Interdisciplinary treatment of post-concussion and post-traumatic headaches.

INTRODUCTION: Chronic headaches following concussion are debilitating and difficult to treat. Commonly employed initial therapeutic modalities include pharmacologic, physical, and psychological interventions. Despite these efforts, a subset of patients with chronic pain remains. Peripheral nerve surgery has never before been reported as an effective treatment for the management of post-concussion headaches. In this study, we report on our early outcomes following peripheral nerve surgery for this novel indication. METHODS: A retrospective review of 28 consecutive patients with post-concussion headaches who underwent occipital nerve surgery was performed. Preoperative and postoperative headache pain was evaluated on visual analog scale (VAS) in 24 patients with at least 6 months follow-up. RESULTS: The average VAS headache pain reduced from 6.4 preoperatively, to 1.4 (P < 0.0001). Twenty-one patients (88%) had a successful outcome of at least a 50% reduction in their VAS following peripheral nerve surgery. Additionally, twelve patients (50%) were pain free at time of final follow-up. There were no surgical complications. CONCLUSIONS: Early results indicate peripheral nerve surgery is a safe and effective new therapy for post-concussion headaches in the properly selected patients, whose chronic pain persists despite initial treatments by a neurologist, specialized in headache management. Future studies should focus on larger patient populations, and examine the long-term durability of outcome. In the meantime, an interdisciplinary approach involving neurologists and a peripheral nerve surgeon is suggested for the care of patients with refractory chronic post-concussion occipital neuralgia and other post-traumatic chronic headaches.

Managing patients with neurologic disorders who participate in sports activities.

PURPOSE OF REVIEW: Patients with neurologic conditions have been discouraged from participating in organized sports because of theoretical detrimental effects of these activities to their underlying conditions. The purpose of this article is to review known risks associated with three specific clinical conditions most commonly encountered in a sports neurology clinic (epilepsy, migraines, and multiple sclerosis and to add to the neurologist's toolkit suggested interventions regarding management of athletes with these disorders. RECENT FINDINGS: Increased participation in sports and athletics has positive benefits for patients with neurologic conditions and can be safely integrated into the lives of these patients with proper supervision from their treating neurologists. SUMMARY: Patients with neurologic conditions can and should be encouraged to participate in organized sports as a method of maintaining their overall fitness, improving their overall level of function, and reaping the physical and psychological benefits that athletic competition has to offer.

Sports neurology topics in neurologic practice: A survey of AAN members.

We sought to assess neurologists' interest in sports neurology and learn about their experience in treating sports-related neurologic conditions. A survey was sent to a random sample of American Academy of Neurology members. A majority of members (77%) see at least some patients with sports-related neurologic issues. Concussion is the most common sports-related condition neurologists treat. More than half of survey participants (63%) did not receive any formal or informal training in sports neurology. At least two-thirds of respondents think it is very important to address the following issues: developing evidence-based return-to-play guidelines, identifying risk factors for long-term cognitive-behavioral sequelae, and developing objective diagnostic criteria for concussion. Our findings provide an up-to-date view of the subspecialty of sports neurology and identify areas for future research.

Advanced neuroimaging of mild traumatic brain injury.

This article focuses on advancements in neuroimaging techniques, compares the advantages of each of the modalities in the evaluation of mild traumatic brain injury, and discusses their contribution to our understanding of the pathophysiology as it relates to prognosis. Advanced neuroimaging techniques discussed include anatomic/structural imaging techniques, such as diffusion tensor imaging and susceptibility-weighted imaging, and functional imaging techniques, such as functional magnetic resonance imaging, perfusion-weighted imaging, magnetic resonance spectroscopy, and positron emission tomography.

Cerebrovascular dynamics and vascular endothelial growth factor in acute mountain sickness.

OBJECTIVE: To determine if serum vascular endothelial growth factor (VEGF) and ultrasonic monitoring of vascular dynamics with dynamic vascular analysis at sea level and high altitude correlate with acute mountain sickness symptoms. METHODS: Nine volunteers participated in a staged ascent from sea level to 4300 m undergoing complete transcranial Doppler studies with dynamic vascular analysis. Serum VEGF levels, Lake Louise scores, Spielberger-1 scores, Subjective Exercise Experiences Scale positive scores, and Symptom Checklist-90 surveys were collected after 24 hours at each altitude. RESULTS: Symptom scores, index of pulsatility, and dynamic flow index differentiated the subjects into 2 distinct groups. Symptomatic subjects had increased VEGF levels at sea level but decreased levels at 4300 m. The dynamic flow index increased in symptomatic subjects at 4300 m compared with the asymptomatic subjects. The mean flow velocity increased in both groups and could not be used to differentiate the subjects. CONCLUSIONS: Altered vascular physiology is associated with acute mountain sickness. Increased vascular permeability increases vascular capacitance, with an increase in dynamic flow index to meet these demands. Altered vascular dynamics were associated with high-altitude cerebral edema in 1 subject. Dynamic vascular analysis demonstrated altered vascular pathophysiology associated with acute mountain sickness. Changes in VEGF were meaningful when interpreted with the dynamic vascular analysis findings. These physiological findings may help explain the vascular changes associated with hypocarbic hypoxemia at altitude.

Differentiating vascular pathophysiological states by objective analysis of flow dynamics.

BACKGROUND AND PURPOSE: There is an unmet need to classify cerebrovascular conditions physiologically and to assess cerebrovascular system performance. The authors hypothesized that by simultaneously considering the dynamic parameters of flow velocity, acceleration, and pulsatility index (PI) (impedance) in individual Doppler spectrum waveforms, they could develop an objective method to elucidate the pathophysiology of vascular conditions and classify cerebrovascular disorders. This method, dynamic vascular analysis (DVA), is described. METHODS: First, a theoretical model was developed to determine how any vascular segment and the ensemble of intracranial vascular segments could be defined according to its dynamic physiological characteristics. Next, the DVA method was applied to 847 anonymous serial complete clinical transcranial Doppler (TCD) studies of patients without regard for their diagnosis to ascertain actual reference ranges and the normality of the distribution curves for each dimension of the 3-parameter nomogram. The authors applied DVA to 2 clinical cases to see if they could track the changes in vascular performance of 2 known progressive diseases. RESULTS: The theoretical analysis identified 295,245 possible vascular states for the ensemble of vascular segments in the cerebral circulation. When applied to clinical TCD data, DVA revealed continuous, normally distributed data for the velocity, PI, and logarithm of the acceleration. CONCLUSIONS: DVA is proposed as a method for monitoring the physiological state of each cerebral artery segment individually and in ensemble. DVA evaluates the relationship among acceleration (force or pressure), velocity, and PI and provides an objective means to evaluate intracranial vascular segments using the paradigm of the well-described pressure-perfusion autoregulation relationship. DVA may be used to study cerebrovascular pathophysiology and to classify, evaluate, and monitor cerebrovascular disorders or systemic disorders with cerebrovascular effects.