Saccade behaviour in migraine patients.

BACKGROUND: Voxel-based morphometry studies in migraine patients showed significant grey matter volume reduction in regions involved in the control of saccadic eye movements. We hypothesized that these changes would be reflected in dysfunctional saccadic behaviour. METHODS: Saccades were recorded by infrared oculography using three different paradigms (pro-saccade with gap, pro-saccade overlap and anti-saccade with gap). We compared the results for migraine patients (n = 80) with those for controls (n = 87). RESULTS: No significant differences were found between migraine patients with (n = 46) and without (n = 34) aura. Migraine patients showed a saccadic behaviour that differed from controls in three respects. In migraine patients, the latencies in the pro-saccade with gap paradigm were borderline significantly longer. Moreover, in both the pro-saccade with gap and the pro-saccade overlap paradigm we observed a larger intra-individual variation of the latency in migraine patients. However, the biggest difference was that the patients who received migraine prophylactic therapy made significantly more anti-saccade errors in the anti-saccade with gap paradigm, suggesting that inhibitory saccade control is impaired in migraine patients depending on the severity of the migraine. CONCLUSION: We suggest a deficient inhibitory control, reflecting an executive dysfunction in the dorsolateral prefrontal cortex or a dysfunction in the cingulate cortex, is present in migraine patients.

Cerebral oedema in episodic ataxia.

We report a patient with episodic ataxia (presumably of type 2) who developed cerebral oedema secondary to a common infection (presumably viral). Cerebral oedema may be a part of the clinical spectrum of familial episodic ataxia and argues for an overlap with hemiplegic migraine. It is suggested to consider a diagnosis of episodic ataxia or familial hemiplegic migraine in catastrophic reactions to apparent trivial trauma or infection.

Diagnostic and therapeutic trajectory of cluster headache patients in Flanders.

OBJECTIVE: A fraction of cluster headache (CH) patients face diagnostic delay, misdiagnosis, undertreatment and mismanagement. Specific data for Flanders are warranted. METHODS: Data on CH characteristics, diagnostic process and treatment history were gathered using a self-administered questionnaire with 90 items in CH patients that presented to 4 neurology outpatient clinics. RESULTS: Data for 85 patients (77 men) with a mean age of 44 years (range 23-69) were analysed. 79% suffered from episodic CH and 21% from chronic CH. A mean diagnostic delay of 44 months was reported. 31% of patients had to wait more than 4 years for the CH diagnosis. 52% of patients consulted at least 3 physicians prior to CH diagnosis. Most common misdiagnoses were migraine (45%), sinusitis (23%), tooth/jaw problems (23%), tension-type headache (16%) and trigeminal neuralgia (16%). A significant percentage of patients had never received access to injectable sumatriptan (26%) or oxygen (31%). Most prescribed preventative drugs after the CH diagnosis were verapamil (82%), lithium (35%), methysergide (31%) and topiramate (22%). Despite the CH diagnosis, ineffective preventatives were still used in some, including propranolol (12%), amitriptyline (9%) and carbamazepine (12%). 31% of patients had undergone invasive therapy prior to CH diagnosis, including dental procedures (21%) and sinus surgery (10%). CONCLUSION: Despite the obvious methodological limitations of this study, the need for better medical education on CH is evident to optimize CH management in Flanders.

False perception of visual verticality in multiple sclerosis.

We wanted to investigate to what extent patients with multiple sclerosis (MS), not complaining of dizziness or disequilibrium, may have problems with the estimation of gravidity. Therefore, we studied the static 'subjective visual vertical' (SVV), a test that is thought to reflect mainly otolith function. Further, we correlated SVV measures with the degree of disease disability. A group of outpatients was compared with a group of age- and sex-matched healthy volunteers. The deviations of SVV in patients were significantly larger than in controls. Overall, SVV was abnormal in 48% of individual patients. There was a significant correlation between SVV and the global disability score. The same held true for correlation with the subscores of brainstem and cerebellar complaints. The SVV test proved to be a simple method that was well tolerated by the patients. It can be considered a complementary otoneurological tool for evaluating MS patients. Further, these findings suggest that misperception of the verticality parallels the disability in MS patients.

Saccadic ping pong gaze in coma.

In this report, we describe the peculiar eye movements of a young man who became comatose after a head injury. The eyes moved rhythmically from one side to another, without pausing in the lateral positions. This phenomenon has been described as "ping pong gaze" (PPG), referring to short-cycling periodic alternating gaze with smooth eye deviations. In the present patient, however, a saccadic type of PPG could be confirmed by oculography. Possible clinical and pathophysiological implications are discussed.

