[Argentinean consensus guidelines on the use of monoclonal antibodies in patients with migraine]. / Consenso sobre el uso de anticuerpos monoclonales en la migraña en Argentina.

INTRODUCTION: Migraine is a very prevalent disorder that is estimated to affect about 15% of adult subjects. Recently, the efficacy and safety of monoclonal antibodies that act on the calcitonin gene-related peptide pathway (MA-CGRP) has been evaluated in migraine. Several groups around the world have developed consensus guidelines about the use of monoclonal antibodies, however, in some regions is difficult to extrapolate the recommendations. AIM: To provide recommendations for the use of MA-CGRP in migraine in Argentina. DEVELOPMENT: A group of neurology experts from Argentina, by using the online surveys methodology as well as face to face meetings developed the intended consensus for the use of MA-CGRP in migraine in Argentina. Recommendations were established based on published evidence and the expert opinion. Recommendations focused on how, when, treatment duration and patients follow up. CONCLUSION: The recommendations of this consensus guidelines attempt to optimize the use of MA-CGRP in migraine in Argentina.

TITLE: Consenso sobre el uso de anticuerpos monoclonales en la migraña en Argentina.Introducción. La migraña es un trastorno muy prevalente que se estima que afecta a alrededor del 15% de los sujetos adultos. Durante los últimos años, se ha evaluado la eficacia y la seguridad de los anticuerpos monoclonales que actúan sobre la vía del péptido relacionado con el gen de la calcitonina (AM-PRGC) en la migraña. Diversos grupos de trabajo internacionales han intentado clarificar y normatizar el uso de estos medicamentos en la migraña. Sin embargo, en muchas ocasiones se extrapolan datos de otras regiones que no contemplan la realidad de cada lugar o son difíciles de implementar. Objetivo. Proveer recomendaciones sobre el uso de AM-PRGC en pacientes con migraña en Argentina. Desarrollo. Un grupo de expertos de Argentina conformado por neurólogos, mediante metodología de ronda de encuestas en la distancia y reuniones presenciales, llevó adelante la elaboración del consenso pretendido para el uso de AM-PRGC en pacientes con migraña en Argentina. Se establecieron las recomendaciones basadas en la evidencia publicada y en el criterio de los expertos que participaron. Las recomendaciones se enfocaron en el momento de usar los AM-PRGC en la migraña tanto crónica como episódica, la duración, los cuidados y el entorno para hacerlo. Conclusión. Las recomendaciones establecidas en el presente consenso permitirán optimizar el manejo de los AM-PRGC en pacientes con migraña en Argentina.

Prediction of Gait without Physical Assistance after Inpatient Rehabilitation in Severe Subacute Stroke Subjects.

BACKGROUND: Gait recovery is one of the main therapeutic goals of the rehabilitation for patients after a stroke. OBJECTIVE: This study is aimed at describing the frequency of achievement of gait without physical assistance in poststroke subacute patients by the time of discharge from a rehabilitation hospitalized program. Secondarily, our goal is to identify gait without physical assistance predictors in this same population based on the admission's clinical and demographic conditions. METHODS: Data from 185 first unilateral hemispheric stroke patients that need physical assistance to walk at admission were analyzed. The sample was dichotomized into gait with physical assistance and gait without physical assistance to calculate the frequency of achievement of gait without assistance at discharge. Multivariate logistic modeling was applied to identify prognostic factors for regaining gait without physical assistance. RESULTS: Gait without assistance was achieved in 50.27% of the subjects. Five variables were identified for the prediction model: age (Odds ratio [OR] = .87, 95% confidence interval [CI] = .83-.92), gender (OR = .37, 95% CI = .14-.94), time between stroke and hospitalization (OR = .96, 95% CI = .94-.99), initial Berg Balance (OR = 1.52, 95% CI = 1.23-1.88), and initial lower limb Fugl Meyer (OR = 1.17, 95% CI = 1.07-1.27). CONCLUSIONS: Although discharge planning is complex, achievement of gait without physical assistance is undoubtedly a landmark to decide on hospitalization discharge. Half of this sample was able to walk without physical assistance at hospitalization discharge. Five clinical and demographic conditions at admission were found predictors of gait without physical assistance at inpatient discharge.

Cranial neuralgias.

