Almotriptan and its combination with aceclofenac for migraine attacks: a study of efficacy and the influence of auto-evaluated brush allodynia.

Early treatment and combining a triptan with a non-steroidal anti-inflammatory drug (NSAID) are thought to improve outcome during migraine attacks, possibly by counteracting the negative influence of cutaneous allodynia. The aim of this multicentre, double-blind pilot study was to evaluate the prevalence of brush allodynia and its relative influence on the efficacy of a triptan-NSAID combination compared with headache intensity at the time of treatment. In a randomized, cross-over design, 112 migraineurs treated two moderate or severe attacks with almotriptan 12.5 mg combined with either aceclofenac 100 mg or placebo. Patients used a 2-cm brush to assess cutaneous allodynia. Allodynia was reported in 34.4% of attacks. The almotriptan-aceclofenac combination was numerically superior to triptan-placebo on 2-24-h sustained pain-free (P = 0.07), 2-h pain-free (P = 0.07) and headache recurrence (P = 0.05) rates, but not on 1-h headache relief. Allodynia numerically reduced treatment success overall, but this effect was not significant for the primary outcome measures. Headache intensity had a significant negative influence on 1-h relief in both attacks (P = 0.0001 and 0.0008, chi(2)) and on 2-24-h sustained pain-free rates in triptan-placebo-treated attacks (P = 0.013). Multivariate logistic regression analysis confirmed that headache intensity at treatment intake, rather than allodynia, significantly influenced most outcome measures, predominantly so in attacks treated with almotriptan and aceclofenac. In the latter, severe compared with moderate headache intensity reduced the likelihood of achieving the primary efficacy end-points [odds ratios (OR) 0.12 and 0.33], whereas allodynia was not a significant explanatory variable (OR 0.76 and 0.65). The results apply to the protocol used here and need to be confirmed in larger studies using quantitative sensory testing.

Cerebellar ataxia following whooping cough.

Bordetella pertussis (BP), the agent of whooping cough, has not been recognized so far as a cause of permanent cerebellar ataxia in human. We describe three patients who developed a disabling and permanent cerebellar syndrome soon after whooping cough. In two patients, diagnosis of BP infection was confirmed by culture of nasopharyngeal secretions. The infection occurred between the age of 13 and 15 years, with neurological symptoms beginning after a delay varying from 3 weeks to 3 months. In our three patients, the cerebellar syndrome was characterized by dysmetria of ocular saccades, scanning speech and ataxic gait. Brain MRI demonstrated a pancerebellar atrophy. The pathogenesis of this cerebellar degeneration is not established. Experimental studies have demonstrated that the cerebellum is particularly vulnerable to lymphocytosis-promoting factor (LPF), one of the exotoxins from BP. The mechanism of this toxicity might be a marked increase in the cellular levels of 3',5'cyclic guanosine monophosphate (cGMP). Since whooping cough is a bacterial exotoxin-mediated disease, this is the first report of a cerebellar syndrome triggered by a bacterial exotoxin.

Bismuth encephalopathy.

Bismuth encephalopathy, characterized by the constant association of acute confusion, myoclonus, severe ataxia and dysarthia has reached "epidemic" proportion since its first description in 1974. The clinical aspects the pathogenic hypothesis, the diagnostic criteria as well as the report of a typical case are described by the authors, who stress the similarities with encephalopathies induced by other metals.

Acute dysautonomia and arteriovenous malformation of the brain stem.

A patient with acute pure dysautonomia also suffered from several episodes of transient diplopia and hemiparesthesiae which were related to an arteriovenous malformation in the pons. The clinical presentations and the radiological diagnosis of arteriovenous malformations of the brain stem are reviewed, as well as the semiology and etiopathogeny of acute dysautonomia. No relationship was found between these two rare affections.

A case of late onset striatonigral degeneration.

We report the case of a 78-year-old patient who had a parkinsonian syndrome which did not respond to levodopa treatment. The duration of the illness was four years. The main clinical features were bradykinesia and rigidity. He also showed pseudobulbar and pyramidal syndromes. The prominent pathological findings were a severe neuronal loss in the depigmented substantia nigra and in the putamen, which showed a brownish discoloration. Although the late age of onset is unusual, the findings suggest striatonigral degeneration. The link of this disease to multiple system atrophy is discussed.

Subcutaneous sumatriptan compared with usual acute treatments for migraine: clinical and pharmacoeconomic evaluation.

Cost-effectiveness and cost per successful treatment has been evaluated in 186 outpatients randomised to treat moderate to severe migraine attacks either with subcutaneous sumatriptan 6 mg (n = 97) or with their current therapy (n = 89) during an open, multicentre study of 3 months. Within 2 hours, headache severity decreased to none/mild in 86% of all attacks in the sumatriptan group (STG) compared to 25% in the customary group (CTG). Migraine was alleviated earlier in the STG than in the CTG (median 3.78 vs. 13.39 hours, p < 0.0001). The direct and total cost of treatment was 133 and 2012 BF, respectively, in the CTG and 1400 and 2522 BF, respectively, in the STG. Measuring the effectiveness of earlier pain relief with sumatriptan, the incremental cost-effective ratios for direct and total cost were 132 and 53 BF per hour of relieved pain, respectively. For this price, significantly more sumatriptan patients improved their quality of life by more than 20% (61.6 vs. 20.6% patients, p < 0.001) and less sumatriptan patient consulted a medical professional (11.3 vs. 29.2% patients, p < 0.01), used less medication for adverse events (6.2 vs. 22.5%, p < 0.001) and suffered less from associated migraine symptoms. The median number of hours of diminished work-efficiency (3 vs. 7 hours, p < 0.01) or of suspension of non-professional activity (10 vs. 24 hours, p < 0.001) was also significantly lower in the STG. The total cost per successfully treated patient was lower in the STG. Sumatriptan is more effective, provides a better quality of life, reduces health care resource utilisation, and improves work productivity as compared to the CTG, thereby resulting in a favourable cost-effectiveness ratio.

