Precisión de la prueba diagnóstica de acentuación de la cefalea mediante sacudidas cefálicas para el diagnóstico de meningitis aguda en urgencias / Diagnostic test accuracy of jolt accentuation for headache in acute meningitis in the emergency setting

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Role of developmental venous anomalies in etiopathogenesis of demyelinating diseases.

OBJECTIVE: Multiple sclerosis (MS) is a demyelinating autoimmune disease of the central nervous system. T2W-hyperintense demyelinating lesions are detected in cranial magnetic resonance imaging (MRI). Developmental venous anomalies (DVAs) have frequently been detected in enhanced cranial MRI images, and are generally accepted as normal variants of venous development. The aim of the present study was to investigate whether there was an association between demyelinating diseases and venous anomalies. METHODS: One hundred five patients who were diagnosed as having MS in accordance with the McDonald diagnostic criteria, and 105 patients who were diagnosed as having vascular headache who had no lesions similar to MS were included in the present retrospective study. RESULTS: DVAs were detected in 31 of the study group and in 14 patients in the control group. A statistically significant higher rate of DVAs and abnormal signal increase in the neighboring tissue was detected in the study group (p = 0.004) (p = 0.006). The DVA was superficially localized in the RRMS, It was deeply located in RIS. CONCLUSION: Recent studies have emphasized the association of the central vein and the lesion severity of MS with the detection of the central collecting vein in MS lesions. In our study, DVAs, which are generally regarded as innocent developmental anomalies, and neighboring signal increase were found significantly higher in the MS group compared with the control group. The role of DVAs in the etiology of demyelinating lesions must be clarified through comprehensive future studies that use more advanced techniques.

Serial magnetic resonance imaging findings in subarachnoid hemorrhage due to an initially angiographically occult type II spinal aneurysm: Case report.

BACKGROUND: Spinal aneurysms are rare causes of spontaneous subarachnoid hemorrhage. METHODS: We present an unusual, initially occult, case of an upper thoracic intradural extramedullary isolated aneurysm arising from the T2 intercostal-radicular circulation that was initially angiographically occult but was discovered due to unique, albeit nonspecific, magnetic resonance imaging findings of spinal cord T2 hyperintensity and contrast enhancement that were noted to progress with a clinical picture of ictal rehemorrhage. RESULTS: Repeat spinal angiography revealed a spinal aneurysm that was treated surgically. CONCLUSION: In cases of sufficient clinical suspicion and nonspecific imaging findings, continued vigilance is advised in seeking an underlying pathoanatomic etiology.

Radiosurgery for Arteriovenous Malformations and the Impact on Headaches.

BACKGROUND: Arteriovenous malformations (AVMs) can underlie many diverse neurological signs and symptoms. Headaches are a common presentation that can have a significant impact on quality of life. OBJECTIVE: The authors investigated Gamma Knife® stereotactic radiosurgery (SRS) outcomes in patients with AVMs and associated headaches. METHODS: This retrospective study analyzed 102 patients with AVMs who underwent SRS between 1995 and 2013. The patient's headache symptoms led to their AVM diagnosis or developed post hemorrhage of their AVM. Information regarding headache characteristics was obtained from the patient's medical records and at follow-up using a scripted clinical interview. The median imaging follow-up was 61.7 months and clinical follow-up was 89.7 months. The median treatment volume at SRS was 4.1 cm3 and the median marginal dose was 20 Gy. RESULTS: The actuarial AVM obliteration rate was 60% at 5 years and 78% at 10 years. Patients reported that their overall headache severity decreased by -43.6% and their headache frequency was reduced by -53.4%. Headache reduction was reported in 49.1% of patients at 1 year and 69.5% at 5 years. The median time until improvement was 6.5 months. After SRS, headache medication usage decreased in 29% of patients. Permanent adverse radiation effects after SRS occurred in 3% of patients. Until obliteration was complete, the annual risk of a hemorrhage after SRS was 0.4% per year. CONCLUSION: Although recall bias related to a retrospective analysis can impact outcomes, headache symptoms associated with AVMs may potentially be decreased or eliminated in a subset of patients treated with Gamma Knife radiosurgery.

