[Posture-dependent headache caused by spontaneous intracranial hypotension]. / Houdingsafhankelijke hoofdpijn door spontane intracraniële hypotensie.

A 36-year-old woman presented with a 3-4 month history of severe, progressive headache. The headache was characterized by postural variation, with excruciating headache in the upright position and near-immediate relief upon recumbence. There was no history of trauma or lumbar puncture. Gadolineum-enhanced brain MRI revealed abnormalities characteristic intracranial hypotension. Spinal MRI showed a longitudinal extradural fluid collection; a localization of the dural defect was not found. The patient was treated with caffeine, bed rest and lumbar epidural blood patches; she recovered completely. Severe orthostatic headache which aggravates upon standing and is relieved by recumbence, can be caused by spontaneous intracranial hypotension. Recognition of its characteristic symptoms is needed for timely referral. Treatment is usually successful and can prevent life-threatening complications.

[Awakening ptosis]. / Kortdurende ptosis bij het ontwaken.

BACKGROUND: A variable ptosis may point towards serious neurological disorders and is presented to general practitioners, ophthalmologists and neurologists. CASE DESCRIPTION: Two patients presented at the neurology outpatient clinic with a ptosis confined to awakening from sleep. There were no other neurological complaints and neurological examination was normal. The diagnosis 'awakening ptosis' was made. CONCLUSION: Awakening ptosis is a benign, but rare disorder. The exact pathophysiology remains unclear. In the case of a classic clinical picture of awakening ptosis, additional examinations are not indicated.

Blended care; development of a day treatment program for medically unexplained physical symptoms (MUPS) in the Dutch Armed Forces.

BACKGROUND: A subgroup of servicemen can be identified that seek a disproportionally amount of health care in comparison to diagnostic and therapeutic perspectives. This group can be identified on the basis of an absence of a structural medical explanation for their symptoms. The symptoms manifest predominantly as fatigue and pain, and are often chronic. Patients with medical unexplained medical symptoms (MUPS) often have multiple and complex problems that would be best treated by a multidisciplinary team of medical specialists and paramedics. The military is characterized by high loyalty towards peers and leadership, leading to neglect for personal care. OBJECTIVE: While consensus on the biological basis for these complaints is lacking, awareness on the need for effective treatments for this patient group is high. METHOD: Based on reviews, expert recommendations and clinical demand, a specialized treatment program for soldiers with MUPS has recently been developed and implemented in the system of health care in the Netherlands Armed Forces. We developed a functional rehabilitation program with blended care elements of cognitive behavioral therapy (CBT), physical therapy, case management, and psychoeducation, embedded in a day treatment setting. RESULTS: The program received high scores on participant as well as team satisfaction. The program is illustrated by two clinical vignettes. CONCLUSION: The blended care program for MUPS that focused on allostatic load awareness offered a more holistic and preventive approach that contributed to a reduction of unnecessary medical consumption, and increased job participation. We recommend that the development of guidelines for diagnoses and treatment of these complaints in military settings will improve the quality of patient care, reduce disability, facilitate reintegration, and encourage scientific research.

Chance of aneurysm in patients suspected of SAH who have a 'negative' CT scan but a 'positive' lumbar puncture.

In patients with sudden severe headache and a negative computed tomography (CT) scan, a lumbar puncture (LP) is performed to rule in or out a subarachnoid haemorrhage (SAH), but this procedure is under debate. In a hospital-based series of 30 patients with sudden headache, a negative CT scan but a positive LP (defined as detection of bilirubin >0.05 at wavelength 458 nm), we studied the chance of harbouring an aneurysm and the clinical outcome. Aneurysms were found in none of both patients who presented within 3 days, in 8 of the 18 (44%) who presented within 4-7 days and in 5 of the 10 (50%) who presented within 8-14 days. Of the 13 patients with an aneurysm, 3 (23%) had poor outcome. In patients who present late after sudden headache, the yield in terms of aneurysms is high in those who have a positive lumbar puncture. In patients with an aneurysm as cause of the positive lumbar puncture, outcome is in the same range as in SAH patients admitted in good clinical condition.

Primary thunderclap headache.

