Neuroimmunological effects of omega-3 fatty acids on migraine: a review.

Migraine is a highly prevalent disease worldwide, imposing enormous clinical and economic burdens on individuals and societies. Current treatments exhibit limited efficacy and acceptability, highlighting the need for more effective and safety prophylactic approaches, including the use of nutraceuticals for migraine treatment. Migraine involves interactions within the central and peripheral nervous systems, with significant activation and sensitization of the trigeminovascular system (TVS) in pain generation and transmission. The condition is influenced by genetic predispositions and environmental factors, leading to altered sensory processing. The neuroinflammatory response is increasingly recognized as a key event underpinning the pathophysiology of migraine, involving a complex neuro-glio-vascular interplay. This interplay is partially mediated by neuropeptides such as calcitonin gene receptor peptide (CGRP), pituitary adenylate cyclase activating polypeptide (PACAP) and/or cortical spreading depression (CSD) and involves oxidative stress, mitochondrial dysfunction, nucleotide-binding domain-like receptor family pyrin domain containing-3 (NLRP3) inflammasome formation, activated microglia, and reactive astrocytes. Omega-3 polyunsaturated fatty acids (PUFAs), particularly eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), crucial for the nervous system, mediate various physiological functions. Omega-3 PUFAs offer cardiovascular, neurological, and psychiatric benefits due to their potent anti-inflammatory, anti-nociceptive, antioxidant, and neuromodulatory properties, which modulate neuroinflammation, neurogenic inflammation, pain transmission, enhance mitochondrial stability, and mood regulation. Moreover, specialized pro-resolving mediators (SPMs), a class of PUFA-derived lipid mediators, regulate pro-inflammatory and resolution pathways, playing significant anti-inflammatory and neurological roles, which in turn may be beneficial in alleviating the symptomatology of migraine. Omega-3 PUFAs impact various neurobiological pathways and have demonstrated a lack of major adverse events, underscoring their multifaceted approach and safety in migraine management. Although not all omega-3 PUFAs trials have shown beneficial in reducing the symptomatology of migraine, further research is needed to fully establish their clinical efficacy and understand the precise molecular mechanisms underlying the effects of omega-3 PUFAs and PUFA-derived lipid mediators, SPMs on migraine pathophysiology and progression. This review highlights their potential in modulating brain functions, such as neuroimmunological effects, and suggests their promise as candidates for effective migraine prophylaxis.

Ventral Displacement of Spinal Cord in Spontaneous Intracranial Hypotension: A Sign Easily Be Overlooked.

PURPOSE: Spontaneous intracranial hypotension (SIH) is suspected in patients presenting orthostatic headache and needs excluding structural or iatrogenic causes. Image studies are required to confirm the diagnosis and define exact locations of cerebrospinal fluid leakage, but currently there is no single study sensitive enough to make identifications among patients with various symptoms. CASE REPORT: We present a 24-year-old young woman having acute orthostatic headache. She denied having previous headache, head trauma, or neuraxial procedures like lumbar punctures. Brain magnetic resonance image (MRI) with gadolinium enhancement reported normal findings on arrival. She received conservative treatment including analgesics and aggressive intravenous hydration, but her headache improved little. Whole spine MRI with gadolinium enhancement revealed no obvious leakage of cerebrospinal fluid but typical dilated epidural veins with ventral displacement of her thoracic spinal cord. After autologous epidural blood patches therapy, her headache relieved completely. CONCLUSION: We review the typical and uncommon findings of spinal MRI in SIH, which is more sensitive than brain MRI in acute stages. Spinal MRI offers the diagnostic value in SIH especially when cranial images do not respond in time.

The Impact of Loading Dose on Outcome in Stroke Patients Receiving Low-Dose Tissue Plasminogen Activator Thrombolytic Therapy.