Diet-induced obesity alters dural CGRP release and potentiates TRPA1-mediated trigeminovascular responses.

Background Clinical studies suggest a link between obesity and the primary headache disorder migraine. In our study we aimed to reveal the effect of obesity on meningeal nociceptor function in rats receiving a high-fat, high-sucrose diet. Methods Transient receptor potential ankyrin 1 (TRPA1) receptor activation-induced changes in meningeal blood flow, release of calcitonin gene-related peptide (CGRP) from trigeminal afferents and TRPA1 protein expression in the trigeminal ganglia were measured in control and obese rats. Metabolic parameters of the animals were assessed by measuring glucose and insulin homeostasis as well as plasma cytokine concentrations. Results The present experiments revealed an enhanced basal and TRPA1 receptor agonist-induced CGRP release from meningeal afferents of obese insulin-resistant rats and an attenuated CGRP release to potassium chloride. Obesity was also associated with an augmented vasodilatation in meningeal arteries after dural application of the TRPA1 agonist acrolein, a reduction in TRPA1 protein expression in the trigeminal ganglia and elevations in circulating proinflammatory cytokines IL-1ß and IL-6 in addition to increased fasting blood glucose and insulin concentrations. Conclusions Our results suggest trigeminal sensitisation as a mechanism for enhanced headache susceptibility in obese individuals after chemical exposure of trigeminal nociceptors.

[Unusual cause of macrohematuria in a 29-year-old woman]. / Seltene Ursache einer Makrohämaturie bei einer 29-jährigen Patientin.

HISTORY AND ADMISSION FINDINGS: We report on the case of a young women presenting with macrohaematuria, petechiae and strong headaches. INVESTIGATIONS: Laboratory showed a thrombotic microangiopathy with helmet cells, increased LDH levels (>600 U/l), and thrombocytopenia (<40,000/µl). DIAGNOSIS, TREATMENT AND COURSE: Due to strong haemolytic activity and headache with blurred vision, immediate plasma separation with fresh frozen plasma was commenced. Markedly decreased ADAMTS13 activity and detection of anti-ADAMTS13 antibodies were consistent with the diagnosis of idiopathic thrombotic thrombocytopenic purpura. In total, 11 plasma separations were required to stop disease activity. In parallel, immunosuppressive therapy using glucocorticoids was initiated. The patient was discharged from the hospital in a good general condition and with normalized laboratory findings 26 days after hospitalization. CONCLUSIONS: All patients with anemia and thrombocytopenia should be tested for haemolysis and helmet cells. An early diagnosis and initiation of necessary therapy are determining for the clinical outcome.

Thunderclap headache with orgasm: a case of basilar artery dissection associated with sexual intercourse.

BACKGROUND: Headaches associated with sexual intercourse (coital cephalgia) have many different causes and are often divided in the literature into pre-orgasmic and orgasmic headaches. OBJECTIVE: To present a case of orgasmic headache caused by a basilar artery dissection and to present a literature-based guide to the diagnosis and management of patients presenting with headaches related to sexual activity. CASE REPORT: We report the case of a 34-year-old man without significant past medical history who presented to the Emergency Department with two episodes of orgasmic headache caused by basilar artery dissection. CONCLUSIONS: The cause of headaches related to sexual activity range from the benign to the life-threatening. Due to the dynamics of cerebral blood flow during sexual intercourse, basilar artery dissections and aneurysms should be considered in patients with sudden-onset headaches during orgasm. Appropriate brain imaging and, possibly, lumbar puncture may assist in identifying potentially life-threatening causes of coital headaches.

Perivascular mantle cell lymphoma affecting a temporal artery--a highly unusual cause of temporal headache.

