Suicidality and Its Risk Factor in Migraine Patients

Background@#Migraine patients have a higher frequency of suicidality than people without migraine. The aim of this study was to identify suicidality and its risk factors in migraine patients. @*Methods@#We enrolled 358 migraine patients from 11 hospitals. We collected data regarding their clinical characteristics and the patients completes the questionnaires. We also interviewed patients with the Mini International Neuropsychiatric Interview (MINI)plus version 5.0.0 to identify their suicidality. The International Classification of Headache Disorders, third edition, beta version was used in headache diagnosis. @*Results@#The frequency of suicidality in migraine patients was 118 (33.0%). Migraine patients with suicidality were more likely to have a major depressive disorder or generalized anxiety disorder than those without suicidality. Among variables, risk factors for suicidality in migraine patients were female (odds ratio [OR], 4.110; 95% confidence interval [CI], 1.55310.878; p=0.004), attack duration (OR, 2.559; 95% CI, 1.2105.413; p=0.011), Patient Health Questionnaire9 (OR, 1.111; 95% CI, 1.0381.189; p=0.002), and Generalized Anxiety Disorder7 (OR, 1.194; 95% CI, 1.1011.294; p<0.001). @*Conclusions@#Suicidality in migraine patients is common. Therefore, clinicians who take care of migraine patients should be concerned about suicidality and its risk factors such as female gender, attack duration, depression or anxiety.

Smoking History and Clinical Features of Cluster Headache:Results from the Korean Cluster Headache Registry

Background@#and Purpose Epidemiologic data suggest that cluster headache (CH) is significantly associated with cigarette smoking. The aim of this study was to determine differences in features between patients with a smoking history and those who are never-smokers, using data from a prospective multicenter registry. @*Methods@#Data used in this study were obtained from the Korean Cluster Headache Registry that collected data from consecutive patients diagnosed with CH. We compared clinical and demographic features between ever-smokers (current or former smokers) and never-smokers. @*Results@#This study enrolled 250 patients who were diagnosed with CH, of which 152 (60.8%) were ever-smokers and 98 (39.2%) were never-smokers. The age at CH onset was significantly lower in the never-smoker group than in the ever-smoker group [27.1±12.9 years vs. 30.6± 10.9 years (mean±standard deviation), p=0.024]. Seasonal rhythmicity (58.1% vs. 44.7%, p= 0.038) and triptan responsiveness (100% vs. 85.1%, p=0.001) were higher in never-smokers, while other clinical features such as pain severity, duration, attack frequency, and associated autonomic symptoms did not differ significantly between the groups. The male-to-female ratio was markedly higher in ever-smokers (29.4:1) than in never-smokers (1.7:1). @*Conclusions@#Most of the clinical features did not differ significantly between patients with a smoking history and never-smokers. However, the age at CH onset, sex ratio, and seasonal rhythmicity were significantly associated with smoking history.

Smoking History and Clinical Features of Cluster Headache:Results from the Korean Cluster Headache Registry

Background@#and Purpose Epidemiologic data suggest that cluster headache (CH) is significantly associated with cigarette smoking. The aim of this study was to determine differences in features between patients with a smoking history and those who are never-smokers, using data from a prospective multicenter registry. @*Methods@#Data used in this study were obtained from the Korean Cluster Headache Registry that collected data from consecutive patients diagnosed with CH. We compared clinical and demographic features between ever-smokers (current or former smokers) and never-smokers. @*Results@#This study enrolled 250 patients who were diagnosed with CH, of which 152 (60.8%) were ever-smokers and 98 (39.2%) were never-smokers. The age at CH onset was significantly lower in the never-smoker group than in the ever-smoker group [27.1±12.9 years vs. 30.6± 10.9 years (mean±standard deviation), p=0.024]. Seasonal rhythmicity (58.1% vs. 44.7%, p= 0.038) and triptan responsiveness (100% vs. 85.1%, p=0.001) were higher in never-smokers, while other clinical features such as pain severity, duration, attack frequency, and associated autonomic symptoms did not differ significantly between the groups. The male-to-female ratio was markedly higher in ever-smokers (29.4:1) than in never-smokers (1.7:1). @*Conclusions@#Most of the clinical features did not differ significantly between patients with a smoking history and never-smokers. However, the age at CH onset, sex ratio, and seasonal rhythmicity were significantly associated with smoking history.

