Ten-year follow-up in a case series of integrative botulinum toxin intervention in adolescents with chronic daily headache and associated muscle pain.

INTRODUCTION: A total of 83% of children report headache during a 6-month period. The estimated 1-year prevalence of chronic daily headache (CDH) in children is at least 1 to 2%. Muscle pain is associated with headache severity and chronicity. Muscle pain can be associated with active muscular trigger points, a functional concept still remaining a controversy. An integrated approach including bio-behavioral management is accepted as standard treatment but does not provide sufficient pain relief in all patients. OBJECTIVE: We report the individual clinical course of five adolescents with treatment-refractory CDH associated with focal muscle pain. We describe a concept of short-term integrative intervention including botulinum toxin (StiBo) in a personalized "follow the referred pain pattern" injection regimen with the focus on long-term follow-up. RESULTS: StiBo showed short-term efficacy on headache frequency and severity. In the long-term follow-up, CDH was not existent in any of the patients. CONCLUSION: The treatment may have enabled the patients to draw attention away from a repeated circle of muscle-triggered pain and withdrawal of daily activities toward self-driven activities, thereby potentially preventing the development of further chronification. To prove this hypothesis, a prospective, placebo-controlled study in young adolescents with CDH should be initiated including objective outcome parameters on muscular level.

[Non-invasive estimation of intracranial pressure : MR-based evaluation in children with hydrocephalus]. / Nichtinvasive Bestimmung des intrakraniellen Drucks : MR-basierte Untersuchung bei Kindern mit Hydrozephalus.

CLINICAL/METHODICAL ISSUE: The intracranial pressure (ICP) is a crucially important parameter for diagnostic and therapeutic decision-making in patients with hydrocephalus. STANDARD RADIOLOGICAL METHODS: So far there is no standard method to non-invasively assess the ICP. Various approaches to obtain the ICP semi-invasively or non-invasively are discussed and the clinical application of a magnetic resonance imaging (MRI)-based method to estimate ICP (MR-ICP) is demonstrated in a group of pediatric patients with hydrocephalus. METHODICAL INNOVATIONS: Arterial inflow, venous drainage and craniospinal cerebrospinal fluid (CSF) flow were quantified using phase-contrast imaging to derive the MR-ICP. PERFORMANCE: A total of 15 patients with hydrocephalus (n=9 treated with shunt placement or ventriculostomy) underwent MRI on a 3 T scanner applying retrospectively-gated cine phase contrast sequences. Of the patients six had clinical symptoms indicating increased ICP (age 2.5-14.61 years, mean 7.4 years) and nine patients had no clinical signs of elevated ICP (age 2.1-15.9 years; mean 9.8 years; all treated with shunt or ventriculostomy). Median MR-ICP in symptomatic patients was 24.5 mmHg (25th percentile 20.4 mmHg; 75th percentile 44.6 mmHg). Median MR-ICP in patients without acute signs of increased ICP was 9.8 mmHg (25th percentile 8.6 mmHg; 75th percentile 11.4 mmHg). Group differences were significant (p < 0.001; Mann-Whitney U-test). ACHIEVEMENTS: The MR-ICP technique is a promising non-invasive tool for estimating ICP. PRACTICAL RECOMMENDATIONS: Further studies in larger patient cohorts are warranted to investigate its application in children with hydrocephalus.

Alterations in the trapezius muscle in young patients with migraine--a pilot case series with MRI.

BACKGROUND/PURPOSE: Migraine is frequent in young adults and adolescents and often associated with neck muscle tension and pain. Common pathophysiological pathways, such as reciprocal cervico-trigeminal activation, are assumed. Tense areas within the neck muscles can be clinically observed many patients with migraine. The aim of this pilot case study was to visualize these tense areas via magnet resonance imaging (MRI). METHODS: Three young patients with migraine were examined by an experienced investigator. In all three patients tense areas in the trapezius muscles were palpated. These areas were marked by nitroglycerin capsules on the adjacent skin surface. RESULTS: The MRI showed focal signal alterations at the marked locations within the trapezius muscles. CONCLUSION: Visualization of palpable tense areas by MRI may be usefully applied in the future to help elucidate the underlying pathophysiological processes of migraine.

Early white matter changes in childhood multiple sclerosis: a diffusion tensor imaging study.

BACKGROUND AND PURPOSE: Loss of integrity in nonlesional white matter occurs as a fundamental feature of multiple sclerosis in adults. The purpose of our study was to evaluate DTI-derived measures of white matter microstructure in children with MS compared with age- and sex-matched controls by using tract-based spatial statistics. MATERIALS AND METHODS: Fourteen consecutive pediatric patients with MS (11 female/3 male; mean age, 15.1 ± 1.6 years; age range, 12-17 years) and age- and sex-matched healthy subjects (11 female/3 male; mean age, 14.8 ± 1.7 years) were included in the study. After we obtained DTI sequences, data processing was performed by using tract-based spatial statistics. RESULTS: Compared with healthy age- and sex-matched controls, children with multiple sclerosis showed a global decrease in mean fractional anisotropy (P ≤ .001), with a concomitant increase in mean (P < .001), radial (P < .05), and axial diffusivity (P < .001). The most pronounced fractional anisotropy value decrease in patients with MS was found in the splenium of the corpus callosum (P < .001). An additional decrease in fractional anisotropy was identified in the right temporal and right and left parietal regions (P < .001). Fractional anisotropy of the white matter skeleton was related to disease duration and may, therefore, serve as a diagnostic marker. CONCLUSIONS: The microstructure of white matter is altered early in the disease course in childhood multiple sclerosis.