Dural sinus collapsibility, idiopathic intracranial hypertension, and the pathogenesis of chronic migraine.

Available evidences suggest that a number of known assumption on idiopathic intracranial hypertension (IIH) with or without papilledema might be discussed. These include (1) the primary pathogenetic role of an excessive dural sinus collapsibility in IIH, allowing a new relatively stable intracranial fluids pressure balance at higher values; (2) the non-mandatory role of papilledema for a definite diagnosis; (3) the possibly much higher prevalence of IIH without papilledema than currently considered; (4) the crucial role of the cerebral compliance exhaustion that precede the raise in intracranial pressure and that may already be pathologic in cases showing a moderately elevated opening pressure; (5) the role as "intracranial pressure sensor" played by the trigeminovascular innervation of dural sinuses and cortical bridge veins, which could represent a major source of CGRP and may explain the high comorbidity and the emerging causative link between IIHWOP and chronic migraine (CM). Accordingly, the control of intracranial pressure is to be considered a promising new therapeutic target in CM.

Can pontine trigeminal T2-hyperintensity suggest herpetic etiology of trigeminal neuralgia?

BACKGROUND: Trigeminal neuralgia (TN) is usually classified into two different categories: idiopathic and secondary. We have investigated the frequency of brainstem pontine lesions in patients with idiopathic TN without multiple sclerosis (MS) or stroke, and their association with herpes zoster (HZ) infection. METHODS: Brain magnetic resonance imaging (MRI) studies of 28 patients with TN were retrospectively reviewed. RESULTS: We found seven patients with clinical suspicion of HZ infection and pontine T2 hyperintense lesions, associated with nerve atrophy in one case. Fifteen patients had a neurovascular conflict (NVC) without brainstem involvement, two of them associated with trigeminal atrophy, while four patients had only volumetric reduction of the nerve. In all patients MRI findings were ipsilateral to the side of TN. CONCLUSIONS: Pontine T2 hyperintensities could be considered as a MRI sign of TN in patients without NVCs. This "trigeminal pontine sign" (TPS) is frequently found in association with herpetic infections.

[DFPP in myasthenia gravis: case report]. / La filtrazione a cascata nel trattamento della miastenia grave: caso clinico.

INTRODUCTION: Myasthenia Gravis (MG) is a neuromuscular disease due to a decrease in the number of acetylcholine receptors (AChR) present at the level of the neuromuscular junction. It is characterized by weakness and muscle fatigue. The pathogenesis of MG would seem to be autoimmune (autoantibodies against AChR, Musk, Titin). The treatment of MG includes acetylcholinesterase inhibitors, immunosuppressants, intravenous human immunoglobulin, thymectomy and therapeutic apheresis. MATERIALS AND METHODS: We report a case of a 40-year-old woman, suffering from MG, subjected to thymectomy, in therapy with corticosteroids, azathioprine and antagonist of acetylcholinesterase. The patient came under our observation for the appearance of a severe acute worsening of neurological disease unresponsive to medical therapy. She underwent a series of four treatments, every other day, of double filtration plasmapheresis (DFPP). RESULTS AND DISCUSSION: The DFPP removed from the patient's blood high-molecular-weight substances. It showed a reduction of Immunoglobulins, Fibrinogen, C3 and C4 complement fractions and anti ACh-R Ab.The DFPP resulted in disappearance of symptoms with improvement in motor and sensory conduction parameters evaluated by electromyography. CONCLUSION: The DFPP quickly reduces the anti ACh-R Ab and anti Titin Ab, as well as the risk of infections and allergies, compared to Plasma Exchange. It improves clinical symptoms, therefore it is proved to be an effective therapy for the acute exacerbation of MG.

Course and outcome of a voltage-gated potassium channel antibody negative Morvan's syndrome.

Morvan's syndrome is a rare disease characterized by peripheral nerve hyperexcitability, associated with CNS and autonomic systems involvement. High serum voltage-gated potassium channel (VGKC) antibody titers have been reported, and, till now, Morvan's syndrome has been considered as a VGKC antibody associated disease. We describe a patient with Morvan's syndrome associated with myasthenia gravis and a thymoma in his previous history, with surprisingly undetectable levels of VGKC antibodies. The clinical course is similar to those cases of Morvan's syndrome with VGKC-Ab, except for the lack of response to plasma exchange, previously considered as the first choice treatment. Nevertheless, the good response to corticosteroids therapy and the association with myasthenia confirm an autoimmune origin of the disease.

Trigeminal stimulation elicits a peripheral vestibular imbalance in migraine patients.

OBJECTIVE: The study explored the hypothesis that spontaneous nystagmus (Ny) in migraine patients can be triggered or modulated by painful trigeminal stimulation, providing evidence of a functional connection between vestibular and trigeminal systems. BACKGROUND: Vertigo attacks are reported by subjects with migraine or a familiar history of migraine, also independently of headache episodes. Idiopathic vertigo is three times more frequent in migraine patients than in controls. Vestibular investigations in migraine patients have consistently demonstrated spontaneous Ny both of central and peripheral origin. DESIGN: In the first phase of the study 10 outpatients experiencing migraine without aura (MO) and 10 healthy volunteers were submitted to the registration of spontaneous primary-position Ny in the dark by Ulmer's video-ocular-nystagmographic equipment. Two electrodes for electrical stimulation were applied on the supraorbital point of one side of the head and the intensity of stimulation corresponding to pain threshold was calculated. Spontaneous ocular movements were recorded for 5 minutes at baseline and after a sequence of five electric pulses (square waves of .5 Hz frequency and 50 micros duration, at pain threshold intensity). Nystagmographic responses were expressed as latency after stimulation, direction of the quick phase, and duration. The second phase of the study explored, with the same procedure, the effects on Ny of supraorbital versus median nerve stimulation in other 10 MO patients. Responses to stimulation were considered the appearance of de novo Ny after stimulation in subjects without baseline Ny, or the change of the frequency (at last a 50% variation) or of the direction of Ny after stimulation in subjects with baseline Ny. The latency and the duration of responses to stimulation were also calculated. RESULTS: In the first series supraorbital painful electric stimulation was able to modify or to evoke Ny in 8 of 10 migraineurs and in none of 10 volunteers (Fisher's exact test, P<.01). Both the baseline and the induced Ny were second degree, stationary persistent, with a linear slow phase and were suppressed by visual fixation. In the second series, supraorbital nerve stimulation was able to induce or modify Ny in all of 10 patients but only in 1 patient Ny was induced by median nerve stimulation. Characters of Ny were the same as previously described. Statistical comparison of the responses at the two sites of stimulation was significant (Fisher's exact test, P<.01). In those 7 patients who presented de novo Ny after stimulation it was possible to calculate Ny latency and duration. The mean latency was 25 s (SD: 16, range: 14 to 60). The mean duration was 120 s (SD: 94, range: 20 to 290). CONCLUSION: The main result of our study is that in migraine patients painful trigeminal stimulation elicits de novo, or modifies pre-existing spontaneous Ny, generally increasing it. The finding was obtained after trigeminal stimulation, but not after median nerve stimulation. We suggest that painful trigeminal stimulation can induce an imbalance of the vestibular system in migraine patients and possibly explain their predisposition to vertigo. Our data require confirmation by other studies.

Acetazolamide efficacy and tolerability in migraine with aura: a pilot study.

The study was an open uncontrolled pilot trial to test the efficacy and the tolerability of acetazolamide in a group of 22 outpatients suffering from migraine with aura (MA) with at least one aura episode in the last 2 months.