Exploratory Study of the Effectiveness of Oxygen Therapy Using Home Oxygen Concentrators for Cluster Headache

Cluster headache attacks can be successfully treated with oxygen. We report four patients with episodic cluster headache were treated with oxygen therapy from one or two oxygen concentrators. Oxygen therapy with two oxygen concentrators seems to be effective in reduction or cessation of pain of cluster headaches. Patients expressed excellent satisfaction to oxygen therapy with two oxygen concentrators. Oxygen concentrators can be considered as an effective and safe alternative of oxygen cylinder for patients with cluster headache.

The Long-term Effects of Prostaglandin Analogues on Central Corneal Thickness and Intraocular Pressure

Purpose@#To evaluate the long-term effect of 0.005% latanoprost (LA) and 0.0015% tafluprost (TA) on intraocular pressure (IOP) and central corneal thickness (CCT) in glaucoma patients. @*Methods@#This study was a retrospective study, which enrolled open-angle glaucoma (OAG) patients treated with one of two prostaglandin analogues. The patients were observed for at least three years and underwent corneal thickness measurements at least once a year. Patients with a history of ocular surgery except cataract surgery or another glaucoma medication during the follow-up were excluded. Goldmann applanation tonometry and specular microscopy were used to measure the IOP and CCT, respectively. Changes in IOP and CCT were compared between the two groups. @*Results@#A total of 55 OAG patients (110 eyes) were enrolled. The patients were divided into two groups; one group (50 eyes) used LA as anti-glaucoma eye drops, and the other group (60 eyes) used TA. Statistically significant reductions in IOP and CCT were observed in both groups. The mean reduction in IOP over a three year period was -2.18 ± 2.83 mmHg in the LA group and -2.08 ± 2.40 mmHg in the TA group (paired t-test, p < 0.001, for both). In terms of CCT, the mean reduction was -20.24 ± 22.92 μm in the LA group and -32.90 ± 32.04 μm in the TA group (paired t-test, p < 0.001, for both) for three years. The decrease in CCT was not significantly different between the two groups (p = 0.061). There was no significant difference in the IOP reduction between the two drugs nor was there a significant correlation between the IOP and the CCT. @*Conclusions@#This study indicated that 0.005% LA and 0.0015% TA had similar effects on the reduction of IOP and CCT for three years without damaging the corneal endothelium.

Development and Validation of the Cluster Headache Screening Questionnaire

BACKGROUND AND PURPOSE: Cluster headache (CH) is frequently either not diagnosed or the diagnosis is delayed. We addressed this issue by developing the self-administered Cluster Headache Screening Questionnaire (CHSQ). METHODS: Experts selected items from the diagnostic criteria of CH and the characteristics of migraine. The questionnaire was administered to first-visit headache patients at nine headache clinics. The finally developed CHSQ included items based on the differences in responses between CH and non-CH patients, and the accuracy and reliability of the scoring model were assessed. RESULTS: Forty-two patients with CH, 207 migraineurs, 73 with tension-type headache, and 18 with primary stabbing headache were enrolled. The CHSQ item were scored as follows: 3 points for ipsilateral eye symptoms, agitation, and duration; 2 points for clustering patterns; and 1 point for the male sex, unilateral pain, disability, ipsilateral nasal symptoms, and frequency. The total score of the CHSQ ranged from 0 to 16. The mean score was higher in patients with CH than in non-CH patients (12.9 vs. 3.4, p 8 points, the CHSQ had a sensitivity, specificity, positive predictive value, and negative predictive value of 95.2%, 96%, 76.9%, and 99.3%, respectively. CONCLUSIONS: The CHSQ is a reliable screening tool for the rapid identification of CH.

