Cranial Autonomic Symptoms in Migraine: An Observational Study.

Objective: Our aim was to observe frequency of cranial autonomic symptoms (CAS) in migraineurs (primary) and its relation with laterality of headache or other factors, if any. Background: Migraine episodes have headaches with or without aura, and sometimes associated with systemic autonomic nervous system symptoms. Primarily presence of cranial autonomic symptoms suggests diagnosis of TACs. But many studies reported cranial autonomic symptoms (CAS) ranging from 26% to 80% in migraine patients. Material and Methods: Consecutive patients of migraine attending our headache clinic were included in our study. Presence of CAS was recorded with respect to ocular, nasal, facial and aural symptoms along with headache characteristics and laterality information. Detailed clinical examination was performed. We used ICHD 3 (beta version) criteria. Results: Our study cohort comprised of 200 patients having mean (± SD) age 31.12 (± 10.67) years. There were 157 (78.5%), females. Out of 200 patients, 148 (74%) were having at least one CAS, of which 70% were having 2 or more CAS. Frequency of CAS was lacrimation (45.5%), conjunctival injection (34.5%), eyelid edema (34%), aural fullness (27.5%), facial sweating (25%), facial flushing (17.5%), nasal congestion (9%), rhinorrhea (5%) and ptosis (4%). Bilateral CAS was present in 129 (87%) and unilateral CAS in 19 (13%) (OR 35.31; 95% CI 9.19 to 135.7), (P < 0.0001). Sunlight as a trigger was present in all 148 (100%) patients. Conclusion: Our study showed that CASs in migraine is common and bilateral. Sunlight triggers headache in almost all CAS positive patients.

Radiofrequency Treatment of Idiopathic Trigeminal Neuralgia (Conventional vs. Pulsed): A Prospective Randomized Control Study.

BACKGROUND: Idiopathic trigeminal neuralgia (TGN) is a chronic pain disorder causing unilateral, severe brief stabbing recurrent pain in the distribution of one or more branches of the trigeminal nerve. Conventional radiofrequency (CRF) and pulsed radiofrequency (PRF) are two types of minimally invasive treatment. CRF selectively ablates the part of ganglion to provide the relief, but it has been found to be associated with some side effects such as dysesthesia or sensory loss in 6%-28% and loss of corneal reflex in 3%-8% of patients. PRF is a comparatively newer modality which is a nondestructive and neuromodulatory method of delivering radiofrequency energy to the gasserian ganglion to produce a therapeutic effect. AIMS: We aimed to compare the efficacy of CRF with long-duration, fixed voltage PRF in the treatment of idiopathic TGN. SETTING: This study was conducted in a tertiary care center research institute. STUDY DESIGN: This was a prospective randomized trial. MATERIALS AND METHODS: Twenty-seven adult patients of TGN were included in the study and randomly allocated into two groups (CRF and PRF). All procedures were performed operation suite with C-arm fluoroscopic guidance. Both, pre- and postprocedure, the patients were assessed for pain on the Visual Analog Scale (VAS) and Barrow Neurological Institute (BNI) Pain Intensity Scale at 1 week and thereafter at 1, 2, 3, and 6 months. Patients with a BNI score ≥4 after 1 month were considered a failure and offered other modes of treatment. A reduction in VAS score ≥50% and a BNI score <4 were considered as effective. STATISTICAL ANALYSIS: Discreet variables were recorded as proportions, ordinal variables and continuous variables with non-Gaussian distribution as medians with interquartile range, and continuous variables with Gaussian distribution as mean ± standard deviation. Association between ordinal variables was tested by Fisher's exact test/Chi-square test whenever appropriate. Equality of means/median was tested by using paired/unpaired t-test or nonparametric tests depending upon the distribution of data. P ≤ 0.5 was considered statistically significant. Data analysis was performed using STATA version 13.04 windows. RESULTS: Efficacy in terms of decrease in VAS ≥50% at 1 month was 33.33% and 83.33% in the PRF and CRF groups, respectively, which was statistically significant(P = 0.036). Effective reduction in BNI scores at the 7th day, 1 month, and 2 months postprocedure was evaluated and found in 41.67% and 83.33% of patients in the PRF and CRF groups, respectively, which was statistically insignificant (P = 0.089). There was a statistically significant reduction in BNI scores in PRF and CRF group patients at 3 and 6 months (at 3 months, 33.33% and 83.33%, P = 0.036 and at 6 months, 25% and 83.33%, P = 0.012). In the CRF group, mild hypoesthesia was evident in three patients which improved by the end of 1 month while no side effects were seen in the PRF group. CONCLUSION: CRF is a more effective procedure to decrease pain in comparison to long-duration, fixed voltage PRF for the treatment of idiopathic TGN. Although the side effects are more with CRF, they are mild and self-limiting.

