Botulinum therapy for chronic migraine.

Chronic migraine (CM) is an important cause of chronic daily headache (CDH), a common severe headache syndrome. Patients with CM are significantly disabled from employment and overuse pain relieving medications. CM is a difficult condition to treat. Overuse of abortive medications and limited benefit from oral preventive medications are an important problem in managing this condition. Recent randomized controlled trials evaluating the efficacy of botulinum toxin A (BoNT-A) have confirmed its efficacy for CM prophylaxis. BoNT-A is a safe drug with no systemic reactions in clinical trials for headache.

Patent foramen ovale and stroke: coincident or real association.

Stroke is a common cause of morbidity and mortality. Approximate 40% of strokes are cryptogenic, because patent foramen ovale (PFO) is commonly found in the normal population. They are conflicting data from studies examining the association between PFO and stroke. Various factors need to be considered such as atrial anatomic variations (PFO size, atrial septal aneurysm, eustachian valve anatomy), the presence of venous thrombosis, and the presence of hypercoagulable state. The presence of any of these findings increases the chance of PFO contributing to a stroke. Limited information suggests no advantage of warfarin over aspirin in preventing recurrent strokes. Both surgical and transcatheter devices have been shown to decrease the rate of subsequent embolic events substantially. Surgical and percutaneous PFO closures have not been directly compared. However, the percutaneous approach appears to be less invasive and so successful that it seems to be a reasonable consideration for first choice treatment of PFO.

Computed tomographic findings in non-traumatic hemorrhagic stroke.

OBJECTIVE: To analyze CT findings in hemorrhagic stroke patients correlation with clinical outcome and assess the interobserver agreement of hemorrhagic stroke identification on CT imaging. MATERIAL AND METHOD: CT imaging features of 131 cases and clinical data were verified and collected at Siriraj Hospital from Jan 2004 to Dec 2005 and retrospectively analyzed for type, location, mass effect, size of hemorrhage, intraventricular extension, initial level of consciousness (GCS), hospital length of stay and patient outcome. The percentages, predictive values, kappa were calculated. RESULTS: From all types of hemorrhagic stroke, intracerebral hemorrhage remains a common and devastating clinical problem. The most common site was the thalamus and basal ganglia. In the present study, the authors found that fifty-three cases (53/131 cases, 40.5%) with thalamic-ganglionic hemorrhage, nineteen cases (19/131 cases, 14.5%) in lobar hemorrhage, five cases (5/131 cases, 3.8%) in cerebellum, five cases (5/131 7 cases, 3.8%) in brainstem and eight cases (8/131 cases, 6.1%) occurred in multiple locations. There were twenty-five cases (25/131 cases, 19.1%) of subarachnoid hemorrhage, thirteen cases (13/131 cases, 9.9%) of subdural hemorrhage and three cases (3/131 cases, 2.3%) of intraventricular hemorrhage. Two variables on CT imaging, identified as significant as early mortality predictors, were hematoma volume more than 60 cm3, and presence of intraventricular hemorrhage extension (p < 0.05). The mass effect defined as midline and/or enlargement of contralateral ventricle was not significant (p = 0.067). The present study found concordance between CT brain interpretation by two neuroradiologists for the type of hemorrhagic stroke was very good, Kappa = 0.861 as well as for location was 0.866. CONCLUSION: CT imaging is an imaging instrument for early identification of hemorrhagic stroke patients and providing imaging evidence of high mortality risk.

The effect of Galantamine on sleep quality in Thai Alzheimer's disease patients.

OBJECTIVE: To study the effect of Galantamine on sleep quality in Thai Alzheimer's disease (AD) patients with or without cerebrovascular disease. MATERIAL AND METHOD: A 6 month, multicenter open-label, uncontrolled trial was undertaken in 75 mild to moderate Alzheimer's disease patients with or without cerebrovascular disease. Eligible patients received a flexible-dose of Galantamine 16 or 24 mg/day for 24 weeks. The Pittsburgh Sleep Quality Index (PSQI) with self-analysis questionnaires were used to evaluate sleep quality. Analyses were based on the intent-to-treat population. RESULTS: Seventy-five eligible patients with mild to moderate Alzheimer's disease with or without cerebrovascular disease (male:female = 32:43, age range 74.5 +/- 0.9) were included and 58 patients (79%) completed the present study. The global PSQI scores showed some improvement over baseline (week 0 = 5.10 +/- 3.08, week 4 = 4.37 +/- 2.48, week 8 = 4.65 +/- 2.71, week 24 = 3.70 +/- 2.12) but were not yet statistical significant. In contrast, most of each component scores such as sleep quality, sleep latency, sleep duration, sleep disturbances, sleep medication, and daytime dysfunction except sleep efficiency, showed significant differences from baseline after week 8. Moreover, there were no significant differences in global PSQI and component scores between mild and moderate stages of Thai AD patients or between men and women patients. CONCLUSION: The result of the present study may be consistent with Galantamine being safe and can maintain good sleep quality for mild to moderate Thai AD patients with or without VaD. Galantamine doses of 16-24 mg/day were well tolerated.