Non-Alcoholic Fatty Liver Disease and Its Association with Depression in Korean General Population

BACKGROUND: Recent studies have indicated the significant association between non-alcoholic fatty liver disease (NAFLD) and depression. However, there is ongoing debate on whether the risk for depression is actually related with the presence and severity of NAFLD. Thus, this study was conducted to investigate the association between depression and NAFLD evaluated by diverse modalities. METHODS: A total of 112,797 participants from the Korean general population were enrolled. The study participants were categorized into three groups according to degree of NAFLD evaluated by ultrasonography, fatty liver index (FLI) and fibrosis-4 score (FIB-4). Depression was defined as a score of Center for Epidemiological Studies-Depression (CES-D) ≥ 16, and the odd ratios (ORs) and 95% confidence interval (CI) for depression (adjusted ORs [95% CI]) were assessed by multiple logistic regression analyses. RESULTS: In the unadjusted model, the presence and severity of NAFLD was not significantly associated with depressive symptoms. However, in the fully adjusted model, ORs for depression increased in proportion to the degree of ultrasonographically detected NAFLD (mild fatty liver: 1.14 [1.06–1.22]; and moderate to severe fatty liver: 1.32 [1.17–1.48]). An association was also observed between depression and FLI (30 ≤ FLI < 60: 1.06 [0.98–1.15]; FLI ≥ 60: 1.15 [1.02–1.29]). CONCLUSION: The presence and severity of NAFLD is significantly associated with depressive symptoms. In addition, this association was more distinct after adjusting for covariates including age, gender and insulin resistance. This finding indicates the necessity of further study evaluating the incidental relationship of depression with NAFLD.

Differences in Characteristics and Comorbidity of Cluster Headache According to the Presence of Migraine

BACKGROUND AND PURPOSE: Cluster headache (CH) can present with migrainous symptoms such as nausea, photophobia, and phonophobia. In addition, an overlap between CH and migraine has been reported. This study aimed to determine the differences in the characteristics of CH according to the presence of comorbid migraine. METHODS: This study was performed using data from a prospective multicenter registry study of CH involving 16 headache clinics. CH and migraine were diagnosed by headache specialists at each hospital based on third edition of the International Classification of Headache Disorders (ICHD-3). We interviewed patients with comorbid migraine to obtain detailed information about migraine. The characteristics and psychological comorbidities of CH were compared between patients with and without comorbid migraine. RESULTS: Thirty (15.6%) of 192 patients with CH had comorbid migraine, comprising 18 with migraine without aura, 1 with migraine with aura, 3 with chronic migraine, and 8 with probable migraine. Compared to patients with CH without migraine, patients with CH with comorbid migraine had a shorter duration of CH after the first episode [5.4±7.4 vs. 9.0±8.2 years (mean±standard deviation), p=0.008], a lower frequency of episodic CH (50.0% vs. 73.5%, p=0.010), and a higher frequency of chronic CH (13.3% vs. 3.7%, p=0.033). Psychiatric comorbidities did not differ between patients with and without comorbid migraine. The headaches experienced by patients could be distinguished based on their trigeminal autonomic symptoms, pulsating character, severity, and pain location. CONCLUSIONS: Distinct characteristics of CH remained unchanged in patients with comorbid migraine with the exception of an increased frequency of chronic CH. The most appropriate management of CH requires clinicians to check the history of preceding migraine, particularly in cases of chronic CH.

Clinical Reasoning: A 51-Year-Old Woman Presenting with Unilateral Severe Headache

No abstract available.

Anti-N-methyl-D-aspartate Receptor Encephalitis after Herpes Simplex Virus Infection

Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis has clinical features of psychiatric symptoms, loss of memory, seizure, dyskinesia and autonomic dysfunction. While Anti-NMDA receptor encephalitis was initially reported in young women with ovarian teratoma, viral infections can trigger anti-NMDA receptor encephalitis as well. Among them, herpes virus is the most common. We report a patient who developed the anti-NMDA receptor encephalitis 47 days after herpes virus encephalitis, which is, to our knowledge, the first case in Korea.

Severe Right Internal Carotid Artery Stenosis Mimicking Behavioral Variant Frontotemporal Dementia

Many kinds of degenerative, psychiatric, and cerebrovascular diseases can mimic behavioral variant frontotemporal dementia. We present a 73-year-old woman who presented with apathy, inappropriate social behavior, and persecutory delusion. A neuropsychological examination revealed frontal/executive dysfunction with relative sparing of episodic memory. Magnetic resonance imaging and F-18 fluorodeoxyglucose positron-emission tomography produced normal findings. However, magnetic resonance angiography revealed severe right internal carotid stenosis. After carotid stenting, her behavioral symptoms disappeared and did not recur during an 18-month follow-up.

