Catechol-O-Methyltransferase Val158Met Polymorphism Is Associated with Anxiety, Depression, and Widespread Pressure Pain Sensitivity in Women with Chronic, but Not Episodic, Migraine.

OBJECTIVES: To analyze the association between the rs4680 catechol-O-methyltransferase Val158Met polymorphism and to determine the association of this polymorphism with clinical, psychological, and pain sensitivity variables in women with episodic or chronic migraine. METHODS: Fifty women with episodic migraine, 50 with chronic migraine, and 50 matched healthy women participated. After amplifying the Val158Met polymorphism by polymerase chain reaction, we assessed genotype frequencies and allele distributions. Participants were classified according to the Val158Met polymorphism genotype into Val/Val, Val/Met, or Met/Met. A headache diary was used for collecting migraine pain features. Disability was assessed with the Migraine Disability Assessment Scale, trait/state anxiety levels with the State-Trait Anxiety Inventory, and depression/anxiety with the Hospital Anxiety and Depression Scale. Pressure pain thresholds (PPTs) were bilaterally assessed over the temporalis, the upper trapezius, the second metacarpal, and the tibialis anterior. RESULTS: The distribution of the rs4680 Val158Met genotype was not significantly different between women with and without migraine (P = 0.157). No differences in migraine features were found to be dependent on the Val158Met genotype. Women with the Met/Met genotype showed higher migraine-related disability than those with the Val/Val or Val/Met genotype in both migraine groups (P < 0.01). Women with chronic, but not episodic, migraine with the Met/Met genotype exhibited higher depressive and anxiety levels and lower PPTs than those with the Val/Val or Val/Met genotype. CONCLUSIONS: The Val158Met rs4680 polymorphism does not appear to be involved in predisposition to suffer from migraine; however, this genetic factor may be involved in the phenotypic expression of chronic migraine, as anxiety, depression, and widespread pressure pain sensitivity were greater in those women with chronic, but not episodic, migraine with the Met/Met genotype.

Trigger points are associated with widespread pressure pain sensitivity in people with tension-type headache.

Objective To investigate the association between trigger points (TrPs) and widespread pressure pain sensitivity in people with tension-type headache (TTH) and to determine if this association is different between frequent episodic (FETTH) or chronic (CTTH) headache. Design A cross-sectional study. Methods One hundred and fifty-seven individuals (29% male) with TTH participated. Clinical features of headache, i.e., intensity, duration, and frequency, were recorded in a headache diary. Active and latent TrPs were bilaterally explored in the temporalis, masseter, suboccipital, upper trapezius, sternocleidomastoid, and splenius capitis muscles. Pressure pain thresholds (PPT) were assessed over the trigeminal area (i.e., temporalis muscle), extra-trigeminal (i.e., C5/C6 zygapophyseal joint), and two distant pain-free points (i.e., second metacarpal and tibialis anterior muscle). Results Eighty (51%) patients were classified as FETTH, whereas 77 (49%) were classified as CTTH. No differences in the number of either active or latent TrPs (all p > 0.171) or widespread pressure pain sensitivity (all p > 0.351) were observed between FETTH and CTTH groups. The number of active and latent TrPs was significantly and negatively associated with PPTs: The higher the number of active or latent TrPs, the lower the widespread PPT, and the more generalized sensitization. This association was stronger within the FETTH group than the CTTH group. Conclusions This study found that the number of TrPs in head and neck/shoulder muscles was associated with widespread pressure hypersensitivity independently of the frequency of headache.

Analysis of Head Posture and Activation of the Cervical Neck Extensors During a Low-Load Task in Women With Chronic Migraine and Healthy Participants.