[Severe myopia and restrictive disorders of ocular motility]. / Myopie importante et troubles restrictifs de la motilité oculaire.

High myopia may produce a masquerade syndrome, exhibiting clinical findings similar to those found in endocrine ophthalmopathy. Several hypotheses have been proposed as an explanation: sixth nerve paresis, structural changes in oculomotor muscles, contact between elongated globes and the bones of the orbital apices. These hypotheses are discussed after the presentation of a case with electroneuro-oculographic and tomodensitometric findings.

[Internuclear bilateral pseudo-ophthalmoplegia and dermatomyositis]. / Pseudo-ophthalmoplégie internucléaire bilatérale et dermatomyosite.

A 60 year-old woman complaining of diplopia presents an ocular motility disturbance mimicking internuclear ophthalmoplegia. Idiopathic dermatomyositis is diagnosed by the help of clinical, biological, electrophysiological and histological data. The outcome is favorable under corticotherapy. Ocular muscle involvement is rare in dermatomyositis. An overlap syndrome with another auto-immune disorder like myasthenia should be excluded in this kind of manifestation.

[Primary malignant lymphoma of the spine: clinical aspects and therapeutic advances]. / Le lymphome malin primitif du rachis: aspects cliniques et progrès thérapeutiques.

Malignant lymphomas are occasionally encountered in the spine, where they are usually secondary deposits. The authors report the case of a primary non-Hodgkin lymphoma of the L1 vertebra in whom surgical treatment (two operations and double approach) was followed by radiotherapy and chemotherapy. The diagnosis is often made at a late stage, when neurological deficits produced by epidural compression become evident. The surgical treatment is only palliative but has several goals: obtaining a biopsy, improving the neurological symptoms through decompression, stabilizing and "rebuilding" the spinal column; it is performed using posterior, anterior or combined approaches which are discussed. The combined surgical, radiotherapeutic and polychemotherapeutic treatment is associated with a 5-year survival rate of 60-80%. Such a prognosis justifies the risk of surgery which will lead to a stable and lasting reconstruction.

[Zolmitriptan]. / Le zolmitriptan.

One of the outstanding therapeutic revolutions of this last decade has been the introduction of selective serotonin agonists in the acute treatment of migraine. After sumatriptan, introduced in Belgium in 1992, other "triptans" are emerging. The efficacy and the pharmacoeconomic profile of zolmitriptan, the second "triptan" now available in Belgium, are reviewed and the arrival of a third triptan, naratriptan is announced.

Benign transient urinary retention.

Three cases of acute urinary retention due to sacral myeloradiculitis are described. The authors stress the importance of diagnosing this rare and benign condition, which, in the past, has too often been mislabelled as either psychogenic or the first manifestation of a demyelinating disease.

Intramedullary ependymoma producing collagen. A clinical and pathological study.

The authors describe the clinical and pathological observations of a thoracolumbar intramedullary ependymoma. A voluminous conus of collagenous tissue was located in the center of the tumor. This most unusual histological finding is compared to rare cases of the literature describing the presence of bone and cartilage in ependymomas.

Cauda equina syndrome in ankylosing spondylitis. Anatomical, diagnostic, and therapeutic considerations.

This article describes a case of cauda equina syndrome associated with ankylosing spondylitis, and reviews 28 additional cases in the literature. The neurological symptoms appear late in the evolution of spondylitis, when it is at an inactive stage. The diagnosis is easily confirmed by myelography, with watersoluble contrast and performed in a supine position, and by computerized tomography (CT) scan of the lumbar spine. The typical features are dilated lumbar sac with multiple dorsal diverticula. The pathogenesis of this entity remains the subject of speculation. Arachnoiditis with subsequent adhesions is the most likely explanation. No treatment has proved helpful so far. Surgery is not indicated.

Self-treatment of acute migraine with subcutaneous sumatriptan using an auto-injector device: comparison with customary treatment in an open, longitudinal study.

In a multicenter open longitudinal clinical trial where 479 patients suffering from migraine with or without aura were recruited, patients treated at home one to three migraine attacks with their customary treatment, and subsequently, over a 3-month period, one to three migraine attacks with 6 mg sumatriptan sc using an autoinjector. The headache response to customary treatment was 19% at 1 h and 30.5% at 2 h, and was not significantly different when only attacks treated "adequately" according to accepted treatment recommendations were considered: 16% at 1 h and 35% at 2 h. In contrast, 69% and 82% of patients treated with 6 mg sumatriptan sc had mild headache or no headache at 1 and 2 h respectively, regardless of migraine type or duration of symptoms prior to treatment. Other migraine symptoms (nausea, vomiting, photo- and phonophobia) were effectively treated with sumatriptan. Recurrence of migraine was observed in 31% of patients and was well controlled by a second injection of sumatriptan. It is concluded that 6 mg sumatriptan sc, self-administered using an autoinjector, is well tolerated and more effective than most currently used acute treatments for migraine in a population of severely affected patients consulting a neurologist.