INTRODUCTION: Temporal artery biopsy is a widely performed procedure for clinically suspected temporal arteritis. We the report the case of a 79-year-old male with mantle cell non-Hodgkin's lymphoma previously treated with chemotherapy under follow-up with right-sided orbital recurrence, who developed right temporal headache, tenderness, and visual symptoms in the right eye. His symptoms were unresponsive to steroid treatment and he underwent a temporal artery biopsy. METHODS: The temporal artery was fixed in standard 10% buffered formalin, processed to paraffin wax, 4 micron sections cut through the entire artery and stained with standard haematoxylin and eosin. Some sections were exposed to CD20, CD5, and cyclin D1 immunohistochemistry. RESULTS: Histology showed a perivascular, nodular lymphoid infiltrate composed of small centrocyte-type lymphocytes around the main artery and identical lymphocytes within the wall of a main artery branch. Additionally, the lymphocytes were located around a peripheral nerve in the peri-artery connective soft tissues. These lymphocytes were positive for CD5, CD20, and cyclin D1 indicating a diagnosis of peri-neural, peri-vascular mantle cell non-Hodgkin's lymphoma of identical appearance to that in the index biopsy. CONCLUSIONS: This report describes a highly unusual histological and clinical scenario of peri-temporal artery Mantle cell lymphoma causing temporal headache from peripheral nerve and artery side branch involvement by the lymphoma immediately adjacent to the temporal artery. We propose that involvement of a temporal artery by lymphoma be considered in the differential diagnosis, in patients with an established diagnosis of lymphoma, if presenting with "temporal arteritis" type headache symptoms.

The radiosurgical treatment of arteriovenous malformations: obliteration, morbidities, and performance status.

OBJECTIVE: This study examined the single-center treatment outcomes of arteriovenous malformations (AVMs) of the brain using stereotactic radiosurgery, with regard to obliteration, predictive factors, morbidities, and patient performance status. PATIENTS AND METHODS: 127 patients were treated between 1990 and 2008 by use of linear accelerator or Gamma Knife. Their median age was 37 years, the median AVM volume was 7.3 cc (range, 0.014-113.13 cc), and the median follow-up duration was 42 months (range, 6-209 months). Forty-two percent of patients presented with intracranial hemorrhage, 31% received embolization, and 8% underwent prior resection. Thirty-one percent of patients received more than one round of radiosurgery. RESULTS: 64% of patients had complete obliteration confirmed by magnetic resonance imaging or angiography. Positive predictors of obliteration included pretreatment hemorrhage (p = 0.042), smaller AVM volume (odds ratio = 1.25; 95% CI, 1.03-1.52), and larger marginal dose (odds ratio = 0.292; 95% CI, 0.100-0.820), whereas embolization (p < 0.001) was a negative predictor . The annual risk of hemorrhage after radiosurgery was 2.2%, and the risk of death as a result of hemorrhage was 0.6-1.3%. Eleven percent of patients reported new or worsened neurologic symptoms. Radiosurgery was effective in treating AVM-related headaches (p < 0.001) but did not improve the performance status of patients. CONCLUSIONS: Stereotactic radiosurgery is an effective tool in the treatment of AVMs and amelioration of AVM-related headaches, but it did not affect the patients' performance status. Factors affecting obliteration include prior hemorrhage, marginal dose, prior embolization, and AVM volume. Risk of hemorrhage persists in the latency period after radiosurgery, and it remains finite even after complete obliteration.

[Relationship between lupus headache and headache due to internal injury in traditional Chinese medicine].

In 1999, the nomenclature and case definitions for neuropsychiatric lupus syndromes were published by American College of Rheumatology (ACR), and the cognition of neuropsychiatric damage of systemic lupus erythematosus (SLE) was gradually unified and standardized. Lupus headache is an intractable problem in SLE, especially in SLE patients complicated with multiple organ injury. In general, vascular headache is common in most SLE patients, and a small number of SLE patients complicated with nervous headache are found in clinic. Moreover, its pathophysiological mechanism is far from being understood. Although early diagnosis is essential for good outcomes, the diagnosis method is rather confused in the world. There still exist some limitations in the proposal of clinical classification of headache from ACR and International Headache Society (IHS), and the proposal does not mention the classification of headache related to psychiatric damage. Current therapeutic regimens are almost exclusively based on empirical evidence. Treatment approaches include symptomatic treatment, immunosuppressive, anticoagulant and anti-aggregant therapies. It provides enormous and hopeful space in research of combined therapy strategy, especially in the field of traditional Chinese medicine. The authors discussed the relationship between lupus headache and headache due to internal injury in the view of integrated traditional Chinese and Western medicine, and suggested that the treatment strategy for lupus headache should be made in argument with the headache due to internal injury. Syndrome differentiation treatment according to deficiency in the root and excess in the branch and the therapy for activating blood to dredge collaterals maybe have great advantages in treatment of the headache in SLE.