Stroke in Henoch-Schönlein purpura associated with methicillin-resistant Staphylococcus aureus septicemia: report of a case and review of the literature.

Neurological involvement in Henoch-SchOnlein purpura (HSP) such as stroke is uncommon manifestiation, particularly in association with Staphylococcus aureus (S. aureus). The authors reported a 17-year-old man who developed sudden onset of right hemiparesis while he was admitted in the hospital about his prolonged fever, palpable purpura and upper gastrointestinal bleeding. He also had evidence of MRSA septicemia before the onset of right hemiparesis. Skin biopsy was done and showed that there was leukocytoclastic vasculitis with IgA deposition. He had received completed course of antibiotics and then he was subsequently improved after steroid therapy in the next 2 weeks. Review of case reports from previous English literatures, discovered the association between MRSA infection and HSP which can cause several CNS manifestations including stroke symptoms from cerebral vasculitis.

Orbital infarction syndrome in nephrotic syndrome patient with extensive carotid arteries occlusion.

Orbital infarction syndrome is defined as ischemia of global intraorbital structures such as extraocular muscles, optic nerves, and retina. The most common cause of this syndrome is carotid arterial occlusion. Other causes include vasculitis, vasospasm, and compression of intraorbital circulation. There has never been reported a case of orbital infarction syndrome in nephrotic syndrome patient. We present a case of 42-year-old Thai man with underlying disease nephrotic syndrome presented with abrupt onset of headache at left temporal area, horizontal diplopia, limitation of eye movement in all directions, ptosis, and blurred vision on the left eye. He was treated with pulse methylprednisolone intravenously for 3 days. Leg edema was improved however, the eye symptoms persisted. There was no evidence of hypercoagulable state. Magnetic resonance imaging (MRI), magnetic resonance angiography (MRA) revealed loss of signal intensity at left internal carotid artery from base of skull to intracavernous part. Cerebral angiography demonstrated complete occlusion of left common carotid artery. After the anticoagulant treatment, his symptoms were gradually improved. The cause of extensive carotid arterial occlusion in this patient is most likely from hypercoagulable state. Although it was negative for hypercoagulable state evidence, the authors assume that the high dose steroid treatment could lead to remission of nephrotic syndrome and resulting in the resolution of hypercoagulable state.

Grave prognosis on spontaneous intracerebral haemorrhage: GP on STAGE score.

BACKGROUND AND OBJECTIVE: Spontaneous intracerebral haemorrhage (ICH) is more common in Asia than in western countries, and has a high mortality rate. A simple prognostic score for predicting grave prognosis of ICH is lacking. Our objective was to develop a simple and reliable score for most physicians. MATERIAL AND METHOD: ICH patients from seven Asian countries were enrolled between May 2000 and April 2002 for a prospective study. Clinical features such as headache and vomiting, vascular risk factors, Glasgow coma scale (GCS), body temperature (BT), blood pressure on arrival, location and size of haematoma, intraventricular haemorrhage (IVH), hydrocephalus, need for surgical treatment, medical treatment, length of hospital stay and other complications were analyzed to determine the outcome using a modified Rankin scale (MRS). Grave prognosis (defined as MRS of 5-6) was judged on the discharge date. RESULTS: 995 patients, mean age 59.5 +/- 14.3 years were analyzed, after exclusion of incomplete data in 87 patients. 402 patients (40.4%) were in the grave prognosis group (MRS 5-6). Univariable analysis and then multivariable analysis showed only four statistically significant predictors for grave outcome of ICH. They were fever (BT > or = 37.8 degrees c), low GCS, large haematoma and IVH. The grave prognosis on spontaneous intracerebral haemorrhage (GP on STAGE) score was derived from these four factors using a multiple logistic model. CONCLUSION: A simple and pragmatic prognostic score for ICH outcome has been developed with high sensitivity (82%) and specificity (82%). Furthermore, it can be administered by most general practitioners. Validation in other populations is now required.

