Some questions provoked by a chronic headache (with mixed migraine and cluster headache features) in a woman with a pineal cyst. Answers from a literature review.

The main known function of the pineal gland in humans is the production of melatonin. Benign cysts of the gland have been related to headache, although the mechanism of production of this assumed clinical manifestation has not been clearly determined, due to the lack of large prospective studies. The question is complicated by the fact that pineal cysts are frequently found on brain magnetic resonance imaging. Much has been published about the possible role of benign pineal cysts in the pathophisiology of headaches and the potential of melatonin in headache therapy, as well as in other disorders. The aim of this article is to review the current state of the subject. We have tried to place accurately the relation between headache and pineal cysts based on the available evidence, as well as the actual role of melatonin in physiology and pharmacology, more specifically in headache therapy. We include a clinical case to illustrate the subject.

Dysphagia as the sole manifestation of myasthenia gravis.

Three patients are described who had dysphagia as the sole manifestation of myasthenia gravis. Severity ranged from the need to be fed by nasogastric tube to moderate dysphagia requiring only diet change. Oesophageal manometry was carried out in two patients and showed generalised weakness of peristaltic contractions which included the smooth muscle part of the oesophagus. These disturbances worsened with repeated swallows. They were partly reversed by intravenous edrophonium and by rest. Repetitive nerve stimulation was normal in all three patients, but stimulated single fibre EMG of the frontalis muscle showed that all had impairment of neuromuscular transmission. Anti-AChR antibodies were found in only one patient. The most affected patient was treated with pyridostigmine, plasmapheresis, and high dose prednisone. The remaining two patients received only oral anticholinesterases.

[Clinical pathways: bases, description and potential uses in neurology]. / Vías clínicas: fundamentos, descripción y posibles aplicaciones en Neurología.

Over the last 10 years, we have witnessed the introduction of different procedures for coordinating clinical care, often shown as new tools in the hospital administration setting. Clinical or critical pathways are among these standardization methods of health care. In this article, we describe the characteristics of the clinical pathways and review their potential uses in neurology, especially in common conditions like stroke. In the following, we describe a clinical pathway for treating acute episodes in patients with relapsing-remitting of secondarily progressive forms of multiple sclerosis which was developed in the Son Dureta Hospital, in Palma de Mallorca, Spain. We carry out a critical assessment of this and other standardization methods.

[Brain death and the donation of organs. A review in the light of current Spanish legislation]. / Muerte encefálica y donación de órganos. Revisión a la luz de la legislación española actual.

INTRODUCTION: Primary brain death (BD) is a clinical situation characterised by the total and irreversible absence of functioning in the brain as a consequence of its being destroyed, while heartbeat and breathing are maintained by artificial means. The Royal Decree 2070/1999, dated 30 December, lawfully regulates the diagnosis of BD and the activities concerning the donation of organs for transplant in Spain. METHOD: In certain patients who have suffered structural injury to the brain, serious intracranial hypertension occurs which blocks the blood flow throughout the brain, while breathing is maintained by mechanical means, together with heartbeat. The diagnosis of BD is eminently clinical and is based on the verification of three circumstances: the existence of a non reactive coma, the disappearance of brain stem reflexes and activity in its parasympathetic nuclei, and the absence of spontaneous breathing. The diagnosis can be reinforced with certain complementary tests, which in some cases are compulsory. In the paper we describe the explorations that are considered to be appropriate by current Spanish legislation. We also review the most important clinical and legal aspects of organ donation. CONCLUSIONS: BD is an iatrogenic state, known only since the development of reanimation and assisted ventilation techniques, which amounts to the death of the person. Obtaining organs for transplants is currently possible in Spain from donors in this situation, but also from those who have died from an initial cardiopulmonary arrest and from live donors.

[Thoracic outlet syndromes]. / Síndromes de salida torácica.

INTRODUCTION: The thoracic outlet syndromes are clinical conditions whose true incidence is low, although they are frequently diagnosed. They are caused by compression of the brachial plexus or vascular structures due to anatomical anomalies of the cervico-axillary region. DEVELOPMENT: Two main types are seen: the neurogenic syndromes and the vascular syndromes. The former make up 90% of all cases; in general these patients are women in their forties or fifties. A common initial symptom is pain along the medial side of the arm, which may be more diffuse and accompanied by paraesthesiae. Most of these patients suffer from amyotrophy and gradually progressive weakness of the intrinsic muscles of the hand, particularly the thenar eminence. The association of vascular signs and symptoms is rare. In almost all cases cervical ribs or elongated transverse aprophyses of C7 are found on plain X-ray. Characteristic changes are seen on electrophysiological studies. Treatment is surgical. This usually relieves pain and paraesthesia and stops progression of the condition to motor deficit, but has no effect on established weakness and amyotrophy. CONCLUSIONS: The opinion of a neurologist is often necessary for diagnosis of neurogenic syndromes. Indication for treatment, usually surgical, should be based on an objective diagnosis.