BACKGROUND: Intravenous tissue plasminogen activator (tPA) (0.9 mg/kg, maximum 90 mg) with a bolus of 10% of the total dose given within 1-2 mins is the standard therapy for patients receiving thrombolytic therapy. Low-dose (0.6 mg/kg) tPA is also approved for thrombolytic therapy for ischemic stroke patients. Low-dose tPA is associated with a low bolus dose. It is unknown whether increasing the bolus dose in patients receiving low-dose tPA thrombolysis may improve outcomes or increase the risk of hemorrhagic transformation (HT). AIM: This study investigated the impact of the bolus dose on the outcome in ischemic stroke patients receiving low-dose tPA thrombolytic therapy. METHODS: In this retrospective, observational study, we enrolled 214 ischemic stroke patients receiving low-dose tPA thrombolytic therapy. Of these 214 patients, 107 patients received 10% of the total dose as a bolus dose, and 107 patients received 15% of the total dose as a bolus dose. The National Institutes of Health Stroke Score (NIHSS) were evaluated before tPA infusion, 24 h after thrombolytic therapy, and at discharge. Stroke severity was categorized as mild (0-5), moderate (6-14), severe (15-24), or very severe (≥25). Neurological improvement (NI) was defined as an improvement of 6 or more points in the NIHSS, and no response (NR) was defined as an increase in the NIHSS of ≤4 points or a decrease ≤6 points. Neurological deterioration (ND) was defined as an increase in the NIHSS >4 points. A good outcome was defined as a modified Ranking Score (mRS) of 0 or 1. We compared the NI, NR, and ND rates at 24 hrs after thrombolytic therapy and discharge between the 15% and 10% bolus dose groups. RESULTS: In patients with mild and moderate stroke, there was no significant difference in the NI, NR, ND, and HT rates and 6-month outcomes between the 15% and 10% bolus groups. In patients with severe and very severe stroke, outcomes at 6 months were significantly better in the 15% bolus group than in the 10% bolus group. The factors affecting the outcomes of severe and very severe stroke patients are hypertension and bolus dose. CONCLUSION: In severe and very severe stroke patients receiving low-dose tPA thrombolytic therapy, a bolus dose of 15% of the total dose can improve outcomes.

The bucket test differentiates patients with MRI confirmed brainstem/cerebellar lesions from patients having migraine and dizziness alone.

BACKGROUND: Amongst the most challenging diagnostic dilemmas managing patients with vestibular symptoms (i.e. vertigo, nausea, imbalance) is differentiating dangerous central vestibular disorders from benign causes. Migraine has long been recognized as one of the most common causes of vestibular symptoms, but the clinical hallmarks of vestibular migraine are notoriously inconsistent and thus the diagnosis is difficult to confirm. Here we conducted a prospective study investigating the sensitivity and specificity of combining standard vestibular and neurological examinations to determine how well central vestibular disorders (CVD) were distinguishable from vestibular migraine (VM). METHOD: Twenty-seven symptomatic patients diagnosed with CVD and 36 symptomatic patients with VM underwent brain imaging and clinical assessments including; 1) SVV bucket test, 2) ABCD2, 3) headache/vertigo history, 4) presence of focal neurological signs, 5) nystagmus, and 6) clinical head impulse testing. RESULTS: Mean absolute SVV deviations measured by bucket testing in CVD and VM were 4.8 ± 4.1° and 0.7 ± 1.0°, respectively. The abnormal rate of SVV deviations (> 2.3°) in CVD was significantly higher than VM (p < 0.001). Using the bucket test alone to differentiate CVD from VM, sensitivity was 74.1%, specificity 91.7%, positive likelihood ratio (LR+) 8.9, and negative likelihood ratio (LR-) 0.3. However, when we combined the SVV results with the clinical exam assessing gaze stability (nystagmus) with an abnormal focal neurological exam, the sensitivity (92.6%) and specificity (88.9%) were optimized (LR+ (8.3), LR- (0.08)). CONCLUSION: The SVV bucket test is a useful clinical test to distinguish CVD from VM, particularly when interpreted along with the results of a focal neurological exam and clinical exam for nystagmus.

Use of antidepressants and risks of restless legs syndrome in patients with irritable bowel syndrome: A population-based cohort study.