After a description of the anatomical-functional organization of the human trigeminal system, this chapter discusses the diagnostic and therapeutic options for trigeminal neuralgia (TN). In about 15% of patients who present with the clinical picture of typical TN, this is secondary to a major neurological disease, i.e., benign tumors of the cerebellopontine angle or multiple sclerosis. Some clinical criteria that were used to distinguish between classic and symptomatic TN, such as age at onset, involvement of the ophthalmic division, and responsiveness to medical treatment, are no longer considered reliable. It is recommended that all patients undergo magnetic resonance imaging (MRI) or trigeminal reflex recording. Carbamazepine (CBZ) and oxcarbazepine (OXC) are the first-choice medical treatments. Although other drugs may be effective, these are indicated when the patient cannot reach the therapeutic dosage of CBZ/OXC because of adverse events. Patients unresponsive to CBZ/OXC should be made aware of the available surgical interventions. Surgical procedures (including percutaneous lesions to the ganglion/root, microvascular decompression (MVD) in the posterior fossa, and gamma knife radiosurgery) are extremely efficacious with relatively few complications: each procedure has some advantage and disadvantage with respect to the other. Only MVD is a non-destructive procedure. This chapter also describes management of glossopharyngeal neuralgia, which is often misdiagnosed, and some other chronic pain conditions mediated by the trigeminal system, such as ophthalmic postherpetic neuralgia (PHN).

Subclinical sensory abnormalities in trigeminal neuralgia.

Trigeminal neuralgia is considered as a paroxysmal single nerve phenomenon. Abnormal sensory perception has been previously described in 15-25% of patients with clinical examination. Quantitative sensory testing (QST) was used to evaluate sensory perception in patients with idiopathic trigeminal neuralgia (ITN). Nine patients and 10 normal control subjects were evaluated in all six trigeminal branches. QST abnormalities were found in the symptomatic division and in the other two branches on the same side. Minor contralateral changes were also found. Differences consisted of cold and warm hypoaesthesia and higher cold and heat pain thresholds in patients. All differences proved statistically significant. Our findings suggest that trigeminal neuralgia is not only a paroxysmal single nerve disorder, but also that other higher structures may be involved.

Intracranial hypotension: the nonspecific nature of MRI findings.

We present three patients who complained of postural headache related to different types of intracranial hypotension: spontaneous or primary, and secondary, but presenting the same findings on brain magnetic resonance imaging. Diffuse pachymeningeal gadolinium enhancement supports the belief that the enhancement is a nonspecific meningeal reaction to low pressure.

Syncope and seizure-like activity secondary to acute herpes zoster infection of the trigeminal nerve.

Syncope may occur with glossopharyngeal neuralgia. We describe a patient with acute herpetic infection of the first branch of the trigeminal nerve associated with episodes of shooting pain, cardiac arrest and tonic-clonic movements. Resemblances with the so-called "cardiovascular" form of glossopharyngeal neuralgia, as well as putative mechanisms of the syncope, are discussed.

Pain threshold in humans. A study with the pressure algometer.

Pain perception threshold (PPT) in the head was assessed with a pressure algometer in 40 control individuals (24 females and 16 males). Threshold was assessed at 11 symmetrical points on each side. The average threshold for each side was calculated, and differences between two sides were evaluated with an asymmetry index. Subjects were studied in relation to age and sex, and any difference in the symmetrical perception of pain on the head was registered. The deltoid muscle was chosen as a reference point, since it is rarely a site of trigger points. The reproducibility of the method was satisfactory. A significantly positive correlation was found between PPT value of the head and the deltoid muscle. There was no tendency to rise or fall in PPT during the same "session", which consisted of 3 separate complete measurements. The mean of mean values showed that there was little asymmetry as for the thresholds pertaining to the head in the total material. Age and sex apparently played little role as for the outcome of the test. The assessment of PPT in the head might be a useful tool in the study of lateralization of pain in unilateral headache syndromes.

Topographic variations in the peripheral course of the greater occipital nerve. Autopsy study with clinical correlations.

The description of the peripheral course of the greater occipital nerve (GON) varies in the literature. An autopsy study was done on 20 cases without known headache problems. These findings showed a marked variation in the relation between the GON and nuchal muscles. The trapezius muscle was penetrated by the GON in 45% of cases, the semispinal muscle of the head was penetrated in 90% of cases, and the inferior oblique muscle of head was penetrated in 7.5% of cases. Macroscopic findings of possible compression were made in 11 cases (27.5%), indicating that nerve compression per se may be of minor importance since it seems to exist in the absence of headache.