PRES: posterior or potentially reversible encephalopathy syndrome?

Posterior reversible encephalopathy syndrome (PRES) is an acronym that identifies a new clinico-neuroradiologic entity occurring in association with different conditions. We report a patient with eclamptic encephalopathy whose clinico-radiological picture normalised after prompt treatment. We suggest defining this condition as potentially RES, to emphasise that reversibility is not spontaneous but is usually related to an adequate treatment, and that the posterior localisation of the lesions, even if constant, may not represent the most relevant finding in some patients.

Acute drug treatment of migraine attack.

The availability of an effective drug for attack treatment is a main need of migraine patients. Symptomatic therapy of migraine now includes three main classes of drugs: ergot alkaloids, nonsteroidal antiinflammatory drugs (NSAIDs) and triptans. Clinical randomised placebo-controlled trials affirmed the efficacy and tolerability of these drugs, when used at the recommended doses and in the absence of contraindications. The efficacy data from comparative trials showed a trend in favour of triptans vs. ergot alkaloids, but failed to show significant differences between triptans and NSAIDs. However, clinical practice experience of most headache clinicians suggests that triptans provide superior efficacy in comparison with nonspecific agents, mainly in that they better satisfy migraine patient expectations. In fact, these selective specific antimigraine drugs are an advance in acute migraine treatment.

Prevalence of atrial septal aneurysm in patients with migraine: an echocardiographic study.

OBJECTIVE: To evaluate the prevalence of atrial septal aneurysm in patients with migraine. BACKGROUND: Migraine has long been considered a risk factor for stroke. Atrial septal aneurysm is often observed in young patients with ischemic stroke and is frequently associated with other conditions potentially leading to embolism. METHODS: We performed a transthoracic echocardiogram in 90 consecutive patients (65 women and 25 men; mean age, 35.3 years [standard deviation, 9]) with migraine but free from cerebral and cardiovascular disease and in 53 control subjects (37 women and 16 men; mean age, 34 years [standard deviation, 10]). The diagnosis of atrial septal aneurysm was performed according to Olivares-Reyes criteria. A transesophageal echocardiogram also was performed in 75 patients with migraine (83.3%). RESULTS: The prevalence of isolated atrial septal aneurysm was higher in patients with migraine with aura (28.5%) than in patients with migraine without aura (3.6%) (P <.005) or in control subjects (1.9%) (P <.005). CONCLUSIONS: Our data suggest a role of atrial septal aneurysm in the genesis of aura in patients with migraine.

Abnormalities of hypothalamic-pituitary-thyroid axis in patients with primary empty sella.

Primary empty sella (PES) is a very frequent neuroradiological finding in the general population, that can induce hypopituitarism. Some studies focused on the association of PES with GH deficiency (GHD) or hypogonadotropic hypogonadism (HH), while data regarding the involvement of hypothalamic-pituitary-thyroid (HPT) axis, despite sporadic reports of central hypothyroidism, or the occurrence of hypoadrenalism (HA) are scanty. In this study, thyroid function and TSH response to exogenous TRH injection (TRH/TSH) were investigated in 43 patients [10 men and 33 women; aged (mean +/- SD), 48+/-12 yr] with PES: 22 patients had total and 21 partial PES. Forty healthy subjects (9 men and 31 women; aged 46+/-12 yr) were enrolled as a control group. Central hypothyroidism was found only in 2/43 cases, whereas one patient showed primary hypothyroidism. In euthyroid patients, mean serum TSH levels were significantly lower than controls (TSH: 1.0+/-0.7 vs 1.4+/-0.6 mU/l, p<0.01) and 79% of them showed abnormal TRH/TSH responses (TRH test was performed in 34 euthyroid patients: 17 cases with total and 17 cases with partial PES), but mean serum free T4 (FT4) and free T3 (FT3) values were not significantly lower than controls (FT4: 15.9+/-0.4 vs 15.0+/-2.1 pmol/l, p=NS; FT3: 5.3+/-1.2 vs 5.8+/-1.5 pmol/l, p=NS). Moreover, no significant differences were evident in mean serum TSH, FT4 and FT3 between patients with total and partial PES (TSH: 1.1+/-0.7 vs 0.9+/-0.8 mU/l, p=NS; FT4: 16.3+/-2.6 vs 15.7+/-2.2 pmol/l, p=NS; FT3: 5.4+/-1.3 vs 5.2+/-0.8 pmol/l, p=NS) and the TRH/TSH peak was impaired or exaggerated/delayed in 9 and 3 patients with total and in 12 and 3 cases with partial PES. No significant differences in the prevalence of abnormal TRH/TSH responsiveness were found between patients with partial or total PES (chi2=1.6, p=NS). Other impairment of pituitary function was detected in 23/43 patients: GHD was present in 15 cases, HH in 11 and central HA in 5 patients. Isolated or combined hypopituitarism was present in 17 and in 6 patients, respectively. In conclusion, pituitary dysfunction is very frequent in patients with PES, but central hypothyroidism occurs rarely. The entity of arachnoid herniation into the sellar fossa does not play a significant role on the degree of HPT axis dysfunction.

A late 'migraine': the only symptom of an intrasellar aneurysm.