Previous research has suggested an association between antidepressants use and clinical restless legs syndrome (RLS) in patients, but there has never been a single study investigating the risk of RLS in irritable bowel syndrome (IBS) patients treated with antidepressants. Hence, we aimed to explore the association between IBS and RLS and to examine the risk of RLS in IBS patients treated with antidepressants. With the use of the National Health Insurance Research Database of Taiwan, 27,437 adults aged ≥ 20 years with newly diagnosed IBS (ICD-9-CM Code 564.1) and gender- and age-matched 54,874 controls without IBS were enrolled between 2000 and 2012. All patients were followed-up until RLS diagnosis, withdrawal from the National Health Insurance program, or end of 2013. We used the Cox proportional hazards model to calculate the hazard ratios (HRs) and 95% confidence intervals (CIs) of RLS. RLS was more prevalent in IBS patients than in the non-IBS group (7.57 versus 3.36 per 10,000 person-years), with an increased risk of RLS (adjusted HR [aHR], 1.91; 95% CI, 1.52-2.40). Multivariate Cox proportional hazards analysis identified older age (age, 51-65 years; aHR, 1.67; 95% CI, 1.09-2.56; and age > 65; aHR, 1.59; 95% CI, 1.02-2.48), hypothyroidism (aHR, 4.24; 95% CI, 1.92-9.37), CAD (aHR, 1.70; 95% CI, 1.17-2.48), and depression (aHR, 3.15; 95% CI, 2.14-4.64) as independent RLS risk factors in IBS patients. In addition, the male SSRIs users were associated with significantly higher risk of RLS (aHR, 3.05 95% CI, 1.34-6.92). Our study showed that the IBS group has higher risk of RLS. Moreover, SSRIs use may increase the risk of RLS in male IBS patients.

Effects of surgical treatment for classical trigeminal neuralgia with concomitant persistent facial pain.

PURPOSE: Classical trigeminal neuralgia with concomitant persistent facial pain responds poorly to conservative treatment. The authors describe the effects of microvascular decompression and radiofrequency thermocoagulation for patients with classical trigeminal neuralgia and concomitant persistent facial pain. CASE REPORT: Case 1 was a 61-year-old man with dull, continuous, aching pain in the left maxillary and mandibular molar area. Case 2 was a 68-year-old woman with aching pain in the maxillary right molar. Case 3 was a 67-year-old woman with severe pain in the right upper lip and maxillary right second premolar. Case 4 was a 42-year-old man with orofacial pain of 14 months' duration. Cases 1 and 2 underwent radiofrequency thermocoagulation and reported good relief of symptoms. Cases 3 and 4 underwent microvascular decompression and attained excellent relief. CONCLUSION: Microvascular decompression may be more effective than radiofrequency thermocoagulation for patients with classical trigeminal neuralgia with concomitant persistent facial pain.

Orofacial Pain and Menstrually Related Migraine.

PURPOSE: Migraine is a common, debilitating, primary headache disorder that can cause and be affected by odontalgia. CASE REPORT: A 49-year-old woman(Patient 1) presented with pulsating pain in the left maxillary molar area, and a history of unsuccessful root canal treatment. She was ultimately diagnosed with menstrually related migraine without aura and zolmitriptan was prescribed, which reduced her headache and toothache together. A 45-year-old woman (Patient 2) presented with throbbing pain in the right maxillary molar and cheek area. Past repeated endodontic therapy had been unsuccessful. She was then diagnosed with menstrually related migraine without aura, and sumatriptan significantly reduced her headache and toothache. A 40-year-old woman (Patient 3) presented with pulsating pain near the left maxillary molar region. Pulpectomy was performed after she had previously received a diagnosis of pulpitis in the left maxillary second molar, but her pain did not subside. Patient 2 and 3 were misdiagnosed as pulpitis by dental practitioners and the pain did not relive after pulpectomy. All patients were diagnosed as migraine by headache specialists and were treated with triptans, which resulted in satisfactory pain relief. CONCLUSION: A thorough history and examination, as well as an understanding of migraine headaches, is necessary to differentiate odontogenic pain and migraine headaches. Key Words: menstrually related migraine, orofacial pain, ICHD-3, headache.

Progression of Mild to Moderate Stenosis in the Internal Carotid Arteries of Patients With Ischemic Stroke.