OBJECTIVE: The purpose of this study was to investigate the correlation between head and neck posture and superficial neck flexor and extensor activity during performance of the craniocervical flexion test (CCFT) in women with migraine and healthy controls. METHODS: Fifty-two women with episodic migraine, 16 with chronic migraine, and 23 healthy controls participated. Head and neck posture were determined by assessing the craniovertebral (CV) angle and cervical lordosis angle. Surface electromyography signals were recorded bilaterally from sternocleidomastoid, anterior scalene, splenius capitis, and upper trapezius muscles as participants performed the CCFT. Differences in electromyogram activity and posture among groups were compared with analyses of variance. Correlations between posture and electromyogram activity were analyzed with the Pearson correlation coefficient. RESULTS: Both migraine groups had a significant increase in splenius capitis muscle activity, when acting as an antagonist, at the last stage of CCFT (F = 4.687; P = .012) compared with controls. No differences among groups were observed for head and neck posture. No significant correlation was found in the episodic migraine group. Moderate correlations between the CV angle and upper trapezius activity at the majority stages of the CCFT (-0.61 < r < -0.65, all P < .05) were observed within the chronic migraine group: the more extended the head posture, the higher the activity of the upper trapezius muscle. The CV angle also was correlated with upper trapezius muscle activity at the first stage of the CCFT and with splenius capitis muscle activity at the last stages (-0.42 < r < -0.52; P < .05). CONCLUSION: An extended (forward) head posture was moderately correlated with an increased in electrical activity of superficial neck extensor muscles, particularly the upper trapezius, when acting as an antagonist, during the performance of the CCFT in women with chronic but not episodic migraine.

Women with Chronic and Episodic Migraine Exhibit Similar Widespread Pressure Pain Sensitivity.

OBJECTIVE: To investigate widespread pressure hyperalgesia in the trigemino-cervical and extra-trigeminal (distant pain-free) regions in women with episodic and chronic migraine. METHODS: Fifty-one women with episodic migraine, 52 women with chronic migraine, and 52 healthy women without headache history were recruited. Pressure pain thresholds (PPT) were bilaterally assessed over the trigeminal area (i.e., temporalis muscle), cervical area (i.e., C5/C6 zygapophyseal joint), and two extra-trigeminal areas (i.e., second metacarpal, tibialis anterior muscle) in a blinded design. Clinical features of migraine and anxiety/depression (Hospital Anxiety and Depression Scale, HADS) were also assessed. RESULTS: The multivariate analysis of covariance (ANCOVA) revealed that PPTs were significantly decreased bilaterally over trigeminal and extra-trigeminal points in migraine patients compared to healthy women (all sites, P < 0.001). No differences between episodic and chronic migraine were observed (all, P > 0.919). The presence of neck pain (all, P > 0.282), anxiety (P > 0.425) or depression (all, P > 0.316) did not influence the results. The intensity of migraine pain was negatively associated with widespread pressure pain sensitivity: The greater the intensity of migraine attacks, the lower the widespread PPT levels, i.e., the greater the widespread sensitization. CONCLUSIONS: This study found similar widespread pressure hypersensitivity in women with episodic or chronic migraine suggesting that central manifestations are involved both in episodic and chronic migraine.

Real-world experience of OnabotulinumtoxinA treatment in female patients with chronic migraine: a qualitative study using in-depth interviews.

BACKGROUND: Chronic migraine (CM) causes great disability and affects an individual's quality of life. OnabotulinumtoxinA (OBT-A, Botox®) was the first prophylactic treatment specifically indicated for CM. The aim of this study was to describe the experiences of women with CM treated with OBT-A. MATERIALS AND METHODS: The study design is a qualitative descriptive study. A purposeful sampling of 30 women (mean age, 42.7; standard deviation, 10.6) who had received at least two administrations of OBT-A for CM (PREEMPT protocol) was performed. Data collection included in-depth interviews and researchers' field notes. A thematic analysis was carried out according to qualitative research guidelines. RESULTS: Five themes were identified: (a) A long way to go before Botox®, (b) First time hearing about the treatment and its expectations, (c) The administration of Botox®, (d) Treatment effects, and (e) Follow-up. Patients described a long history of treatment failures prior to the start of OBT-A treatment. Information about this migraine treatment came from the neurologist; following the information, patients had high expectations, including unrealistic expectations regarding the onset and duration of effect. They acknowledged fear of the injections and some discomfort due to the procedure. With treatment, participants reported better migraine control and an improvement in their quality of life. Follow-up had some barriers, such as delayed appointments for subsequent doses, but also strengths, such as effectiveness and few side effects. CONCLUSIONS: Qualitative research offers insight into how patients with CM experience treatment with OBT-A. Our results highlight some relevant aspects that should be considered when providing OBT-A treatment.

