Clinical Correlation of Abnormal Transcranial Doppler in Migraineurs

BACKGROUND: It is well-known that migraineurs frequently have abnormal findings on transcranial Doppler ultra-sound (TCD), but their clinical implications are not clear. We investigated the clinical significance of TCD findings in migraineurs. METHODS: One hundred thirty-seven consecutive migraineurs were prospectively gathered. The following clinical parameters were investigated : 1) age and sex, 2) time from onset of headache to visiting hospital, 3) frequency, duration, laterality, pulsating quality, and severity of headache, 4) presence of nausea, vomiting, photophobia, and phonophobia, 5) aura, and 6) aggravation of headache by routine physical activity. TCD was performed during a headache-free period to measure the mean flow velocities (MFVs) and other parameters of 13 intracranial and 2 extracranial vessels. If MFV of any artery or its side-to-side difference in each migraineur was beyond 2 standard deviations of corresponding age and sex-matched reference subgroups, the TCD result was regarded as abnormal. Correlations between abnormal TCD and clinical parameters were examined by univariate and multivariate analyses. RESULTS: Results of TCD were abnormal in 84 patients (61.3%). Pulsatility of headache and absence of aura were significantly correlated with abnormal TCD on univariate analyses (p=0.003 and 0.049 respectively). On multivariate analysis, pulsatility of headache was the only statistically significant predictor of abnormal TCD (p=0.015). Headache attacks tended to be less frequent in patients with abnormal TCD with marginal significance (p=0.050). CONCLUSIONS: Our study shows that abnormal results on TCD are more frequent in migraineurs with pulsatile headache. An association between abnormal TCD and frequency of headache attacks is suggested.

A Case of Miller Fisher Syndrome Presenting as Sudden Vertigo

Ophthalmoplegia, ataxia, and areflexia are a classical triad of Miller Fisher syndrome (MFS). The experience of dizziness secondary to ophthalmoplegia is also not uncommon. However, nystagmus is rare and vertigo, a symptom of vestibulocerebellar dysfunction, has not been reported yet. A 56-year-old woman visited our hospital due to sudden vertigo. Initial examination revealed nystagmus evoked by a bilateral horizontal gaze with left side dysmetria. The next day, her symptoms rapidly aggravated to ophthalmoplegia, severe ataxia, areflexia, and quadriplegia. She was diag-nosed with MFS and was treated with intravenous immunoglobulin. On the fourth day, she developed respiratory fail-ure and a ventilator was applied. Twenty-eight days after her admission, she recovered to the point of walking without any aid and was discharged with minimal disability. There are still controversies surrounding the nosology of MFS and many investigators have reported evidence for brainstem involvement. Vertigo can be additional evidence for the involvement of the central nervous system in MFS.

Multifocal ischemic lesions and focal hematoma formation in a meningitis

Cerebrovascular complications are of the most frequent intracranial complications of bacterial meningitis. Most of the previous reports suggest that the prognosis for the pafients with cerebrovascular complications was unfavorable. We recently experienced a case of meningococcal meningitis with fulminant meningococcemia associated with multifocal non-enhancing lesions on, initial brain MRI. These lesions were hyperintense on T2weighted image and were located in left basal ganglia, both medial thalami, periventricular white matter, left cerebellar hemisphere, and right midbrain and were considered to be resulted from small vessel involvement. Gram negative diplococci were detected by Gram staining of specimens from skin lesion. After antimicrobial therapy and glucocorticoid replacement the patient was recovered without any neurologic sequelae. After one month, follow-up MRI showed resolution of all the ischemic lesions except in midbrain. Additionally there was a small focal hemtoma formation in left basal ganglia. The small hematoma was considered to be resulted from rupture of microaneurysm and disappeared on follow up MRI performed after 3 months. This case suggests that the cerebrovascular complications in meningococcal mningitis might be treated successfully.