Use of Hachinski Ischemic Score in the memory clinic: Thai experience.

BACKGROUND: The validity ofHachinski Ischemic Score (HIS) in differentiating between Alzheimer's disease (AD) and Vascular dementia (VaD) has been questioned and compared with the gold standard autopsy. OBJECTIVE: To confirm that the HIS can be used to differentiate related VaD from AD in a Thai population. MATERIAL AND METHOD: A prospective study of 398 patients who were attending the Memory Clinic, at Siriraj Hospital between January 2001 and October 2003. RESULTS: The 214 patients, with a mean age of 71.15 + 10.20 years, were classified as AD, VaD or mixed dementia (AD with cerebrovascular disease) in proportion of 60.2%, 30.4%, and 9.3% respectively. The authors propose HIS at 5 as a cut off point to differentiate patients with AD and those with VaD or AD with cerebrovascular disease with sensitivity of 85.3% and specificity of 72.9%. CONCLUSION: The HIS can be applied to differentiate dementia related vascular etiology from AD in a Thai population.

Chrono impact versus enteric coated valproate in Thai epileptic patients.

BACKGROUND: Since its first clinical use more than 30 years ago, Valproic acid is still being widely prescribed It has been available in Thailand for more than 20 years. Sodium valproate slow-released (SVSR) form has been used in clinical practice in Thailand since 1990. The objectives of this open study were to access the compliance and satisfaction consequences in the epileptic patients. MATERIAL AND METHOD: In this prospective, multi-center study, the authors compared the compliance and satisfaction consequences in epileptic patients switched from more than two times daily sodium valproate enteric-coated tablet (SVEC) regimen to the same total daily dose of SVSR form given once or twice daily. RESULTS: Eighty-nine of the 100 patients completed the study. 43.8% were male (39 of 89 patients). Mean age was 34.74 +/- 12.67 years. Most common etiology of epilepsy was idiopathic 40.4%. Patients were very/fairly happy with the SVSR form 94.4% compared to the SVEC form 56.2% (p = 0.000). Patients had been experiencing no problem with the SVSR form 67.4% compared to SVEC form 38.2% (p = 0.000) and also never missing taking SVSR. form 77.5% compared to SVEC form 40.4% (p = 0.000). According to convenience, patients preferred to administer SVSR form once a day 92.1% and never over taking dosed the antiepileptic drug 96.6%. SVSR form had fewer side effects than the enteric-coated form interms of memory problem (40.4% vs 48.3%) (p = 0.000), sleepiness (30.3% vs 42.7%) (p = 0.041) and difficulty in thinking clearly (38.2% vs 44.9%) (p = 0.001). The patients were seizure free during the study period comparing SVSR form 76.4% to SVEC form 65.2% (p = 0.011). CONCLUSION: Patients preferred once daily regime. Switching from SVEC to SVSR form increased seizure free, reduced side effects, improved patient's compliance and satisfaction.

Vascular loop compressing facial nerve in hemifacial spasm: demonstrated by 3D-phase contrast magnetic resonance angiography in 101 patients.

BACKGROUND: Vascular compression of the facial nerve is deemed to be the common cause of hemifacial spasm producing emphatic transmission. Although facial nucleus supersensitivity is more accepted as the main cause of hemifacial spasm. PURPOSE: To determine the vascular loop compression of the facial nerve in patients with hemifacial spasm by 3D-phase contrast (PC) magnatic resonance imaging (MRI). MATERIAL AND METHOD: A retrospective study of 101 patients with hemifacial spasm who went MRI and magnetic resonance angiography (MRA) of the brain was done. The magnitude images of the 3D-PC MRA was evaluated in axial and oblique coronal reconstruction planes blindly from symptomatic information. RESULTS: Among 101 patients, 53 affected the left side, 48 patients were right sided and none had bilateral involvement. Vascular loop compressing on the symptomatic side was found in 61 (60.4%) patients. For the asymptomatic side, there were 14 (13.86%) with vascular loop contact. Five patients (4.9%) had bilateral vascular compression. The proportion of vascular contact of the symptomatic and asymptomatic side was significantly different (with p < 0.001). The offending vessels were vertebral artery (32, 52.46%), posterior inferior cerebellar artery (7, 6.93%), anterior inferior cerebellar artery (6, 5.94%) and artery of uncertain origin (16, 26.23%). CONCLUSION: The study implied the usefulness of this simple technique to demonstrate the neurovascular contact of the facial nerve.