Women had unrealistic expectations regarding the onset and duration of OBT-A effect.With OBT-A treatment, women perceived better migraine control and improved quality of life.Follow-up had barriers, such as delayed appointments for subsequent doses.

Path Analysis Models Integrating Psychological, Psycho-physical and Clinical Variables in Individuals With Tension-Type Headache.

Tension type headache (TTH) is a prevalent but poorly understood pain disease. Current understanding supports the presence of multiple associations underlying its pathogenesis. Our aim was to compare competing multivariate pathway models that explains the complexity of TTH. Headache features (intensity, frequency, or duration - headache diary), headache-related disability (Headache Disability Inventory-HDI), anxiety/depression (Hospital Anxiety and Depression Scale), sleep quality (Pittsburgh Sleep Quality Index), widespread pressure pain thresholds (PPTs) and trigger points (TrPs) were collected in 208 individuals with TTH. Four latent variables were formed from the observed variables - Distress (anxiety, depression), Disability (HDI subscales), Severity (headache features), and Sensitivity (all PPTs). Structural equation modelling (SEM) and Bayesian network (BN) analyses were used to build and compare a theoretical (modeltheory) and a data-driven (modelBN) latent variable model. The modelBN (root mean square error of approximation [RMSEA] = 0.035) provided a better statistical fit than modeltheory (RMSEA = 0.094). The only path common between modelbn and modeltheory was the influence of years with pain on TrPs. The modelBN revealed that the largest coefficient magnitudes were between the latent variables of Distress and Disability (ß=1.524, P = .006). Our theoretical model proposes a relationship whereby psycho-physical and psychological factors result in clinical features of headache and ultimately affect disability. Our data-driven model proposes a more complex relationship where poor sleep, psychological factors, and the number of years with pain takes more relevance at influencing disability. Our data-driven model could be leveraged in clinical trials investigating treatment approaches in TTH. PERSPECTIVE: A theoretical model proposes a relationship where psycho-physical and psychological factors result in clinical manifestations of headache and ultimately affect disability. A data-driven model proposes a more complex relationship where poor sleep, psychological factors, and number of years with pain takes more relevance at influencing disability.

Network Analysis Reveals That Headache-Related, Psychological and Psycho-Physical Outcomes Represent Different Aspects in Women with Migraine.

Evidence supports that migraine is a complex pain condition with different underlying mechanisms. We aimed to quantify potential associations between demographic, migraine-related, and psychophysical and psychophysical variables in women with migraine. Demographic (age, height, and weight), migraine-related (intensity, frequency, and duration), related-disability (Migraine Disability Assessment Scale, Headache Disability Inventory), psychological (Hospital Anxiety and Depression Scale), and psycho-physical (pressure pain thresholds -PPTs-) variables were collected from a sample of 74 women suffering from migraine. We calculated adjusted correlations between the variables by using a network analysis. Additionally, we also calculated centrality indices to identify the connectivity among the variables within the network and the relevance of each variable in the network. Multiple positive correlations (ρ) between PPTs were observed ranging from 0.1654 (C5-C6 and tibialis anterior) to 0.40 (hand and temporalis muscle). The strongest associations within the network were those between migraine attack frequency and diagnosis of chronic migraine (ρ = 0.634) and between the HDI-E and HDI-P (ρ = 0.545). The node with the highest strength and betweenness centrality was PPT at the second metacarpal, whereas the node with the highest harmonic centrality was PPT at the tibialis anterior muscle. This is the first study applying a network analysis to understand the underlying mechanisms in migraine. The identified network revealed that a model where each subgroup of migraine-related, psychological, and psycho-physical variables showed no interaction between each variable. Current findings could have clinical implications for developing multimodal treatments targeting the identified mechanisms.

Blood-brain barrier opening with focused ultrasound in Parkinson's disease dementia.