Spontaneous Thrombosis of Posterior Inferior Cerebellar Artery Aneurysm Presenting as Cerebellar Infarction

Ischemic stroke caused by spontaneous thrombosis of posterior inferior cerebellar artery (PICA) aneurysm has been rarely reported. A 52-year-old man presented with sudden headache, dizziness, and gait disturbance. Diffusion-weighted MRI showed acute infarction in left PICA territory. A saccular aneurysm with internal thrombus at the distal PICA was detected by CT angiography and conventional angiography. The thrombus resolved spontaneously at 2 months after stroke onset with aspirin medication. At that time, endovascular coiling was underwent successfully to prevent aneurysmal rupture.

Cerebral Arterial Stenosis in Patients with Spontaneous Intracerebral Hemorrhage

OBJECTIVE: Spontaneous intracerebral hemorrhage (ICH) and ischemic stroke share common vascular risk factors such as aging and hypertension. Previous studies suggested that the rate of recurrent ICH and ischemic stroke might be similar after ICH. Presence of cerebral arterial stenosis is a potential risk factor for future ischemic stroke. This study investigated the prevalence and factors associated with cerebral arterial stenosis in Korean patients with spontaneous ICH. METHODS: A total of 167 patients with spontaneous ICH were enrolled. Intracranial arterial stenosis (ICAS) and extracranial arterial stenosis (ECAS) were assessed by computed tomography angiography. Presence of ICAS was defined if patients had arterial stenosis in at least one intracranial artery. ECAS was assessed in the extracranial carotid artery. More than 50% luminal stenosis was defined as presence of stenosis. Prevalence and factors associated with presence of ICAS and cerebral arterial stenosis (presence of ICAS and/or ECAS) were investigated by multivariable logistic regression analysis. RESULTS: Thirty-two (19.2%) patients had ICAS, 7.2% had ECAS, and 39 (23.4%) patients had any cerebral arterial stenosis. Frequency of ICAS and ECAS did not differ among ganglionic ICH, lobar ICH, and brainstem ICH. Age was higher in patients with ICAS (67.6±11.8 vs. 58.9±13.6 years p=0.004) and cerebral arterial stenosis (67.9±11.6 vs. 59.3±13.5 years, p<0.001) compared to those without stenosis. Patients with ICAS were older, more frequently had diabetes, had a higher serum glucose level, and had a lower hemoglobin level than those without ICAS. Patients with cerebral arterial stenosis were older, had diabetes and lower hemoglobin level, which was consistent with findings in patients with ICAS. However, patients with cerebral arterial stenosis showed higher prevalence of hypertension and decreased kidney function compared to those without cerebral arterial stenosis. Multivariable logistic regression analyses showed that aging and presence of diabetes independently predicted the presence of ICAS, and aging, diabetes, and hypertension were independently associated with presence of cerebral arterial stenosis. CONCLUSION: 19.2% of patients with spontaneous ICH had ICAS, but the prevalence of ECAS was relatively lower (7.2%) compared with ICAS. Aging and diabetes were independent factors for the presence of ICAS, whereas aging, hypertension, and diabetes were factors for the cerebral arterial stenosis.

The Usefulness of Proximal Radial Motor Conduction in Acute Compressive Radial Neuropathy

BACKGROUND AND PURPOSE: The objective of this study was to determine diagnostic and prognostic values of proximal radial motor conduction in acute compressive radial neuropathy. METHODS: Thirty-nine consecutive cases of acute compressive radial neuropathy with radial conduction studies-including stimulation at Erb's point-performed within 14 days from clinical onset were reviewed. The radial conduction data of 39 control subjects were used as reference data. RESULTS: Thirty-one men and eight women (age, 45.2+/-12.7 years, mean+/-SD) were enrolled. All 33 patients in whom clinical follow-up data were available experienced complete recovery, with a recovery time of 46.8+/-34.3 days. Partial conduction block was found frequently (17 patients) on radial conduction studies. The decrease in the compound muscle action potential area between the arm and Erb's point was an independent predictor for recovery time. CONCLUSIONS: Proximal radial motor conduction appears to be a useful method for the early detection and prediction of prognosis of acute compressive radial neuropathy.