Background and purpose: Severe stenosis in the internal carotid artery may increase the risk of ischemic stroke. The factors that affect the progression of carotid artery stenosis in patients with ischemic stroke are poorly studied. No guidelines for the duration of follow-up of patients with ischemic stroke through carotid ultrasonography exist. Methods: In this retrospective study, 179 patients (108 men; mean age, 68 years) with ischemic stroke and mild to moderate stenosis in the internal carotid artery (ICA) were recruited. Carotid artery ultrasonography was performed over the period of January 2013 to June 2016 with a median follow-up of 36 months (mean 36.5 ± 3.5 months). The severity of carotid artery stenosis was estimated with the following equation: 1- (narrowest ICA diameter/total lumen diameter at the narrowest site). The severity of stenosis was categorized into grades I (0-29%), II (30-49%), III (50-59%), and IV (60-69%). The patient's stenosis grade was defined on the basis of the stenosis rate of the ICA side with most severe stenosis. Results: Stenosis progressed in 17.9% (64/358) of the vessels in 30.7% (55/179) of patients. The risk of stenosis progression increased as the severity of ICA stenosis increased. Patients with stenosis rates of above 50% are at a higher risk of stenosis progression than those with stenosis rate of < 50%. Relative to the patient group with an ICA stenosis rate of 0-29%, the adjusted odds ratios of stenosis progression were 2.33 (p = 0.03; 95% CI: 1.05~5.17), 3.50 (p = 0.09; 95% CI: 0.81~15.84), and 6.61 (p = 0.03; 95% CI: 1.01~39.61) in patient groups with ICA stenosis rates of 30-49%, 50-59%, and 60-69%, respectively. Hyper-LDL-cholesterolemia (Hyper-LDL-c) also increased the risk of stenosis progression, with an adjusted odds ratio of 2.22 (p = 0.03; 95% CI: 1.05~4.71). Conclusion: The rate of ICA stenosis progression increases with stenosis grade. Patients with ICA stenosis severity >50% and Hyper-LDL-c have high rates of stenosis progression. For the patients with stroke and ICA stenosis severity >50%, annual follow up through carotid artery ultrasonography may be necessary.

Medical Treatment Guidelines for Acute Migraine Attacks.

In 2015, the American Headache Society (AHS) amended the treatment guideline of acute migraine based on evidence-based medicine (EBM) that all triptans in any form of preparations, acetaminophen, and non-steroid anti-inflammation drugs-NSAID (aspirin, diclofenac, ibuprofen, naproxen), sumatriptan/naproxen, combined acetaminophen/aspirin/caffeine are considered effective (Level A). Previously effective drugs as prochlorperazine, and dihydroergotamine-DHE (excluded inhaled form) were downrated to probable effective (Level B). Taiwan Headache Society published its treatment guideline for acute migraine attack in 2007. It should be updated based on the new available evidence. The Treatment Guideline Subcommittee of Taiwan Headache Society reviewed the recent trials, evaluated the grade of evidence, and appraised the clinical efficacy to reach a new consensus. We also referred to the guidelines from United States, Europe, Canada and other countries to make this one meets our needs and feasible. Acute medications currently available in Taiwan can be categorized into "migraine-specific"and"migraine-nonspecific" groups. Migraine-specific triptans and migraine-nonspecific nonsteroidal antiinflammatory drugs (NSAIDs) have the best levels of evidence, and are recommended as the first-line medications for acute migraine attacks. The administration should follow the concept of "stratified care". For mild to moderate migraine attacks, oral NSAIDs are the first choice; with oral aspirin, combination analgesics, intravenous/intramuscular NSAIDs as alternatives. For moderate to severe attacks, oral or nasal spray triptans and ergotamine/caffeine compounds are recommended and should be administered in the early stage of migraine attacks. Antiemetics can be used as supplement to alleviate nausea and vomiting. Notably, a combination of a triptan and a NSAID yielded a better efficacy compared with either therapy alone. Parenteral steroid and fluid supply are the first choice in treatment of status migrainosus. Acetaminophen is suitable for mild to moderate migraine attacks and remains the first choice for children and pregnant women. Opiates are not recommended for acute migraine treatment at the present time because of serious adverse events. To prevent medication-overuse headache, the use of acute treatment should be limited to a maximum of ten days a month.