MR-guided focused ultrasound (MRgFUS), in combination with intravenous microbubble administration, has been applied for focal temporary BBB opening in patients with neurodegenerative disorders and brain tumors. MRgFUS could become a therapeutic tool for drug delivery of putative neurorestorative therapies. Treatment for Parkinson's disease with dementia (PDD) is an important unmet need. We initiated a prospective, single-arm, non-randomized, proof-of-concept, safety and feasibility phase I clinical trial (NCT03608553), which is still in progress. The primary outcomes of the study were to demonstrate the safety, feasibility and reversibility of BBB disruption in PDD, targeting the right parieto-occipito-temporal cortex where cortical pathology is foremost in this clinical state. Changes in ß-amyloid burden, brain metabolism after treatments and neuropsychological assessments, were analyzed as exploratory measurements. Five patients were recruited from October 2018 until May 2019, and received two treatment sessions separated by 2-3 weeks. The results are set out in a descriptive manner. Overall, this procedure was feasible and reversible with no serious clinical or radiological side effects. We report BBB opening in the parieto-occipito-temporal junction in 8/10 treatments in 5 patients as demonstrated by gadolinium enhancement. In all cases the procedures were uneventful and no side effects were encountered associated with BBB opening. From pre- to post-treatment, mild cognitive improvement was observed, and no major changes were detected in amyloid or fluorodeoxyglucose PET. MRgFUS-BBB opening in PDD is thus safe, reversible, and can be performed repeatedly. This study provides encouragement for the concept of BBB opening for drug delivery to treat dementia in PD and other neurodegenerative disorders.

Variables Associated With the Use of Prophylactic Amitriptyline Treatment in Patients With Tension-type Headache.

OBJECTIVE: The objective of this study was to investigate differences in clinical, psychological, and psychophysical outcomes according to use of prophylactic medication (amitriptyline) in tension-type headache (TTH). METHODS: In total, 173 individuals with TTH participated. Headache features and symptomatic medication intake were collected with a 4-weeks headache diary at baseline and at 6-months. Burden of headache (Headache Disability Inventory-HDI), sleep quality (Pittsburgh Sleep Quality Index-PSQI), anxiety/depression (Hospital Anxiety and Depression Scale-HADS), and trait/state anxiety levels (State-Trait Anxiety Inventory-STAI) were also assessed at baseline. Pressure pain thresholds (PPT) were assessed over the temporalis, C5-C6 joint, second metacarpal, and tibialis anterior at baseline. Differences between participants taking or not taking prophylactic medication based on self-perceived effectiveness of the medication on headache characteristics were assessed. RESULTS: In total, 49 (28%) reported taking prophylactic medication for the headaches (amitriptyline: 100%). From these, 11 (23%) reported no effect, 25 (51%) reported moderate effect, and 13 (26%) reported positive effect with medication. Patients taking prophylactic medication had longer headache history, higher frequency of headaches (61% CTTH), higher headache burden, worse quality of sleep, and higher depression than those not taking medication. Prophylactic medication was less effective in patients with generalized pressure pain hyperalgesia. No other significant differences were found. CONCLUSIONS: Prophylactic medication is used by TTH patients with higher headache frequency, higher headache burden, worse sleep quality, and higher depression. Lower effectiveness of prophylactic amitriptyline was associated with widespread pain hyperalgesia.

Spatial Distribution of Temporalis Pressure Pain Sensitivity in Men with Episodic Cluster Headache.

