Spontaneous intracranial hypotension and epidural blood patch: a report involving seven cases.

Spontaneous intracranial hypotension is a rare condition caused by spontaneous cerebrospinal fluid leak. It is characterised by orthostatic headache, diffuse pachymeningeal enhancement on brain imaging and low cerebrospinal fluid pressure. Seven patients with spontaneous intracranial hypotension were treated conservatively: of these, four responded to drug treatment and three underwent a lumbar autologous epidural blood patch (EBP). A complete response was obtained in two patients after a single EBP; one patient underwent a second EBP and then became asymptomatic. Clinical improvement coincided with a dramatic reduction of pachymeningeal enhancement. The aetiology and brain imaging findings, and the technique and effectiveness of EBP are discussed.

[Different use/abuse patterns (overweight/obesity, alcohol, smoking, drugs, cannabis, opiates, cocaine) according to job category. Results of a survey on 4024 young workers from Abruzzo, Italy: the Valentino Study]. / Gli abusi farmacologici, alimentari, da alcool, fumo e droga nelle diverse categorie professionali. Risultati di un'indagine conoscitiva su 4024 giovani lavoratori abruzzesi: il Progetto Valentino.

Using a multidisciplinary questionnaire containing items from previously validated instruments (i.e. CAGE), during the year 2007 a survey (Valentino Project) was carried out on 4024 young workers (18-35 y) from Abruzzo, Italy to investigate the prevalence of use/abuse of alcohol, food, smoking, and drugs in different types of job categories, and to evaluate the potential association between occupational class and type of use/abuse. With the exception of cannabis use/abuse (13.5%), the prevalence of incorrect behaviours was higher than the young-adult general population (workers and non-workers) from Central-South Italy: overweight/obesity = 30.8%; current smoking = 45.7%; alcohol addiction = 17.3%; use/abuse of psychotropic legal drugs = 4.7%; cocaine = 4.5%; opiates = 1.0%; > 1 illegal drug (multiple abuse) = 3.9%. This negative scenario is accentuated by a probable > or = 25% underestimation of illegal drug use/abuse, and because drug use/abuse is inversely associated with age. Using logistic regression analyses (controlling for age, gender marital status, education, job-strain, self-reported health, and all other types of use/abuse), a significant independent association was found for the first time between specific types of use/abuse and some job categories (i.e. cocaine for traders/consultants; legal psychoactive drugs and cannabis for unqualified professions such as itinerants or precarious workers; smoking for Call-Center operators; overweight/obesity for farmers/artisans). These findings should be used to maximize the efficacy of substance use/abuse preventive strategies, which could be more precisely targeted to different professions, and raise the need to control for job category in future multivariate analyses investigating substance use/abuse predictors.

Multiple sclerosis and headache co-morbidity. A case-control study.

The prevalence of primary headache (PH) in a multiple sclerosis (MS) sample vs. control healthy subjects was investigated at a neurological clinic in 2004-2005: 122 of 238 (51%) MS patients and 57 of 238 (23%) controls proved to be affected by headache. The groups did not differ for the rates of PH types. Headache types of MS patients were comparable to those of PH patients that were observed at the same institute in a case-control comparison. First symptoms of headache preceded those of MS in two thirds of cases. Headache features did not significantly change after MS onset. Comorbidity of MS and PH could be explained by some common clinical and biological traits.

Migraine and epilepsy: clinical and pathophysiological relations.

Migraine and epilepsy are both chronic disorders characterised by recurrent neurological attacks, with a partial clinical and therapeutic overlap and frequently occurring together. Although still incompletely clarified, the possible existence of a link between migraine and epilepsy has long been debated. In this paper the epidemiologic evidence of migraine and epilepsy comorbidity, the possible occurrence of both disturbances in close temporal association, possible shared physiopathologic mechanisms and the rationale for antiepileptic drug use in migraine prophylaxis will be discussed.

Validation of AIDA Cefalee, a computer-assisted diagnosis database for the management of headache patients.

AIDA Cefalee is a database for the management of headache patients developed on behalf of the Italian Neurological Association for Headache Research (ANIRCEF). The system integrates a diagnostic expert system able to suggest the correct ICHD-II diagnosis once all clinical characteristics of a patient's headache have been collected. The software has undergone a multicentre validation study to assess: its diagnostic accuracy; the impact of using the software on visit duration; the userfriendliness degree of the software interface; and patients' acceptability of computer-assisted interview. Five Italian headache centres participated in the study. The results of this study validate AIDA Cefalee as a reliable diagnostic tool for primary headaches that can improve diagnostic accuracy with respect to the standard clinical method without increasing the time length of visits even when used by operators with basic computer experience.