Sex-related differences in the risk factors for in-hospital mortality and outcomes of ischemic stroke patients in rural areas of Taiwan.

BACKGROUND AND PURPOSE: Sex-related differences in the clinical presentation and outcomes of stroke patients are issues that have attracted increased interest from the scientific community. The present study aimed to investigate sex-related differences in the risk factors for in-hospital mortality and outcome in ischemic stroke patients. METHODS: A total of 4278 acute ischemic stroke patients admitted to a stroke unit between January 1, 2007 and December 31, 2014 were included in the study. We considered demographic characteristics, clinical characteristics, co-morbidities, and complications, among others, as factors that may affect clinical presentation and in-hospital mortality. Good and poor outcomes were defined as modified Ranking Score (mRS)≦2 and mRS>2. Neurological deterioration (ND) was defined as an increase of National Institutes of Health Stroke Score (NIHSS) ≥ 4 points. Hemorrhagic transformation (HT) was defined as signs of hemorrhage in cranial CT or MRI scans. Transtentorial herniation was defined by brain edema, as seen in cranial CT or MRI scans, associated with the onset of acute unilateral or bilateral papillary dilation, loss of reactivity to light, and decline of ≥ 2 points in the Glasgow coma scale score. RESULTS: Of 4278 ischemic stroke patients (women 1757, 41.1%), 269 (6.3%) received thrombolytic therapy. The in hospital mortality rate was 3.35% (139/4278) [4.45% (80/1757) for women and 2.34% (59/2521) for men, p < 0.01]. At discharge, 41.2% (1761/4278) of the patients showed good outcomes [35.4% (622/1757) for women and 45.2% (1139/2521) for men]. Six months after stroke, 56.1% (1813/3231) showed good outcomes [47.4% (629/1328) for women and 62.2% (1184/1903) for men, p < 0.01]. Atrial fibrillation (AF), diabetes mellitus, stroke history, and old age were factors contributing to poor outcomes in men and women. Hypertension was associated with poor outcomes in women but not in men in comparison with patients without hypertension. Stroke severity and increased intracranial pressure were associated with increased in-hospital mortality in men and women. AF was associated with increased in-hospital mortality in women but not in men compared with patients without AF. CONCLUSION: The in-hospital mortality rate was not significantly different between women and men. Functional outcomes at discharge and six months after stroke were poorer in women than in men. Hypertension is an independent factor causing poorer outcomes in women than in men. AF is an independent factor affecting sex differences in hospital mortality in women.

Orofacial pain and headaches associated with exfoliation glaucoma.

BACKGROUND AND OVERVIEW: Exfoliation syndrome is the most common identifiable cause of open-angle glaucoma. The authors report a case of exfoliation glaucoma in a patient who had orofacial pain. CASE DESCRIPTION: A 77-year-old woman was treated at the orofacial pain clinic for left-sided facial pain and headaches of 7 months' duration. Her cataracts and open-angle glaucoma had been diagnosed approximately 3 years earlier. Her main symptoms were orofacial pain, eye redness, inflammation of the eyelids, and eyelid edema. Magnetic resonance imaging showed no evidence of intracranial or extracranial pathology. Hemicrania continua was considered as a possible diagnosis. Indomethacin was prescribed but did not affect her headaches. She then went to an ophthalmologist to rule out secondary headaches. Intraocular pressure was 13 millimeters of mercury in the right eye and 67 mm Hg in the left eye. The ophthalmologist made a diagnosis of exfoliation glaucoma, and the patient underwent surgical treatment for the glaucoma and cataracts. After surgery, she was free of symptoms, and intraocular pressure was 15 mm Hg in the left eye. CONCLUSIONS AND PRACTICAL IMPLICATIONS: During differential diagnosis, dentists need to consider intraoral and systemic conditions that can mimic odontogenic or orofacial pain disorders in the patient's medical history and that have a higher incidence associated with the patient's age.

Clinical Profile and Outcome of Myasthenic Crisis In Central Taiwan.