Dopa-responsive Dystonia in a Child Misdiagnosed as Cerebral Palsy.

Dopa-responsive dystonia also known as "Segawa's syndrome" was first described in 1976. The dystonia typically shows diurnal variations and is more marked toward the end of the day and improves in sleep. This entity is often misdiagnosed in the clinical setting, mostly due to the lack of awareness, and these patients are exposed to various treatment regimens and nonpharmacological measures. We present a boy being treated as dystonic cerebral palsy who showed significant improvement in dystonic symptoms with L-dopa therapy.

Stroke Associated With Varicella Zoster Vasculopathy: A Clinicoradiological Profile of 3 Patients.

INTRODUCTION: Varicella zoster (VZ) vasculopathy is a rare but well recognized cause of stroke. In the absence of zoster rash and infection in remote past, the disease can pose diagnostic challenge. We report 3 cases of anterior circulation stroke occurring in close temporal relation to VZ. Their clinical, radiologic, and angiographic features are discussed. CASE REPORT: Of the 3 patients, 2 had stroke within a span of 4 to 6 weeks of herpes zoster ophthalmicus while the third patient had zoster of cervical dermatome. Magnetic resonance imaging revealed acute subcortical infarcts in 2, while 1 patient showed acute on chronic infarct in left middle cerebral artery territory. The magnetic resonance angiography was abnormal in 2 patients while it was normal in third. All the patients were treated with acyclovir and antiplatelets with good recovery in 2. CONCLUSIONS: VZ associated vasculopathy may have diverse clinical profile and neuroimaging features. It should be considered as an important and treatable cause of stroke in appropriate clinical settings.

Rapidly Resolving Weakness Related to Hypokalemia in Patients Infected With Dengue Virus.

OBJECTIVES: Dengue is a mosquito-borne disease caused by arbovirus and well known for its typical fever with thrombocytopenia syndrome. Acute hypokalemic quadriparesis is a rare presentation of dengue with uncertain pathogenesis. We aim to describe the clinical and biochemical characteristics of rapidly resolving weakness related to hypokalemia in patients infected with dengue virus. METHODS: A retrospective review of the records of patients with diagnosis of dengue-associated hypokalemic weakness was performed. Demography, clinical, biochemical characteristics, and outcome of the patients were recorded during acute phase of illness. RESULTS: Our study cohort comprised 12 patients and all were males from urban dwelling. The median age was 34.5 years (range, 18-50). Presentation was acute onset rapidly worsening pure motor quadriparesis preceded by short lasting febrile episode. Weakness ranged from 2/5 to 4/5 on Medical Research Council (MRC) scale with generalized hyporeflexia or areflexia. The baseline serum potassium was mean ± SD (2.7 ± 0.48 mmol/L). All patients showed elevation of liver transaminases and elevated creatine phosphokinase level. Weakness improved in 24-72 hours in all patients with correction of serum potassium. CONCLUSIONS: Dengue-associated acute hypokalemic paralysis is an underrecognized entity having favorable outcome. It should be suspected in patients presenting as acute pure motor quadriparesis after febrile illness in dengue endemic areas.

Knowledge awareness and attitude about epilepsy among schoolteachers in India.

PURPOSE: Despite recent advances in the management of epilepsy the efforts to assess knowledge, attitude and practice towards epilepsy are limited, particularly in the developing countries. To delineate the magnitude and scope of this problem, present study was conducted to assess the knowledge attitude and practice about epilepsy amongst schoolteachers in Northeast Uttar Pradesh, the most populous state of India. The basis of involving schoolteachers was their special role in Indian society with their larger interaction among the segment of population most affected by epilepsy. METHODS: Simple self-administered questionnaires were sent to the schoolteachers of primary and secondary levels. The questionnaires contained 15 questions related to awareness and attitudes towards epilepsy with details of first aid management of seizures. RESULTS: We found that 97% of schoolteachers were aware of epilepsy with majority including it as a brain disease. A substantial proportion (38.2%) was uncertain about relation of epilepsy and insanity and 31.7% felt epileptics to be of below average intelligence. Only about half of them (55.3%) preferred their children to play with an epileptic. An overwhelming no was obvious about marriage with an epileptic (86.8%). Only 27.8% of the respondents had given any first aid measure to a seizing patient with only 16.3% giving it properly. CONCLUSION: Despite a great degree of awareness about epilepsy amongst schoolteachers in India negative and wrong attitudes still exist. Stress on proper first aid measure to a seizing child needs greater emphasis to remove fright and fear amongst the public. Besides adequate management, public education to address existing biases and fear are equally important to improve the quality of life of epileptics.