The accuracy of magnetic resonance venography for diagnosis of dural sinus thrombosis.

A retrospective study of 24 patients who underwent magnetic resonance venography (MRV) was performed. The MRV was using a 3D-PC technique and thick-slab multiplanar reconstruction. Four patients underwent conventional angiography. There were 4 males and 20 females with an age range of 8-71 years. The MRV was considered as positive for dural sinus thrombosis (DST) in 8 patients and negative in 16 patients. There were 2 false positive in the MRV.The sensitivity of MRV is 100%,specificity 88%,positive predictive value 75% and negative predictive value 100%.We concluded that MRV is a valuable screening method for DST. One pitfall concerning the use of MRV is that a false positive interpretation may occur due to hypoplasia of the transverse sinus which is a normal variant.

Siriraj acute stroke unit: The experience of 614 patients.

Background : Stroke is a leading cause of mortality and morbidity worldwide. Establishing a stroke unit is one of the most recent advance in an acute stroke management. A number of trials have shown the benefit of stroke unit. In Thailand, the Siriraj Acute Stroke Unit ( SASU) is the first and only unit in the country. It has been established since May 1997. Methods : We analysed the data from the acute stroke patients admitted to the SASU from May 1997 to January 2001. The main criteria for admission to the SASU were stroke patients of either sex, aged over 13 years, with a Glasgow Coma Scale over 11/ 15 , and those who did not require ventilation. Results : The total number of patients admitted to the SASU was 614. There were 310 males (50.49 per cent) and 304 females (49.51 per cent). The mean age of all patients was 63.79 years (range19-94 yrs ). CT or MRI brain scans were done on 580 patients (94.46%). Stroke subtypes were classified as cerebral infarction in 488 patients (79.40% ) and cerebral haemorrhage in 102 patients (16.61% ). Fifteen patients (3.07% ) were diagnosed with a transient ischaemic attack .Seven patients (1.14% ) initially diagnosed as having a stroke were found to have a brain tumour ( 4 primary and, 3 metastatic tumours). Risk factors for stroke were as follows :- hypertension (57.32% ), diabetes mellitus (30.94%), hyperlipidaemia ( 30.13% ), heart disease ( 24.08% ), and smoking ( 23.28% ). The mortality rate of acute stroke patients in SASU was 1.95 percent (12 patients) mainly due to brain herniation ( 6 patients ). The mean total hospital stay of stroke patients at the SASU was15.64 days ( ranging from 1-120 days ). Conclusion : The mortality rate of acute stroke patients in SASU was very low. The main cause of death was brain herniation. The hospital stay in the SASU is reduced by half in comparision with a general medical ward. An acute stroke patient admitted to the SASU has a better chance of survival as well as a shorter length of stay.

Hemifacial spasm treated with botulinum toxin injection: A ten-year experience at Siriraj Hospital.

Background : Hemifacial spasm is a common movement disorder in Thailand. Botulinum toxin has been introduced as an advanced treatment for this condition recently. Objective: To evaluate the efficacy and complication of botulinum toxin in the treatment of hemifacial spasm. Methods: We reviewed all files of patients with hemifacial spasm in the Movement Disorders Clinic at Siriraj Hospital, Mahidol University, who were treated with botulinum toxin injection from January, 1989 until September, 1999. Sex, age, duration of treatment, times of injection, treatment outcome, and complications were analysed. Results: There were 913 patients of which 38 patients were excluded because they were loss to follow up. 875 patients were analysed, (269 males, 606 females sex ratio 1:2.25). The mean age of all patients was 50.86+12.53 years with a range of 18 to 81 years. The follow up period ranged from 1-130 months (mean = 32.5+35.05 months). The outcome were classified as excellent (improvement >50%) in 58.9%, good (improvement >25%) in 37.3%, fair (improvement <25%) in 3.1%, and no improvement in 0.8%. Thus the efficacy of this treatment (improvement >25%) was 96.2 percent. There were complications of mild facial paresis in 80 patients (9.1%), ptosis in 39 patients (4.5%), excessive lacrimation in 7 patients (0.8%), and others (including pain and itching at the injection sites and double vision) in 7 patients (0.8%). All of the complications ere transient. ? Conclusion: Botulinum toxin A injection is a safe and effective way with no long term systemic complications (of treating patients with hemifacial spasm).