BACKGROUND: Myasthenia gravis (MG) is an autoimmune disease caused by antibodies to acetylcholine receptors of the skeletal muscle. Myasthenic crisis (MC) is a complication observed during both early and late stage MG cases. In this study, we examined current treatments and three years outcomes in patients with MG and MC. We also investigated the impact of thymectomy and systemic lupus erythematosus (SLE) in patients with MG and MC. METHODS: In this retrospective study, we reviewed the medical records of all patients admitted to one teaching hospital between January 2006 and December 2014 and identified those for whom discharge diagnosis included the International Classification of Diseases, ninth revision (ICD-9) codes corresponding to MG (358.X, all extensions and all positions). RESULTS: We identified 29 patients and 49 hospitalizations. Among these patients, the cause for initial hospitalization was MG in 16 cases and MC in 13 cases. Six out of the 16 MG patients were readmitted within 3 years; with 2 of the cases due to MC. Eight of the initial 13 MC patients were readmitted within 3 years, and 6 of the cases due to MC. Among these 15 MC patients, 14 were admitted to the intensive care unit (ICU), and 8 were intubation and put on mechanical ventilators. The median ICU stay was 7 days (3-45). Both MG patients who were also diagnosed with SLE experienced MC. One patient died during the first-time hospitalization, and one patient died during re-hospitalization within 2 years. CONCLUSION: Plasma exchange (PE) is the main treatment modality of MC, and most patients in our cohort had a good response. Infection is the most common trigger of MC and a significant cause of death. Despite significant morbidity and mortality in patients with MC, a favorable long-term outcome is possible with intensive treatment. Key Words: myathenia gravis, myasthenic crisis, systemic lupus erythematosus, outcome.

Underestimated Rate of Status Epilepticus according to the Traditional Definition of Status Epilepticus.

PURPOSE: Status epilepticus (SE) is an important neurological emergency. Early diagnosis could improve outcomes. Traditionally, SE is defined as seizures lasting at least 30 min or repeated seizures over 30 min without recovery of consciousness. Some specialists argued that the duration of seizures qualifying as SE should be shorter and the operational definition of SE was suggested. It is unclear whether physicians follow the operational definition. The objective of this study was to investigate whether the incidence of SE was underestimated and to investigate the underestimate rate. METHODS: This retrospective study evaluates the difference in diagnosis of SE between operational definition and traditional definition of status epilepticus. Between July 1, 2012, and June 30, 2014, patients discharged with ICD-9 codes for epilepsy (345.X) in Chia-Yi Christian Hospital were included in the study. A seizure lasting at least 30 min or repeated seizures over 30 min without recovery of consciousness were considered SE according to the traditional definition of SE (TDSE). A seizure lasting between 5 and 30 min was considered SE according to the operational definition of SE (ODSE); it was defined as underestimated status epilepticus (UESE). RESULTS: During a 2-year period, there were 256 episodes of seizures requiring hospital admission. Among the 256 episodes, 99 episodes lasted longer than 5 min, out of which 61 (61.6%) episodes persisted over 30 min (TDSE) and 38 (38.4%) episodes continued between 5 and 30 min (UESE). In the 38 episodes of seizure lasting 5 to 30 minutes, only one episode was previously discharged as SE (ICD-9-CM 345.3). Conclusion. We underestimated 37.4% of SE. Continuing education regarding the diagnosis and treatment of epilepsy is important for physicians.

Spontaneous intracranial hypotension resulting from a thoracic osteophyte.

We report a 34-year-old woman who presented with progressive postural headache and neck tightness over 1week. We confirmed the diagnosis of spontaneous intracranial hypotension (SIH) and spinal images showed a thoracic osteophyte caused the cerebrospinal fluid (CSF) leak. SIH caused by spinal CSF leak is generally thought to be a consequence of deficiency of the spinal meninges in conjunction with trivial trauma. Less commonly, spinal bony pathology can lead to SIH. We reviewed 13 reported patients with bony structural pathology related SIH. After two to three epidural blood patches, eight patients underwent surgery. They generally had good outcomes. In conclusion, even though surgical repair confers specific risks, it should be considered after repetitive failures of epidural blood patches. The long-term prognoses of surgical versus non-surgical patients warrants further investigation.

Chiari Malformation Type I Presenting as Cluster-like Headache.

