ABSTRACT
Headache is consistently one of the most common complaints reported by patients in the medical setting worldwide. Headache can be a symptom of another condition or illness, secondary to the disruption of homeostasis, or can be a primary disorder with inherent variability and patterns. Headache disorders, whether primary or secondary, can cause significant disability and loss of quality of life for those affected. As such, it is important for primary care providers to feel confident evaluating and treating patients with headache, especially given the limited access to Headache Medicine subspecialists.
Subject(s)
Headache , Primary Health Care , Humans , Diagnosis, Differential , Headache/diagnosis , Headache/therapy , Headache Disorders/diagnosis , Headache Disorders/therapyABSTRACT
BACKGROUND AND OBJECTIVES: Existing tools to diagnose spontaneous intracranial hypotension (SIH), namely spinal opening pressure (OP) and brain MRI, have limited sensitivity. We investigated whether evaluation of brain MRI using the Bern score, combined with calculated craniospinal elastance, would aid in diagnosing SIH and provide insight into its pathophysiology. METHODS: A retrospective chart review was performed of patients who underwent brain MRI and pressure-augmented dynamic CT myelography (dCTM) for suspicion of SIH. Two blinded neuroradiologists assigned Bern scores for each brain MRI. OP and incremental pressure changes after intrathecal saline infusion were recorded to calculate craniospinal elastance. The relationship between Bern score, OP, and elastance and whether a leak was found were analyzed. RESULTS: Seventy-two consecutive dCTMs were performed in 53 patients. Twelve CSF-venous fistulae, 2 ruptured meningeal diverticula, 2 dural defects, and 1 dural bleb were found (17/53, 32%). Among patients with imaging-proven CSF leak/fistula, OP was normal in all but 1 patient and was not significantly different in those with a leak compared with those without (15.1 vs 13.6 cm H2O, p = 0.24, A = 0.40). The average Bern score in individuals with a leak was significantly higher than that in those without (5.35 vs 1.85, p < 0.001, A = 0.85), even when excluding pachymeningeal enhancement from the score (3.77 vs 1.57, p = 0.001, A = 0.78). The average elastance in those with a leak was higher than that in those without, but this difference was not statistically significant (2.05 vs 1.20 mL/cm H2O, p = 0.19, A = 0.40). Increased elastance was significantly associated with an increased Bern score (95% CI -0.55 to 0.12, p < 0.01) and was significantly associated with venous distention, pachymeningeal enhancement, prepontine narrowing, and subdural collections, but not a narrowed mamillopontine or suprasellar distance. DISCUSSION: OP is not an effective predictor for diagnosing CSF leak and if used in isolation would result in misdiagnosis of 94% of patients in our cohort. The Bern score was associated with a higher diagnostic yield of dCTM. Elastance was significantly associated with certain components of the Bern score.
Subject(s)
Intracranial Hypotension , Humans , Intracranial Hypotension/diagnostic imaging , Intracranial Hypotension/complications , Retrospective Studies , Spine , Myelography , Magnetic Resonance Imaging , Cerebrospinal Fluid Leak/diagnosisABSTRACT
A healthy middle-aged man presents with symptoms of dysphagia and dysphonia following an upper respiratory infection, and is diagnosed and treated for complications of pharyngitis. He presents for evaluation at a tertiary care hospital after symptoms fail to resolve, with the final diagnosis being a carotid artery dissection with compressing pseudoaneurysm. This patient's constellation of symptoms and physical examination findings are consistent with Collet-Sicard syndrome, a rare disorder caused by cranial nerve compression at the skull base. Understanding the morbidity of missing, or delaying, a diagnosis of carotid artery pathology, such as Collet-Sicard syndrome, underscores the importance of an accurate diagnosis. A review of cranial nerve anatomy, surrounding structures and potential mechanism of injury to the carotid artery are emphasised as key learning points.
Subject(s)
Cranial Nerve Diseases , Deglutition Disorders , Dysphonia , Hypoglossal Nerve Diseases , Cranial Nerve Diseases/diagnosis , Cranial Nerve Diseases/etiology , Deglutition Disorders/etiology , Dysphonia/etiology , Humans , Hypoglossal Nerve Diseases/diagnosis , Hypoglossal Nerve Diseases/etiology , Male , Middle Aged , TongueABSTRACT
INTRODUCTION: Alemtuzumab is a monoclonal antibody that targets for the destruction CD52+ cells, particularly B and T cells. Alemtuzumab is approved in more than 50 countries around the world for the treatment of adult patients with relapsing remitting multiple sclerosis (MS). Areas covered: In this review, the authors summarize biological, clinical and safety data related to the use of alemtuzumab in patients with MS. The authors then provide their expert opinion on alemtuzumab and the field as of whole before providing their perspectives for the future. Expert opinion: Alemtuzumab is highly efficacious; more so than first line treatments but comparable to natalizumab. Treatment schedule makes alemtuzumab administration easy and attractive to patients. However, its safety profile makes it a choice for a very limited number of patients, in a specific disease window. As of now, a cure for MS remains elusive and there is an unmet need for a safe and highly potent agent at the level of and beyond the blood brain barrier.