Hypnic headache: an update.

Hypnic headache (HH) is a rare sleep-associated primary headache disorder, usually affecting aged people, first described by Raskin in 1988. The headache attacks, single or multiple in one night, occur exclusively during sleep and tend to present at a consistent time each night, sometimes during a dream. Compared to the original description, newly reported cases have expanded the clinical spectrum of the disorder to include unilateral forms (about 40%, half of which are side-locked), forms with a longer duration (up to 3 h) and cases with onset in juvenile/adult age. The male predominance found in Raskin's series has not been confirmed by subsequent observations. To date the reported F/M ratio is 1.7/1. Pain is of severe intensity in less then one-third of cases and mild-moderate in about two-thirds. The location of pain is fronto-temporal in over 40% of cases; headache is throbbing in 38% of cases, dull in 57% and stabbing in less than 5%. Nausea is reported in 19% of cases; photophobia, phonophobia or both are present in 6.8%. Mild autonomic signs (lacrimation, nasal congestion, ptosis) may rarely be present. In 2004, HH was included in Group 4 of the International Classification of Headache Disorders-II (Other primary headaches). Sufficient evidence, mainly from polysomnographic studies, indicates that HH is a primary rapid eye movement (REM) sleep-related headache disorder of chronobiological origin. Lithium, melatonin, indomethacin and caffeine at bedtime are among the most effective therapeutic options. The pathophysiology of HH is still unclear. Available data allow speculation that, in predisposed subjects, an age-related impairment of suprachiasmatic nucleus could cyclically activate a disnociceptive mechanism leading to both a sudden awakening and headache. The mechanism may be precipitated by neurophysiologic events such as the strong reduction of firing occurring in the dorsal raphe nucleus during a REM sleep phase.

A clinical comparison of trigeminal neuralgic pain in patients with and without underlying multiple sclerosis.

Despite clinical similitude, there is a tendency to consider trigeminal pain in multiple sclerosis (MS) as a distinct condition. To evaluate clinical differences in trigeminal pain presentation in patients with and without underlying MS, we compared clinical characteristics of facial pain found in 15 consecutive MS patients with those reported by 13 consecutive subjects diagnosed with classical trigeminal neuralgia. The only significant difference between MS and non-MS neuralgic patients was the age of onset of pain (43.4+/-10.5 in MS vs. 59.6+/-11.50 in non-MS patients, p=0.000629, unpaired Student's t-test). No differences were observed for side, duration and quality of pain, trigeminal branches involved, presence of trigger areas or factors, pain refractive period, remitting-relapsing or chronic course. There was only a trend without statistical significance in interval pain and trigeminal hypoesthesia, more frequent in MS population. Only one patient in the MS group presented with long-lasting episodes (45-60 min) of atypical odontalgia. Our findings support the view of a common pathogenetic mechanism underlying TN in the two groups, possibly related to demyelination of the trigeminal entry root in the pons. Typical TN in MS patients should be considered as "symptomatic trigeminal neuralgia".

Sudden re-opening of collapsed transverse sinuses and longstanding clinical remission after a single lumbar puncture in a case of idiopathic intracranial hypertension. Pathogenetic implications.

The aetiopathogenetic role of sinus venous obstructions carried by most idiopathic intracranial hypertension (IIH) patients is controversial. We report the case of a young woman diagnosed with IIH with papilloedema and narrowing of transverse sinuses, in which lowering of intracranial pressure by a single 20 ml cerebrospinal fluid (CSF) resulted in a strong dimensional increase of the transverse sinuses. Changes were followed by clinical remission and normalisation of optical nerve calibre, maintained after a 2-month follow-up. Our findings indicate that, although secondary to CSF hypertension, venous sinuses compression may have an important role in hypertensive status maintenance. Pathogenetic implications of venous sinus compression by hypertensive CSF in IIH are discussed.

Kinematic strategies for lowering of upper limbs during suggestions of heaviness: a real-simulator design.