PURPOSE: Although different types of headache have been described in Chiari malformation type I, reports of cluster-like headaches are rare. CASE REPORT: We report a 26-year-old man who presented with a two-week history of excruciating headache in the right temporal region after coughing, which was accompanied by autonomic features including right-sided nasal congestion and tearing from his right eye. Sensory deficits in the first branch of the right trigeminal nerve and along C3-5 dermatomes were noted, and brain magnetic resonance imaging was compatible with a diagnosis of Chiari malformation type I. CONCLUSION: A diagnosis of secondary cluster headache was made due to a lack of typical periodicity, and the presence of anhidrosis and sensory abnormalities and cough headache.

Anton-Babinski syndrome in an old patient: a case report and literature review.

Anton-Babinski syndrome is a rare disease featuring bilateral cortical blindness and anosognosia with visual confabulation, but without dementia or any memory impairment. It has a unique neuropsychiatric presentation and should be highly suspected in those with odd visual loss and imaging evidence of occipital lobe injury. In the case discussed herein, a 90-year-old man presented with bilateral blindness, obvious anosognosia, and vivid visual confabulation, which he had had for 3 days. Brain computed tomography demonstrated recent hypodense infarctions at the bilateral occipital lobes. Thus, the patient was diagnosed with Anton-Babinski syndrome. Because of his age and the thrombolytic therapy during the golden 3 hours after ischemic stroke, the patient received aspirin therapy rather than tissue plasminogen activator or warfarin. He gradually realized he was blind during the following week, but died of pneumonia 1 month later. In the literature, it is difficult to establish awareness of blindness in patients with Anton-Babinski syndrome, but optimistically, in one report, a patient was aware of blindness within 2 weeks, without vision improvement. Our case illustrates that elderly patients with Anton-Babinski syndrome can partially recover and that 1 week is the shortest time for the establishment of awareness of blindness for sufferers without vision improvement.

Vestibular migraine has higher correlation with carsickness than non-vestibular migraine and Meniere's disease.

PURPOSE: To investigate whether patients with vestibular migraine (VM) are more susceptible to carsickness than patients with non-vestibular migraine (NVM) or Meniere's disease (MD). METHODS: Consecutive patients with a diagnosis of definite VM, probable VM, NVM, or MD at our Headache and Dizziness clinics were interviewed using the same three questions to investigate the history of carsickness. The patients who had experienced carsickness in their lifetime and those who had still experienced carsickness in the past ten years were identified. The rates of carsickness were compared between groups. RESULTS: 78.4% of the VM patients had experienced carsickness in their lifetime, which was significantly higher than the patients with NVM (43.6%) and MD (18.2%). Both the lifetime rate of carsickness and the rate in the past ten years were highest in the patients with definite VM, followed by probable VM, NVM, and MD (p less than 0.05, chi-square test). The odds ratio of lifetime carsickness for VM versus MD was high (8.7). CONCLUSION: Both patients with definite VM and probable VM were more susceptible to carsickness than the patients with NVM or MD. This reinforces the theory of vestibular hypersensitivity in VM. We suggest that a past history of carsickness may help in the diagnosis of VM, and especially in distinguishing VM from MD.

Spontaneous vertebral artery dissection with thunderclap headache: a case report and review of the literature.

PURPOSE: Vertebral artery dissection (VAD) is an important and under-recognized etiology of stroke in young patients. No clinical symptoms or signs appear to be specific for VAD. This report describes a representative patient and reviews the headache pattern and imaging findings commonly noted in VAD to help with the early diagnosis of VAD. CASE REPORT: A 44-year-old female presented with severe right posterior neck pain and vertigo followed closely by thunderclap headache that was confirmed as right VAD (V4 segment) with delayed right dorsal medullary infarction two days later. Her headache, vertigo, and truncal ataxia were completely improved one week later. CONCLUSION: The most common neuroimaging findings of VAD were vertebral artery stenosis, followed by the string and pearls sign, arterial dilation, arterial occlusion, and the less common but most characteristic features of pseudoaneurysm formation, double lumen, and intimal flap. Pain in VAD mostly occurred in the ipsilateral posterior occipitonuchal region, with throbbing features in 50- 60% of the patients. Only one fifth of patients with VAD present with a thunderclap pattern. In stroke among young patients or stroke with pain in the head and neck, angiography study of the craniocervical artery is highly recommended.