Neurosarcoidosis: First reported case in Thailand.

Sarcoidosis is a chronic multisystem granulomatous disease of unknown aetiology, which has a propensity to affect the lungs and rarely the nervous system; neurosarcoidosis may be an enigmatic diagnosis which is often entertained but rarely made with conviction. Prevalence rates for intrathoracic sarcoidosis vary from greater than 50 per 100, 000 e.g. in New York African-Americans, to under 10 per 100,0002. Much higher prevalence rates were obtained when consecutive postmortems were performed on approximately 60% of all deaths in an area of Sweden, of known to have sarcoidosis during life, yielding a prevalence of 641 per 100,0003. Previous data from large series of patients with sarcoidosis have estimated that approximately 5% of such patients will have clinical involvement of the nervous system4-7, although post-mortem studies suggest that ante-mortem diagnosis is only made in 50% with nervous system involvement. Therefore one can estimate that about 5 to 10 patients per million population will have clinical neurosarcoidosis. In Thailand there has been no previous report of neurosarcoidosis, thus our patient is the first documented case in the Kingdom.

Do physicians recognise dementia.

Background : Recognition and diagnosis of dementia is frequently overlooked by attending physicians both in the community and hospital settings. Objective : To determine the ability of attending physicians to recognise dementia. Methods : A cross-sectional survey of cognitive impairment in 150 medical inpatients at Siriraj Hospital, Bangkok, Thailand was done from May to November 1999. Inclusion criteria were patients aged over 50 year-old with Glasgow coma score over 12/15, no delirium and no active medical problems. Cognitive assessment was done before the discharge date by means of clinical evaluation, neurological examination and mental state examination. Dementia was diagnosed by DSM-IV criteria. The severity of dementia was classified by using the degree of dependency. Diagnosis of dementia in the medical records was categorised as whether dementia was recognised by the attending physicians. Results : Forty nine patients out of a total of 150 patients (32.67 per cent) were demented of which thirty three patients had mild dementia, thirteen patients had moderate dementia and three patients had severe dementia. The attending physicians recognised two patients out of forty nine dementia patients (4%). However, both of them had previously been diagnosed as having dementia before the admission. Conclusion : Delayed diagnosis of dementia is frequently due to attending physicians not recognising this condition. Early recognition of dementia usually leads to its proper management, thus internists should be more alert for this condition.

Streptococcus suis meningitis: A case report.

We reported 51 year old man from Kanchanaburi Province presented with acute bacterial meningitis. The pathogenic bacteria was identified as g-haemolytic streptococci ( non gr D ). The cerebrospinal fluid (CSF) showed lymphocytic pleocytosis which were indistinguishable to tuberculous or fungal infections. After treatment with penicillin and third generation cephalosporin for 2 weeks, CSF culture for bacteria was negative, but the symptoms were still persisting and later on developed sensorineural hearing loss. Antibiotics were continued for another 6 weeks. Patient responsed to medication well but complicated with hydrocephalus and sensorineural hearing loss that both were treated promptly. The most likely pathogenic organism in this patient is Streptococcus suis.

The life threatening bilateral subdural haematoma: A case report.

Chronic subdural haematona (CSH) is one of the great mimicker in neurology and usually leading to misdiagnosis, because the symptoms and sign are variable. Most patients usually had no previous history of head injury. Bilateral subdural haematoma is even more different to diagnosis and it is one of the most life threatening condition, but fortunately it is a very rare event. We report a 52 year old man who had suffered from severe headache for 1 mouth and later developed confusion. CT scan and lumbar puncture were done at the other hospital. But the diagnosis was dubious and paracetamol was prescribed. He was referred to Siriraj Hospital by himself. Repeated lumber puncture was done and the result was still normal then he was consulted but his previous neuroimagine revealed bilateral isodensity subdural haematoma. Haemolytic clot from subdural haematoma was removed bilaterally in the same day which resulted in complete resolution of confusion and headache.