The aim of the experiment was to study possible differences between the kinematic strategies for the "involuntary" arm lowering of hypnotized highly susceptible subjects (H-Highs) and for the voluntary movement of non-hypnotizable simulators (Sims) during suggestions of arm heaviness (Part I). In addition, a comparison between awake susceptible subjects (W-Highs) and H-Highs was carried out to clarify the specific role of the hypnotic state and hypnotizability (Part II). Subjects' absorption and attentional/imagery capabilities were evaluated through neuropsychological tests. Their arm movements were monitored three-dimensionally at hand, wrist and elbow level through a Polhemus Fastrack system. A final interview collected self-reports concerning the perception of movement involuntariness. Neuropsychological tests showed better "absorption" and imagery capabilities in Highs. In the interview, H-Highs perceived a higher involvement in the task and greater involuntariness and difficulties in contrasting the arm lowering than the Sims. Kinematic analysis showed significant differences between H-Highs and Sims for arm displacements along the vertical axis and on the horizontal plane. In fact, the former lowered the left arm earlier and to a greater degree than the right arm; on the horizontal plane, a forearm flexion was observed for H-Highs on the right side. On comparing W-Highs and H-Highs, hypnosis appeared to magnify the waking motor strategies, but also to induce specific changes, mainly concerning the horizontal plane. These results cannot be interpreted on the basis of "role playing" and socio-cognitive factors. They are believed to be due to a balance between the effectiveness of the frontal executive control towards the selection of behaviors and movement automaticity, which is in line with the neo-dissociation theory of hypnosis.

Towards the computerisation of ANIRCEF Headache Centres. Presentation of AIDA CEFALEE, a computer assisted diagnosis database for the management of headache patients.

Because of the lack of biochemical or neuroradiological markers, the diagnostic assessment of primary headaches rests on a clinical history collected by an experienced physician; the articulated criteria of the International Headache Society (IHS) represent the only available tool to test objectively the diagnostic hypothesis rising from clinical interview. However, the complexity reached by IHS criteria still represents its major limit to extensive application, at least in common clinical settings. The use of modern information technology (IT), which is specifically designed to manage complex problems with a large number of variables, seems to be the best choice to counteract the complexity of IHS classification. In this paper AIDA CEFALEE, a user-friendly client-server database for the management of headache patients, is presented. The system integrates a computer assisted diagnosis module, which may help to extend the correct use of IHS diagnostic criteria to any clinical setting. The interoperability of the system may represent the possible infrastructure of a National Network of ANIRCEF Headache Centres.

HELLP syndrome with reversible posterior leukoencephalopathy.

We report the case of a 30-year-old primipara who developed a triplet pregnancy after having received artificial insemination. At the end of the eighth month of pregnancy she had a generalized tonic-clonic seizure and at the same time blood chemistry was indicative of HELLP syndrome. Brain MRI and EEG were altered immediately after the episode but returned to normal during a 6-month follow-up period.

The thymus and myasthenia gravis: immunological and neurophysiological aspects.

Myasthenia gravis (MG) is an autoimmune disorder, in which end-plate membrane damage is induced by antibodies directed toward various epitopes of the main immunogenic region of the nicotinic acetylcholine receptor (AChR). This article reviews the mechanisms responsible for the development of MG. Recent investigations into the roles of the thymus, antibodies against AChR, cytokines, and neuromuscular transmission have given new insight into the pathogenesis of MG. These new advances have led to a better understanding of the immune mechanisms in MG and have opened new therapeutic horizons.

Long-term outcome of migraine therapy: predictive value of the frontotemporal nitroglycerin test.

We evaluated whether type of response to the migraine-induction test with a nitroglycerin ointment applied to the frontotemporal head region could predict the efficacy of antimigraine therapy. Forty-two patients with migraine without aura underwent the test before and 2 months after antimigraine therapy. Two and 4 months after treatment withdrawal, most subjects with a negative response to the post-treatment test maintained treatment benefit, whereas benefit was lost in patients with an early onset migraine response.

The frontotemporal region plays a role in the genesis of migraine without aura.

We have compared the migraine-inducing effect of nitroglycerin ointment applied to the frontotemporal region of the head, which is innervated by the ophthalmic and maxillary divisions of the trigeminal nerve, with that of nitroglycerin applied to the chin (innervated by the mandibular division), the posterolateral region of the neck (innervated by the second and third cervical roots), the lateral surface of the proximal third of the forearm (innervated by the sixth cervical root), and the medial surface of the upper-arm region (second dorsal root). One hundred patients suffering from migraine without aura were randomly divided into five equal groups. Each group received an application of 5 mg nitroglycerin in 2% ointment on a preselected body area for 2 hours. Frontotemporal nitroglycerin induced a significantly greater number of early onset migraine attacks with respect to the arm and forearm regions. In all cases, nitroglycerin applied to the frontotemporal region resulted in subsequent migraine, whereas there was a significant number of negative trials with nitroglycerin applied to the neck, arm, and forearm vs the frontotemporal area. It, therefore, appears that the trigeminal nerve endings in the affected frontotemporal region are particularly sensitive to the migraine-inducing effect of the nitrate. This suggests a peripheral neurogenic hypothesis of migraine genesis.