Brachioradial pruritus--a peculiar neuropathic disorder.

The case is presented of a middle-aged woman who suffered from lancinating itch on the dorsolateral aspect of the upper arm after a loco-regional injury, first on the right and later on the left side. Brachioradial pruritus (BRP) was diagnosed. Neurophysiologic examination was compatible with a neuropathy at the C5-C6 level, while a negative nerve root block supported an additional central impact. The presumed pathophysiology of BRP is discussed in terms of a neuropathic disorder. We suggest that damage from whatever cause from either the cutaneous nerves or from the more proximal sensory pathways may be the causative physiopathologic basis for this enigmatic disorder. BRP was refractory to different therapeutic approaches, except to lamotrigine. As BRP presents a therapeutic challenge, it seems important to report lamotrigine as a potential new therapy.

Carotid artery aneurysm in human immunodeficiency virus infection.

The case is reported of a patient with human immunodeficiency virus (HIV) infection presenting with isolated headache as the presumed manifestation of a cavernous carotid aneurysm. The relationship between HIV and aneurysms is discussed. Clinicians should be aware of the possibility of carotid aneurysms in HIV-positive patients, even in areas where HIV is not endemic and when no neurological deficit is present. Magnetic resonance imaging is recommended as the initial diagnostic study.

Pathogenesis of Binswanger chronic progressive subcortical encephalopathy.

We studied the clinicopathologic findings in four hypertensive patients with multiple leukomalacia, demyelinated lesions, and lacunar state. Only one patient had clinical evidence of dementia. The periventricular watershed infarcts were attributed to transient episodes of cardiac failure in brains with a compromised circulation in the territory of the deep perforating branches. These observations suggest that Binswanger encephalopathy does not differ from multi-infarct dementia.

Antisaccades and remembered saccades in mild traumatic brain injury.

The most common site of focal lesions after mild traumatic brain injury (MTBI) is the frontal lobe. This lobe, however, is difficult to examine clinically. Neuroimaging is not performed routinely and usually shows normal results in uncomplicated trauma. Antisaccades (AS) and remembered saccades (RS) are neuro-ophthalmological tests of frontal function. This study examined whether there are disturbances of latency time or error rate of AS and RS in patients within 24 h after MTBI. Eye movements were studied with infrared-oculography. Data were obtained prospectively from 25 patients. An additional group of 6 patients with MTBI and alcohol intoxication were also examined. No statistical differences in AS or RS, either for errors or for latency time, were found between a group of age-matched controls and the patients, except in the group of alcohol-intoxicated MTBI patients. Our findings indicate that visual reflex inhibition and initiation of voluntary saccades were not disturbed in the nonintoxicated patients. It is hypothesized that the responsible frontal area was not affected. It is concluded that error rate and latency time of AS and RS are inappropriate measures for evaluating acute MTBI.

Granulomatous angiitis of the nervous system: a clinicopathological study of one case.

The clinical history is presented of a 69-year-old man with a disease starting with a herpes zoster infection and an acute ascending myelopathy, and ending with an intracerebral hemorrhage. The postmortem examination revealed multiple angiitis lesions, restricted to the central nervous system. In review of the 31 previously described cases there were four other patients in whom the granulomatous angiitis of the nervous system (GANS) was associated with a herpes zoster infection. The relation between both disorders is discussed.

Paralytic pontine exotropia in subarachnoid hemorrhage. A clinicopathological correlation.

A syndrome of combined right lateral gaze palsy and right internuclear ophthalmoplegia, followed by a left exotropia in a case of subarachnoid hemorrhage is presented. At necropsy a single small pontine end-zone infarction was found, involving the medial part of the right paramedian pontine reticular formation, the tectospinal tract and the ventral part of the right medial longitudinal fasciculus. The fila radicularia of the right abducens nerve passed through the necrotic area. The mechanism of these characteristic ocular motor disturbances in relation to the post mortem findings and the topopathogenesis of the pontine infarction are discussed.

Migraine-like headache in intraventricular tumours.

In a series of 39 intraventricular tumours, 7 patients had paroxysmal headache as the most important early complaint. The striking similarities with migraine and the misleading role of antimigraine drug therapy are illustrated. Special emphasis is placed on the importance of additional investigations such as funduscopy, EEG, skin X-rays and Ct-scan.