(1) Background: Spatial changes in pressure sensitivity have been described in migraine and tension-type headaches. Our aim was to determine differences in the spatial distribution of pressure pain sensitivity of the temporalis muscle between cluster headache (CH) patients and headache-free controls; (2) Methods: Pressure pain thresholds (PPTs) were determined over nine points covering the temporalis muscle in 40 men with episodic CH and 40 matched headache-free controls in a blinded fashion. Topographical pressure pain sensitivity maps were constructed based on interpolation of the PPTs. Patients were evaluated in a pain-free period (remission phase), at least 3 months from the last attack and without medication; (3) Results: The analysis of covariance (ANCOVA) found significant difference between points (F = 21.887; P < 0.001) and groups (F = 24.416; P = 0.602), but not between sides (F = 0.440; P = 0.508). No effect of depression (F = 0.014; P = 0.907) or anxiety (F = 0.696; F = 0.407) was observed. A post-hoc analysis revealed: 1) lower PPTs at all points in patients than in controls, 2) an anterior-to-posterior gradient in patients but not in controls, with lower PPTs located in the anterior column. Large between-groups effects were shown in all points (standardized mean difference, SMD > 0.8); (4) Conclusions: Bilateral pressure pain hypersensitivity to pressure pain in the temporalis muscle and an anterior-to-posterior gradient to pressure pain was observed in men with episodic CH.

Musculoskeletal disorders of the upper cervical spine in women with episodic or chronic migraine.

BACKGROUND: The role of musculoskeletal disorders of the cervical spine in migraine is under debate. AIM: To investigate differences in musculoskeletal impairments of the neck including active global and upper cervical spine mobility, the presence of symptomatic upper cervical spine joints, cervicocephalic kinesthesia and head/neck posture between women with episodic migraine, chronic migraine, and controls. DESIGN: A cross-sectional study. SETTING: Tertiary university-based hospital. POPULATION: Fifty-five women with episodic migraine, 16 with chronic migraine, and 22 matched healthy women. METHODS: Active cervical range of motion, upper cervical spine mobility (i.e., flexion-rotation test), referred pain from upper cervical joints, cervicocephalic kinesthesia (joint position sense error test, JPSE), and head/neck posture (i.e. the cranio-vertebral and cervical lordosis angles) were assessed by an assessor blinded to the subject's condition. RESULTS: Women with migraine showed reduced cervical rotation than healthy women (P=0.012). No differences between episodic and chronic migraine were found in cervical mobility. Significant differences for flexion-rotation test were also reported, suggesting that upper cervical spine mobility was restricted in both migraine groups (P<0.001). Referred pain elicited on manual examination of the upper cervical spine mimicking pain symptoms was present in 50% of migraineurs. No differences were observed on the frequency of symptomatic upper cervical joints between episodic and chronic migraine. No differences on JPSE or posture were found among groups (P>0.121). CONCLUSIONS: Women with migraine exhibit musculoskeletal impairments of the upper cervical spine expressed as restricted cervical rotation, decreased upper cervical rotation, and the presence of symptomatic upper cervical joints. No differences were found between episodic or chronic migraine. CLINICAL REHABILITATION IMPACT: Identification treatment of the musculoskeletal impairments of the cervical spine may help to clinician for better management of patients with migraine.

Active Trigger Points in the Cervical Musculature Determine the Altered Activation of Superficial Neck and Extensor Muscles in Women With Migraine.

OBJECTIVE: Previous studies have demonstrated the presence of active trigger points (TrPs) in women with migraine reproducing their headache attacks. No study has investigated whether these TrPs can alter cervical muscle function in migraine. Our objective was to analyze differences in the activation of superficial neck flexor and extensor muscles in women with migraine considering the presence of active TrPs in the splenius capitis (SC), the upper trapezius (UT), and the sternocleidomastoid (SCM) muscles. METHODS: Surface electromyography (EMG) was recorded from the superficial flexors (SCM and anterior scalene) and the extensor (SC, UT) muscles bilaterally as participants performed a staged task of cranio-cervical flexion (CCF; 5 contractions representing a progressive increase in CCF range of motion) in 70 women with migraine. They were stratified according to the presence or the absence of active TrPs in the SCM, the SC, or the UT musculature. A comparison of EMG normalized root mean square (RMS) values was conducted with a 2×5 analysis of covariance with the task level as the within-subject variable, group stratified by active TrPs as the between-subjects variable and the presence of neck pain as a covariable. RESULTS: All patients exhibited active TrPs in their cervical muscles, which reproduced their migraine. Women with migraine exhibiting active TrPs in the SCM (P<0.01), the UT (P<0.05), or the SC (P<0.05) muscles had lower normalized RMS values of their superficial neck flexors than those without active TrPs in the same muscles. In addition, individuals exhibiting active TrPs in the SC and the UT (both, P<0.05) muscles had higher normalized RMS values in the SC muscle than those without active TrPs in the same muscles. CONCLUSIONS: The presence of active TrPs in the cervical musculature determines an altered activation of superficial neck and extensor muscles during low-load, isometric CCF contractions in women with migraine.