The history of a 62-year-old woman affected by an intrasellar aneurysm is described. A migrainelike headache was, for many years, her only complaint.

Migraine stroke: a possible complication of both migraine with and without aura.

We describe four migraine patients who developed an ischemic stroke during their typical migraine attacks. Cerebral infarction as a possible complication of migraine without aura is discussed. We propose a review of the migraine stroke definition of the International Headache Society.

Cluster-like headache and a median intracranial calcified lesion: case report.

A 69 year old man complaining of a cluster-like headache is reported. CT scan showed a median intracranial calcified lesion. Two main considerations are: 1) the importance of searching for an underlying structural lesion in patients with an "atypical" cluster headache; 2) the possible significance of a lesion localized close to the midline structures in the pathogenesis of cluster headache.

Hormonal disregulation and catamenial epilepsy.

Six epileptic women, showing a clear increase in seizure frequency in the perimenstrual period, were studied during three consecutive menstrual cycles. At each control seizure occurrence, EEG recordings, endocrine profile and antiepileptic drug plasma levels were evaluated. The only pathological finding was the progesterone deficiency with a relative hyperestrogenism during the late luteal phase. Our data agree with other reports suggesting that catamenial epilepsy may result from a sex hormone disregulation.

Bilateral cortical calcifications with benign clinical course: an unusual case of Sturge-Weber syndrome?

A case of a 13-year-old girl with bilateral cortical calcifications of the Sturge-Weber type at CT examination, without cutaneous lesions and ocular abnormalities is described. She had seizures appearing within the first year of life which never recurred since the age of two years. At the age of ten years she began to suffer from occasional migraine attacks. Her neurological examination and psychological testing did not show any significant abnormality. This case can be regarded as an unusual atypical form of Sturge-Weber syndrome, unless the existence of a new disorder is assumed.

Effect of viloxazine on serum carbamazepine levels in epileptic patients.

The present study describes the interaction between carbamazepine (CBZ) and viloxazine, a recently synthesized antidepressant agent. Seven epileptic patients on chronic anticonvulsant therapy showed a significant (p less than 0.005) increase in steady-state serum CBZ levels (from 8.1 +/- 2.5 SD to 12.1 +/- 2.5 SD micrograms/ml) when viloxazine (300 mg/day) was added to the therapy. The effect was associated with the appearance of mild CBZ intoxication. The symptoms of this intoxication (i.e., dizziness, ataxia, fatigue, drowsiness) disappeared rapidly, and serum CBZ levels decreased to the basal values, when viloxazine administration was stopped.

Valproic acid-ethosuximide interaction: a pharmacokinetic study.

The present pharmacokinetic study was designed to investigate the possible interaction between valproic acid (VPA) and ethosuximide (ESM) in humans. Six drug-free healthy volunteers, four men and two women, 18-42 years of age, received a single oral dose of 500 mg ESM before and during a treatment with VPA at 800- to 1,600-mg daily doses. The second ESM dose was given 9 days after VPA administration was started. In this latter condition, a significant (p less than 0.05) increase in ESM serum half-life, from 44 to 54 h on average, and a significant (p less than 0.05) decrease in total body clearance, from 11.2 to 9.5 ml/min on average, were observed. Other pharmacokinetic parameters were unchanged and showed values similar to those reported in the literature. Serum VPA levels ranged between 66.8 and 95 micrograms/ml. Two subjects showed no evidence of interaction. Although a great interindividual variability in the occurrence of VPA-ESM interaction can be observed, the present study indicates that VPA is able to inhibit the metabolism of ESM. Possible factors affecting this interaction are hypothesized and discussed.

[Epilepsy and pregnancy (review of the literature)]. / Epilessia e gravidanza (rassegna della letteratura).

The relationship between pregnancy and epilepsy has often been object of particular attention and care by many epileptologists. The aim of this survey of the literature is to give an up-to-date and comprehensive review of this relation and to focalize the many related problems which still are unsolved. The following principal chapters are discussed: 1) the influence of pregnancy on epilepsy; 2) the influence of epilepsy on pregnancy and delivery; 3) the influence of epilepsy on newborns; 4) the teratogenic effects of antiepileptic medication. Many conflicting data make it very difficult to summarize the results, however it is clear that the effect of pregnancy on seizure frequency may be quite variable. Seizures, in fact, during pregnancy may be increased, decreased or remain unchanged. The most conflicting data are those related to the effects of epilepsy on pregnancy and delivery, while concordant opinions indicate an increased perinatal mortality and morbidity in offsprings of epileptic women. Special attention has to be payed to the offsprings of epileptic mothers. The presence of congenital abnormalities in fact, is about 2 times higher for newborns of mothers with epilepsy than for offsprings of mothers without the disease. Another important problem is related to the presumed teratogenicity of antiepileptic drugs. It has not yet been demonstrated that antiepileptic compounds have a teratogenic effect on offsprings. However it has been shown that this assumption is often associated to a higher presence of congenital malformations. The majority of malformations (facial clefts and heart defects) occur in association with the use of trimethadione, phenobarbital, primidone and acetazolamide, whereas they are much less frequent in association with phenytoin, carbamazepine, valproate.