Thunderclap headache is an uncommon type of headache, but recognition and diagnosis are important because of the possibility of a serious underlying brain disorder. In this chapter, primary thunderclap headache in relation to other primary headache disorders and secondary, symptomatic headache disorders are discussed. Most importantly, subarachnoid hemorrhage should be excluded. The first investigation is a computed tomography (CT) scan, and, if the CT scan is negative, investigation of the cerebrospinal fluid. Other symptomatic vascular causes are intracranial hemorrhage, cerebral venous sinus thrombosis, cervical artery dissection, or a reversible vasoconstriction syndrome. These and other serious underlying intracranial disorders should be detected by magnetic resonance imaging or the appropriate investigations. The remaining patients with thunderclap headache most likely represent a primary headache disorder, including migraine, primary cough headache, primary exertional headache, or primary headache associated with sexual activity. Within the group of primary headache disorders, primary thunderclap headache represents a distinct clinical entity; it is characterized by a sudden severe headache lasting from 1h up to 10 days and not attributed to another disorder. The pathogenesis of primary thunderclap headache is still not known, but the sympathetic nervous system may play an important role.

Incidence of subarachnoid haemorrhage: a systematic review with emphasis on region, age, gender and time trends.

BACKGROUND AND AIM: To update our 1996 review on the incidence of subarachnoid haemorrhage (SAH) and assess the relation of incidence with region, age, gender and time period. METHODS: We searched for studies on the incidence of SAH published until October 2005. The overall incidences with corresponding 95% confidence intervals were calculated. We determined the relationship between the incidence of SAH and determinants by means of univariate Poisson regression. RESULTS: We included 51 studies (33 new), describing 58 study populations in 21 countries, observing 45,821,896 person-years. Incidences per 100,000 person-years were 22.7 (95% CI 21.9 to 23.5) in Japan, 19.7 (18.1 to 21.3) in Finland, 4.2 (3.1 to 5.7) in South and Central America, and 9.1 (8.8 to 9.5) in the other regions. With age category 45-55 years as the reference, incidence ratios increased from 0.10 (0.08 to 0.14) for age groups younger than 25 years to 1.61 (1.24 to 2.07) for age groups older than 85 years. The incidence in women was 1.24 (1.09 to 1.42) times higher than in men; this gender difference started at age 55 years and increased thereafter. Between 1950 and 2005, the incidence decreased by 0.6% (1.3% decrease to 0.1% increase) per year. CONCLUSIONS: The overall incidence of SAH is approximately 9 per 100,000 person-years. Rates are higher in Japan and Finland and increase with age. The preponderance of women starts only in the sixth decade. The decline in incidence of SAH over the past 45 years is relatively moderate compared with that for stroke in general.

Visual inspection versus spectrophotometry in detecting bilirubin in cerebrospinal fluid.

OBJECTIVES: To compare the diagnostic accuracy of visual inspection and spectrophotometry for identifying the presence of bilirubin in the cerebrospinal fluid (CSF). METHODS: Clinicians and students assessed CSF specimens with seven degrees of extinction between 0.00 and 0.09 at 450-460 nm as "yellow," "doubtful," or "colourless" after random presentation under standard conditions. The assessments were compared with spectrophotometry, with 0.05 being taken as the cut off level for the presence of bilirubin. Results were compared between the two groups and explored by means of receiver operating characteristic (ROC) curves. RESULTS: All 51 clinicians and 50 of 51 students scored the tubes with extinction of 0.06 or higher as "yellow" or "doubtful." Tubes without any bilirubin were scored as "yellow" by three of the students only. The ROC curves confirmed that the diagnostic properties of the visual inspection versus spectrophotometry were slightly better for the clinicians than for the students. CONCLUSIONS: If CSF is considered colourless, the extinction of bilirubin is too low to be compatible with a diagnosis of recent subarachnoid haemorrhage. If CSF is not considered colourless, spectrophotometry should be carried out to determine the level of extinction of bilirubin.

Causes and management of thunderclap headache: a comprehensive review.

BACKGROUND: Thunderclap headache (or sudden severe headache) is an uncommon type of headache. Recognition and accurate diagnosis of this headache are important, because there is often a serious underlying brain disorder. SUMMARY: In this article, causes and management of thunderclap headache are discussed. In the primary care setting, there is a serious cause in one third of patients, but in the hospital setting, up to two thirds of patients have a serious underlying brain disorder. Clues in history and physical examination can point to a possible serious underlying cause of thunderclap headache, such as subarachnoid hemorrhage, intracranial hematoma, or cerebral venous thrombosis. The remaining patients with thunderclap headache, however, have a primary headache disorder, such as migraine or (less frequently) tension headache with an unusual sudden onset, exertional headache, coital headache, cough headache, or cluster headache. The concept of thunderclap headache as a distinct clinical entity is discussed, with implications for its evaluation. Present radiological techniques are reviewed with regard to their diagnostic utility in detecting a serious brain disorder. CONCLUSIONS: Thunderclap headache is an uncommon type of headache, and a serious underlying cause should be excluded.