[Neurological examination in patients undergoing sedation with propofol: a descriptive study]. / Exploracion neurologica en pacientes sometidos a sedacion con propofol: estudio descriptivo.

INTRODUCTION: The neurological examination is a resource used in evaluating patients who are in coma. Anaesthesia can be a factor that exerts an influence on the findings. We evaluated the examination of the comatose patient in the case of patients anaesthetised with propofol in order to define its clinical value. PATIENTS AND METHODS: A prospective study was conducted among those who had undergone heart surgery in the intensive care unit of a tertiary hospital during the months of April and May 2011. Aspects that were analysed were the examination of the anaesthetic coma, pharmacological or medical factors that can have an influence and a full neurological examination following recovery. Patients with previous neurological symptoms were excluded. RESULTS: Thirty patients were selected (16 males and 14 females); mean age: 72 ± 10 years. All the patients were sedated with propofol. During sedation, 17 (46.7%) presented unreactive pupils. No spontaneous eye movements were observed in 100% of the sample. Ocular alterations in primary position were observed in 23.3% of them. Oculocephalic reflexes were absent in 93.3% and oculovestibular reflexes, in 100%; the corneal reflex, was absent in 70% (with asymmetry), as was the ciliospinal reflex, in 83.3%. The algesic motor response was absent in 93.3%, as were the cutaneous plantar extensor reflexes, in 20%; and 66.7% were indifferent. Following anaesthesia, the neurological examination was normal in 80%, there were slight orientation impairments in 16.7% and a hemispheric syndrome was found in one patient. CONCLUSIONS: Anaesthesia with propofol alters the reversible cutaneous-plantar, pupillary, trunk and motor response reflexes on withdrawing sedation. The alterations may be asymmetrical. Neurological examinations should not be used in the case of patients sedated with propofol in order to make clinical decisions.

TITLE: Exploracion neurologica en pacientes sometidos a sedacion con propofol: estudio descriptivo.Introduccion. La exploracion neurologica es un recurso en la evaluacion de los pacientes en coma. La anestesia puede ser un factor influyente en los hallazgos. Evaluamos la exploracion del paciente en coma en pacientes anestesiados con propofol para definir su valor clinico. Pacientes y metodos. Estudio prospectivo en sometidos a cirugia cardiaca en los cuidados intensivos de un hospital terciario durante los meses de abril y mayo de 2011. Se analiza la exploracion del coma anestesico, factores farmacologicos o medicos que pueden influir y exploracion neurologica completa tras la recuperacion. Se excluyeron pacientes con sintomas neurologicos previos. Resultados. Se seleccionan 30 pacientes (16 hombres y 14 mujeres); edad media: 72 ± 10 años. Todos los pacientes estaban sedados con propofol. Durante la sedacion, 17 (46,7%) presentaban pupilas arreactivas. En el 100% no se observaron movimientos espontaneos de los ojos. El 23,3% presentaba alteracion ocular en posicion primaria. Los reflejos oculocefalicos estaban ausentes en el 93,3%, y los oculovestibulares, en el 100%; el reflejo corneal, en el 70% (con asimetria); el espinociliar, en el 83,3%. La respuesta motora algesica estaba ausente en el 93,3%; en un 20%, los reflejos cutaneoplantares extensores; e indiferentes, en el 66,7%. Tras la anestesia, la exploracion neurologica fue normal en el 80%, hubo leves alteraciones de orientacion en un 16,7% y se encontro un sindrome hemisferico en un paciente. Conclusiones. La anestesia con propofol altera los reflejos pupilares, del tronco, respuestas motoras y reflejo cutaneoplantar reversibles al retirar la sedacion. Las alteraciones pueden ser asimetricas. No se deberia utilizar la exploracion neurologica en el paciente sedado con propofol para la toma de decisiones clinicas.