Oxfordshire Community Stroke Project classification improves prediction of post-thrombolysis symptomatic intracerebral hemorrhage.

BACKGROUND: The Oxfordshire Community Stroke Project (OCSP) classification is a simple stroke classification system with value in predicting clinical outcomes. We investigated whether and how the addition of OCSP classification to the Safe Implementation of Thrombolysis in Stroke (SITS) symptomatic intracerebral hemorrhage (SICH) risk score improved the predictive performance. METHODS: We constructed an extended risk score by adding an OCSP component, which assigns 3 points for total anterior circulation infarcts, 0 point for partial anterior circulation infarcts or lacunar infarcts. Patients with posterior circulation infarcts were assigned an extended risk score of zero. We analyzed prospectively collected data from 4 hospitals to compare the predictive performance between the original and the extended scores, using area under the receiver operating characteristic curve (AUC) and net reclassification improvement (NRI). RESULTS: In a total of 548 patients, the rates of SICH were 7.3% per the National Institute of Neurological Diseases and Stroke (NINDS) definition, 5.3% per the European-Australasian Cooperative Acute Stroke Study (ECASS) II, and 3.5% per the SITS-Monitoring Study (SITS-MOST). Both scores effectively predicted SICH across all three definitions. The extended score had a higher AUC for SICH per NINDS (0.704 versus 0.624, P = 0.015) and per ECASS II (0.703 versus 0.612, P = 0.016) compared with the SITS SICH risk score. NRI for the extended risk score was 22.3% (P = 0.011) for SICH per NINDS, 21.2% (P = 0.018) per ECASS II, and 24.5% (P = 0.024) per SITS-MOST. CONCLUSIONS: Incorporation of the OCSP classification into the SITS SICH risk score improves risk prediction for post-thrombolysis SICH.

Early neurological improvement after intravenous tissue plasminogen activator infusion in patients with ischemic stroke aged 80 years or older.

BACKGROUND: Early neurological improvement has been observed in patients with stroke receiving treatment with standard intravenous recombinant tissue plasminogen activator. However, the effectiveness of thrombolytic treatment and the risk of hemorrhagic transformation are not well understood in patients aged ≥ 80 years. In this study, we investigated the influence of age on early neurological improvement and hemorrhagic transformation rates in patients with stroke aged ≥ 80 years and receiving recombinant tissue plasminogen activator. METHODS: The study included 157 patients who received recombinant tissue plasminogen activator infusion at a teaching hospital. The National Institutes of Health Stroke Scale was used to evaluate stroke severity. Early neurological improvement was defined as an improvement of 8 or more points on this scale (compared with baseline) 24 hours after thrombolytic treatment. Neurological improvement was defined as an improvement of 8 or more points (compared with baseline) at discharge. Neurological deterioration was defined as an increase of 4 or more points (compared with baseline). Multivariate analysis was used to evaluate the associations among age, neurological improvement, and hemorrhagic transformation. RESULTS: The rate of early neurological improvement was 36.9% (58/157 patients) and the rate of hemorrhagic transformation was 22.3% (35/157 patients). At discharge, the rate of neurological improvement was 50.9% (80/157 patients) and the rate of neurological deterioration was 13.4% (21/157 patients). There was no statistically significant difference between patients aged ≥ 80 years and those <80 years of age with respect to rates of early neurological improvement, neurological deterioration, or hemorrhagic transformation. Among patients ≥ 80 years, the rate of neurological improvement in those receiving thrombolytic treatment was higher than the rate in those patients not receiving thrombolytic treatment (58.8% vs. 14.1%, p < 0.01). We concluded that thrombolysis increases the rate of neurological improvement in patients aged ≥ 80 years. CONCLUSION: In older patients, thrombolytic treatment increased the rate of neurological improvement compared with patients not receiving the treatment. The study showed that thrombolytic treatment may be beneficial for patients ≥80 years, but should be performed with extreme care.