Effects of Repetitive Transcranial Magnetic Stimulation on Behavioral Recovery during Early Stage of Traumatic Brain Injury in Rats

Repetitive transcranial magnetic stimulation (rTMS) is a promising technique that modulates neural networks. However, there were few studies evaluating the effects of rTMS in traumatic brain injury (TBI). Herein, we assessed the effectiveness of rTMS on behavioral recovery and metabolic changes using brain magnetic resonance spectroscopy (MRS) in a rat model of TBI. We also evaluated the safety of rTMS by measuring brain swelling with brain magnetic resonance imaging (MRI). Twenty male Sprague-Dawley rats underwent lateral fluid percussion and were randomly assigned to the sham (n=10) or the rTMS (n=10) group. rTMS was applied on the fourth day after TBI and consisted of 10 daily sessions for 2 weeks with 10 Hz frequency (total pulses=3,000). Although the rTMS group showed an anti-apoptotic effect around the peri-lesional area, functional improvements were not significantly different between the two groups. Additionally, rTMS did not modulate brain metabolites in MRS, nor was there any change of brain lesion or edema after magnetic stimulation. These data suggest that rTMS did not have beneficial effects on motor recovery during early stages of TBI, although an anti-apoptosis was observed in the peri-lesional area.

Effect of Cisternal Drainage on the Shunt Dependency Following Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE: Shunt-dependent chronic hydrocephalus (SDCH) is known to be a major complication associated with aneurysmal subarachnoid hemorrhage (aSAH). Old age is known to be one of numerous factors related to the development of SDCH. This study investigated whether postoperative cisternal drainage affects the incidence of SDCH and clinical outcome in elderly patients with aSAH. METHODS: Fifty-nine patients participated in this study. All patients underwent aneurysmal clipping with cisternal cerebrospinal fluid (CSF) drainage. Clinical variables relevant to the study included age, sex, location of ruptured aneurysm, CT finding and clinical state on admission, clinical outcome, and CSF drainage. We first divided patients into two groups according to age ( or =70 years of age) and compared the two groups. Secondly, we analyzed variables to find factors associated with SDCH in both groups ( or =70 years of age). RESULTS: Of 59 patients, SDCH was observed in 20 patients (33.9 %), who underwent shunt placement for treatment of hydrocephalus. Forty seven percent of cases of acute hydrocephalus developed SDCH. In the elderly group (> or =70 years of age), the duration and amount of CSF drainage did not affect the development of chronic hydrocephalus. CONCLUSION: In elderly patients, although the incidence of SDCH was significantly higher, clinical outcome was acceptable. The duration and the amount of cisternal drainage did not seem to be related to subsequent development of chronic hydrocephalus within elderly patients aged 70 or older.

Ischemic Stroke and Cancer: Stroke Severely Impacts Cancer Patients, While Cancer Increases the Number of Strokes

BACKGROUND: Cancer and ischemic stroke are two of the most common causes of death among the elderly, and associations between them have been reported. However, the main pathomechanisms of stroke in cancer patients are not well known, and can only be established based on accurate knowledge of the characteristics of cancer-related strokes. We review herein recent studies concerning the clinical, laboratory, and radiological features of patients with cancer-related stroke. MAIN CONTENTS: This review covers the epidemiology, underlying mechanisms, and acute and preventive treatments for cancer-related stroke. First, the characteristics of stroke (clinical and radiological features) and systemic cancer (type and extent) in patients with cancer-specific stroke are discussed. Second, the role of laboratory tests in the early identification of patients with cancer-specific stroke is discussed. Specifically, serum D-dimer levels (as a marker of a hypercoagulable state) and embolic signals on transcranial Doppler (suggestive of embolic origin) may provide clues regarding changes in the levels of coagulopathy related to cancer and anticoagulation. Finally, strategies for stroke treatment in cancer patients are discussed, emphasizing the importance of preventive strategies (i.e., the use of anticoagulants) over acute revascularization therapy in cancer-related stroke. CONCLUSION: Recent studies have revealed that the characteristics of cancer-related stroke are distinct from those of conventional stroke. Our understanding of the characteristics of cancer-related stroke is essential to the correct management of these patients. The studies presented in this review highlight the importance of a personalized approach in treating stroke patients with cancer.