Epicrania fugax como forma de inicio de ataques de migraña / Epicrania fugax as the initial presentation of migraine attacks

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Exploración neurológica en pacientes sometidos a sedación con propofol: estudio descriptivo / eurological examination in patients undergoing sedation with propofol: a descriptive study

Introducción. La exploración neurológica es un recurso en la evaluación de los pacientes en coma. La anestesia puede ser un factor influyente en los hallazgos. Evaluamos la exploración del paciente en coma en pacientes anestesiados con propofol para definir su valor clínico. Pacientes y métodos. Estudio prospectivo en sometidos a cirugía cardíaca en los cuidados intensivos de un hospital terciario durante los meses de abril y mayo de 2011. Se analiza la exploración del coma anestésico, factores farmacológicos o médicos que pueden influir y exploración neurológica completa tras la recuperación. Se excluyeron pacientes con síntomas neurológicos previos. Resultados. Se seleccionan 30 pacientes (16 hombres y 14 mujeres); edad media: 72 ± 10 años. Todos los pacientes estaban sedados con propofol. Durante la sedación, 17 (46,7%) presentaban pupilas arreactivas. En el 100% no se observaron movimientos espontáneos de los ojos. El 23,3% presentaba alteración ocular en posición primaria. Los reflejos oculocefálicos estaban ausentes en el 93,3%, y los oculovestibulares, en el 100%; el reflejo corneal, en el 70% (con asimetría); el espinociliar, en el 83,3%. La respuesta motora algésica estaba ausente en el 93,3%; en un 20%, los reflejos cutaneoplantares extensores; e indiferentes, en el 66,7%. Tras la anestesia, la exploración neurológica fue normal en el 80%, hubo leves alteraciones de orientación en un 16,7% y se encontró un síndrome hemisférico en un paciente. Conclusiones. La anestesia con propofol altera los reflejos pupilares, del tronco, respuestas motoras y reflejo cutaneoplantar reversibles al retirar la sedación. Las alteraciones pueden ser asimétricas. No se debería utilizar la exploración neurológica en el paciente sedado con propofol para la toma de decisiones clínicas (AU)

Introduction. The neurological examination is a resource used in evaluating patients who are in coma. Anaesthesia can be a factor that exerts an influence on the findings. We evaluated the examination of the comatose patient in the case of patients anaesthetised with propofol in order to define its clinical value. Patients and methods. A prospective study was conducted among those who had undergone heart surgery in the intensive care unit of a tertiary hospital during the months of April and May 2011. Aspects that were analysed were the examination of the anaesthetic coma, pharmacological or medical factors that can have an influence and a full neurological examination following recovery. Patients with previous neurological symptoms were excluded. Results. Thirty patients were selected (16 males and 14 females); mean age: 72 ± 10 years. All the patients were sedated with propofol. During sedation, 17 (46.7%) presented unreactive pupils. No spontaneous eye movements were observed in 100% of the sample. Ocular alterations in primary position were observed in 23.3% of them. Oculocephalic reflexes were absent in 93.3% and oculovestibular reflexes, in 100%; the corneal reflex, was absent in 70% (with asymmetry), as was the ciliospinal reflex, in 83.3%. The algesic motor response was absent in 93.3%, as were the cutaneous plantar extensor reflexes, in 20%; and 66.7% were indifferent. Following anaesthesia, the neurological examination was normal in 80%, there were slight orientation impairments in 16.7% and a hemispheric syndrome was found in one patient. Conclusions. Anaesthesia with propofol alters the reversible cutaneous-plantar, pupillary, trunk and motor response reflexes on withdrawing sedation. The alterations may be asymmetrical. Neurological examinations should not be used in the case of patients sedated with propofol in order to make clinical decisions (AU)

Aura sensitiva genital en la migraña / Genital sensory aura in migraine

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Otosífilis como causa de desviación en skew y vértigo posicional paroxístico benigno / Otosyphilis as the cause of skew deviation and benign paroxysmal positional vertigo

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