may occur slowly due to mechanical compression or rapidly, secondary to pituitary apoplexy. Magnetic resonance imaging (MRI) with and without gadolinium DTPA enhancement provides excellent anatomical detail and is useful in the planning of the operative procedure. When correctly diagnosed and treated, the third nerve dysfunction appears to be reversible. We report a case of a pituitary adenoma presenting with an isolated, partial oculomotor nerve palsy in the setting of apoplexy. The pathophysiology, prognostic factors and MRI findings of this entity are discussed.

Uncal herniation secondary to bacterial meningitis in a newborn.

A newborn with bilateral uncal herniation secondary to acute bacterial meningitis is reported. The findings of previous neuropathologic studies of neonatal bacterial meningitis are reviewed and the factors most likely responsible for the relative rarity of herniation in this disease in newborns are discussed.

Unilateral oculomotor palsy and bilateral ptosis from paramedian midbrain infarction.

Lesions of the oculomotor fascicles are localized clinically by associated neurologic deficits. We present two patients with bilateral ptosis, unilateral paresis of all other muscles innervated by the oculomotor nerve, and sparing of the contralateral superior rectus muscle--findings suggesting a lesion of the proximal oculomotor fascicles and the central caudal subnucleus. To our knowledge, these are the first such cases with radiologic confirmation of a lesion within the dorsal, paramedian midbrain.

Delayed oculogyric crises associated with striatocapsular infarction.

Oculogyric crises are dystonic, usually upward, conjugate eye deviations. We describe an 11-year-old girl who developed oculogyric crises 3 1/2 years after infarction of the right caudate, putamen, and internal capsule. Her abnormal eye movements responded to anticholinergic agents. This is the first reported association between oculogyric crises and striatocapsular infarction.

Isolated central nervous system aspergillosis in the acquired immunodeficiency syndrome.

Aspergillus infection involving the central nervous system are unusual, but should be included in the differential diagnosis in patients with the acquired immunodeficiency syndrome and neurologic signs and symptoms. Of the few reported AIDS cases with central nervous system aspergillosis, the majority have had focal brain abscesses. We report an atypical case that presented as a basal meningitis with pontine infarction secondary to invasive Aspergillus sinusitis.

Cerebral toxoplasmosis in patients with AIDS.

Toxoplasma gondii, a previously rare cause of central nervous system infection, has become a major cause of encephalitis in patients with acquired immunodeficiency syndrome. The diagnosis of cerebral toxoplasmosis should be kept in mind when neurologic signs and symptoms develop in patients with AIDS. Patients with positive serology and characteristic lesions on computed tomographic scans should receive two weeks of antitoxoplasma therapy. Biopsy is recommended for patients with atypical presentation, negative serology, progressive clinical deterioration or differential response of lesions to empiric therapy.