Myopathy Following Ingestion of Ma-huang (Ephedra)-based Herbal Remedy

Ma-huang (Ephedra sinica) is a herb that exhibits sympathomimetic activity. We report a patient with acquired myopathy following ingestion of a Ma-huang-based herbal remedy for 6 months. A 50-year-old woman was admitted for progressive muscular weakness. An electrodiagnostic study and muscle biopsy sampling revealed generalized active myopathy with nonspecific inflammation. It appears that Ma-huang, along with Raynaud's phenomenon and pericardial effusion, may be a causative agent of myopathy. As such, attention should be paid to the possibility that herbal medication with Ma-huang can result in myopathy.

Initial Troponin Level as a Predictor of Prognosis in Patients with Intracerebral Hemorrhage

OBJECTIVE: It has been suggested that elevated cardiac troponin T (cTnT) level is a marker of increased risk of mortality in acute ischemic stroke and subarachnoid hemorrhage (SAH). However, the association of serum cTnT level and prognosis of intracerebral hemorrhage (ICH) has been sparsely investigated. The aim of this study was to identify the relationship between cTnT level and the outcome in patients with spontaneous ICH. METHODS: We retrospectively investigated 253 patients identified by a database search from records of patients admitted in our department for ICH between January 1, 2003 and December 31, 2007. The patients were divided into 2 groups; the patients in group 1 (n=225) with serum cTnT values of 0.01 ng/mL or less, and those in group 2 (n=28) with serum cTnT values greater than 0.01 ng/mL. RESULTS: The serum cTnT level was elevated in 28 patients. There were significant differences in sex, hypertension, creatine kinase-myocardial band, midline shift, side of hematoma, and presence of intraventricular hemorrhage between the 2 groups. Logistic regression analysis identified the level of consciousness on admission, cTnT and midline shift as independent predictors of hospital mortality. CONCLUSION: Theses results suggest that increased serum cTnT level at admission is associated with in-hospital mortality and the addition of a serum cTnT assay to routine admission testing should be considered in patients with ICH.

Cardiac Troponin T Elevation After Stroke: Relationships Between Elevated Serum Troponin T, Stroke Location, and Prognosis

Background and Purpose: Elevation of serum cardiac troponin T (cTnT) is regarded as a specific marker of acute coronary syndrome. Serum cTnT can be increased in patients with acute ischemic stroke, but its clinical implications remain unclear. The aim of this study was to identify the relationships between elevated cTnT and stroke severity, location, and prognosis. Methods: From January 2005 to December 2006, this study recruited 455 consecutive patients who were admitted to Kangbuk Samsung Hospital due to acute ischemic stroke within 3 days of onset, which was confirmed by diffusion magnetic resonance imaging. A total of 416 patients was finally included and divided into 2 groups: an elevated cTnT group (n=45) and a normal cTnT group (n=371). The short-term prognosis was assessed by 30-day modified Rankin Scale responder analysis was compared between the two groups. Results: Serum cTnT was elevated in 10.8% of cases, with elevated cTnT associated with greater stroke severity, as assessed by the National Institutes of Health Stroke Scale score, Insular-lobe involvement was more common in patients with elevated cTnT than in the normal cTnT group. Short-term prognosis was more unfavorable in the elevated cTnT group than in the normal cTnT group. Multivariate regression analysis indicated that elevated cTnT was independently related to insular involvement, cardioembolism, and unfavorable outcome. Conclusions: Elevated cTnT in acute ischemic stroke was associated with severe neurological deficits at stroke onset and damages to the insular lobe. The outcome of acute ischemic stroke was worse for patients with elevated cTnT than for those with normal cTnT. The pathomechanism underlying acute ischemic stroke and subclinical myocardial damage warrants further study.