Central nervous system vasculitis.

PURPOSE OF REVIEW: In the past decade, primary and secondary central nervous system (CNS) vasculitides have been more commonly diagnosed and recognized than previously. With the increasing awareness of these disorders, it is crucial for the treating physician to differentiate between causes of CNS vasculitis and to recognize their marked clinical and pathophysiological heterogeneity. This review focuses on the major forms of primary CNS vasculitis, as well as secondary CNS vasculitis with emphasis on their clinical findings, diagnoses, and treatment. RECENT FINDINGS: The proposal of reversible cerebral vasoconstriction syndromes (RCVS) as a unifying concept for a group of disorders which are characterized by acute-onset severe recurrent headaches, with or without additional neurologic signs and symptoms, and prolonged but reversible vasoconstriction of the cerebral arteries, has been a major breakthrough in this field over the past decade. Recognition of this common mimic (i.e. RCVS) has allowed optimal management of a sizable group of patients previously confused with pathologically documented CNS vasculitis. SUMMARY: Sound treatment decisions are based on accurate diagnosis. It is essential for the clinicians involved in the evaluation of patients with CNS vasculitis to be aware of its mimics especially RCVS. This article provides a comprehensive review of CNS vasculitis and its differential diagnosis. Furthermore, it touches upon workup and treatment of CNS vasculitis.

Dissection of bilateral intracranial vertebral artery with basilar artery involvement: a case report of a patient free from neurological deficits.

We report a patient with dissection of the bilateral intracranial vertebral artery (VA) that did not present any symptoms other than occipital headache, which was probably associated with sleeping overnight in a car seat with unsteady head position. Although cerebral angiography revealed extensive dissection of the bilateral VA after branching of the posterior inferior cerebral artery, retrograde flow to the basilar artery (BA) via the right posterior communicating artery contributed to preserved posterior circulation. These findings indicate that even in patients without neurological deficits, the involvement of BA cannot be excluded and that accurate evaluation using radiological techniques should be considered.

Headache following cervical sympathectomy and results of a blood flow study in the cat.

BACKGROUND: A patient developed severe, continuous, unilateral headache that was "vascular" in nature, following cervical sympathectomy. OBJECTIVE: To determine the changes in cranial blood flow in the cat following lesioning and stimulation of the cervical sympathetic nerve. METHOD: Carotid blood flow was determined by electromagnetic flowmetry and its tissue distribution by intra-arterial injection of 15-microm radioactive microspheres. RESULTS: Following sympathetic lesioning, an increase in carotid blood flow was observed and reversed with stimulation. The distribution of carotid blood flow changed for the brain only, maintaining relatively constant tissue perfusion. CONCLUSION: An increase in cerebral blood flow could not have accounted for the sympathectomy-induced headache. Dilation of major cerebral arteries and cranial noncerebral vasodilation probably constitutes its mechanism.

The paroxysmal hemicrania-tic syndrome.

Two cases of paroxysmal hemicrania (PH) associated with trigeminal neuralgia are reviewed. The paroxysmal hemicrania component in one patient was episodic, while it was chronic in the other. Each headache type responded completely to separate treatment, highlighting the importance of recognizing this association. We review the six other cases of chronic paroxysmal hemicrania-tic (CPH-tic) reported, and suggest that the term paroxysmal hemicrania-tic syndrome (PH-tic) be used to describe this association.