Traumatic dissection of the internal carotid artery as unusual cause of hypoglossal nerve dysfunction.

A dissection of the internal carotid artery (ICA) in a 50-year-old man with hypoglossal nerve dysfunction is reported. This case illustrates how non-invasive imaging techniques, such as computed tomography and magnetic resonance angiography, can demonstrate this unusual etiology.

Optic nerve metastasis simulating optic neuritis.

A 68-year-old man developed subacutely bilateral loss of visual acuity without any other neurological sign. Magnetic resonance images showed some small scattered periventricular white matter T2 hypersignals. On spinal fluid analysis a mononuclear pleocytosis and an oligoclonal gamma-pattern was found. Treatment with intravenous corticosteroids had no effect. The clinical situation deteriorated and the patient died of bronchopneumonia. Postmortem examination revealed manifest metastatic invasion of both the optic nerves by a non-detectable primary tumor.

Vertebrobasilar insufficiency due to Tumoural emboli.

A case, which is clinically characterized by a subacute vertebrobasilar syndrome, is presented. The necropsy reveals multiple infarcts in brainstem, cerebellum and left cerebral hemisphere, due to tumoural emboli of a non-detected primary tumour. It is postulated that the latter has to originate in the lungs in order to produce this unique type of cerebral arterial embolism.

Positron emission tomographic study of late-onset cryptogenic symptomatic seizures.

Ten patients with epilepsy of unknown origin, starting after the age of 50 years, and without clear evidence of cognitive decline were studied with positron emission tomography, using the steady state technique with 15O. Cerebral blood flow and oxygen metabolism were significantly decreased in all cortical areas. No focal areas of hypometabolism were detected. Treatment with phenytoin did not influence the results. It is suggested that late-onset seizures could be the premonitory signs of a progressive encephalopathy of unknown origin.

The effect of cognitive load on saccadic eye movements.

The present study tested the hypothesis that, unlike prosaccades, antisaccades require controlled processing, due to the prepotent response that needs to be inhibited. The effect of the Random time Interval Generation (RIG) task (Vandierendonck, A., De Vooght, G., & Van der Goten, K. (1998). European Journal of Cognitive Psychology, 10, 413-444) on these saccade latencies and errors was studied. This task has the advantage that it loads executive processes, with only minimal interference with verbal or visuo-spatial components. A first experiment compared saccade performance within the prosaccade and the antisaccade task, executed alone and in combination with the RIG task and fixed tapping (added to exclude possible motor component interference explanations). A second experiment investigated the influence of task characteristics on the effects found. Although it was shown that antisaccades are more prone to interference of an executive interference task, it seems that prosaccades are also vulnerable. Interference on prosaccades could originate from a controlled execution of these saccades. A third experiment confirmed that endogenously generated prosaccades are susceptible to dual-task interference and showed that controlled saccade execution, without the need to inhibit a prepotent response, is sufficient to produce interference.

Abnormal psychophysical visual perception in Parkinson's disease patients.

Several visual dysfunctions in Parkinson's disease (PD) are described. Most of them are subtle or only demonstrated by stimulus-specific electrophysiologic or psychophysical testing. However, these minor deficits are thought to be of clinical relevance as they are related to direct or indirect complaints. Special emphasis is laid on visual hallucinations. These are most likely of multifactorial origin. The relation between hallucinations in PD and in dementia with Lewy bodies has to be elaborated further. Visual loss, as a possible and reversible cause of visual hallucinations should be actively sought and corrected as far as possible. An underlying role of dopaminergic retinal cells in visual dysfunction of PD patients is widely recognised. However, whether the basic abnormality resides also in the visual cortex remains to be elucidated. Other neurotransmitters may also be involved. It has not been answered whether visual dysfunction might distinguish PD from other forms of parkinsonism.

Central pontine myelinolysis and its arterial blood supply.

A case of central pontine myelinolysis is described. The clinical, angiographic and post mortem findings suggest that among the associated disorders the oligemic shock combined with a local decreased flow in the basilar artery was the most important cause of this patholigical entity. The angioarchitecture findings in the brain stem, compared to these in 26 normal brains, confirm this hypothesis.

Electrophoretic study of the cerebrospinal fluid proteins of a patient with multiple sclerosis and recurrent meningitis (with rhinorrhea).

Case report on a 33 year old multiple sclerosis patient showing recurrent meningitis with an episode of rhinorrhea. The emphasis was put on the protein electrophoresis patterns.