OPTIC NERVE SHEATH SONOGRAPHY IS A PROMISING TOOL FOR ASSESSMENT OF RAISED INTRACRANIAL PRESSURE IN PATIENTS ADMITTED TO NEUROLOGICAL INTENSIVE CARE UNIT.

Optic nerve sheath diameter (ONSD) enlargement is detectable in traumatic brain injury patients with raised intracranial pressure (ICP). The aim was to assess its value in neurological patients suspected to have increased ICP. Patient clinical imaging data and hospitalization outcome were analyzed. Patients were divided into groups according to brain pathology and level of consciousness with Glasgow Coma Score (GCS). Poor hospitalization outcome was assessed by modified Rankin scale (mRS) >3. Data obtained by ocular sonography performed in acute setting were compared with data of 100 control subjects. Data were expressed as mean ± SD. Intergroup comparison was performed by Student's t-test. Data of 34 patients (63+16 years) were suitable for analysis, including 8 primary intracerebral hemorrhage (PICH), 8 subarachnoid hemorrhage (SAH), 12 PICH or SAH and intraventricular hemorrhage (IVH), 4 tumors and 2 ischemic strokes. The mean ONSD was 5.86+0.69 mm in patients versus 4.38+0.41 mm in controls (p<0.01). ONSD was 6.28+0.61 mm in patients with GCS <8 and 5.77+0.55 mm in other patients (p<0.05). ONSD was 5.72+0.59 mm in PICH versus 6.20+0.65 mm in PICH/SAH with IVH (p=0.1). ONSD was 5.73+0.38 mm in SAH in comparison to PICH/SAH with IVH (p=0.05). There was no statistically significant difference in optic nerve diameter between patients and controls (2.48+0.28 mm vs. 2.39+0.33 mm; p>0.05). Pronounced enlargement of ONSD was observed in patients with ICH or SAH with IVH, and in patients with GCS <8. Enlarged ONSD was associated with poor neurological outcome (mRS >3).

Efficacy and safety of Ginkgo biloba standardized extract in the treatment of vascular cognitive impairment: a randomized, double-blind, placebo-controlled clinical trial.

OBJECTIVES: The aim of this randomized, double-blind, placebo-controlled trial was to determine the efficacy and safety of Ginkgo biloba extract in patients diagnosed with vascular cognitive impairment (VCI). METHODS: A total of 90 patients (aged 67.1±8.0 years; 59 women) were randomly allocated (1:1:1) to receive G. biloba 120 mg, G. biloba 60 mg, or placebo during a 6-month period. Assessment was made for efficacy indicators, including neuropsychological tests scores (Sandoz Clinical Assessment Geriatric Scale, Folstein Mini-Mental State Examination, Mattis Dementia Rating Scale, and Clinical Global Impression) and transcranial Doppler ultrasound findings. Safety indicators included laboratory findings, reported adverse reactions, and clinical examination. RESULTS: At the end of 6-month study period, G. biloba 120 and 60 mg showed a statistically significant positive effect in comparison with placebo only on the Clinical Global Impression score (2.6±0.8 vs 3.1±0.7 vs 2.8±0.7, respectively; P=0.038). The Clinical Global Impression score showed a significant deterioration from the baseline values in the placebo group (-0.3±0.5; P=0.021) as opposed to G. biloba groups. No significant differences were found in the transcranial Doppler ultrasound findings. Adverse reactions were significantly more common and serious in the placebo group (16 subjects) than in either of the two G. biloba extract groups (eight and nine subjects, respectively), whereas laboratory findings and clinical examinations revealed no differences between the groups receiving G. biloba extract and placebo. CONCLUSION: According to our results, G. biloba seemed to slow down the cognitive deterioration in patients with VCI, but the effect was shown in only one of the four neuropsychological tests administered. However, because of this mild effect in combination with a few adverse reactions, we cannot say that it is ineffective or unsafe either. Further studies are still needed to provide unambiguous evidence on the efficacy and safety of G. biloba extract.

Visual evoked potentials in patients with pineal gland cyst.

AIMS: The functional effect of the pineal gland cyst is difficult to evaluate with visual field examination. The aim of this study is to investigate the usefulness of visual evoked potentials (VEP) in patients with pineal gland cyst due to the possible compression on the visual pathway. SUBJECTS AND METHODS: Black-and-white pattern-reversal checkerboard VEP were recorded in 75 patients (50 females and 25 males, mean age 26.3 ± 15.7 and 25.6 ± 17.6 years, respectively) with pineal gland cyst detected on magnetic resonance of the brain (subject group) and 75 age and sex-matched control subjects (control group). Amplitudes and P100 latencies were collected and later grouped as: (1) normal finding; (2) prechiasmal; (3) prechiasmal and postchiasmal; and (4) postchiasmal dysfunction. RESULTS: P100 latencies differed significantly between subject (110.26 ± 13.23 ms) and control group (101.01 ± 5.36 ms) (p < 0.01). Findings of the VEP differed significantly (p < 0.01) between subject and control group, mainly due to the postchiasmal dysfunction frequency in subject group. Findings of the VEP differed significantly according to the pineal gland cyst volume (p = 0.006) with more frequent postchiasmal dysfunctions among subjects with larger cysts. Postchiasmal changes were significantly more frequent in patients with described compression of the cyst on surrounding brain structures (p = 0.016). CONCLUSIONS: Postchiasmal dysfunction on VEP can be seen in patients with pineal gland cyst, mostly with larger cysts and with compression of the cyst on surrounding brain structures. VEP serve as a useful method to determine functional impairment of the visual pathway in patients with pineal gland cyst.

Treatment of migraine and tension-type headache in Croatia.

The aim of this study was to assess the treatment patterns of migraine and tension-type headache in the Croatian population. Analysis included the proportion of patients who were taking specific antimigraine therapy and the number of tablets per attack per month, the proportion of patients who were taking prophylactic therapy or using alternative treatment methods and their satisfaction with the treatment. The design of the study was a cross-sectional survey. Self-completed questionnaires were randomly distributed to adults >18 years of age in the Croatian population. A total of 616 questionnaires were analyzed: 115 patients with migraine (M), 327 patients with tension-type headache (TTH), and 174 patients with probable migraine (PM) and TTH. Specific antimigraine therapy was taken by half of patients with migraine: 35.7% of patients used triptans and 21.7% ergotamines. Prophylactic treatment had been used by 13.9% of M, 1.2% of TTH, and 6.9% of PM patients. Alternative methods of treatment were tried by 27% of M and TTH patients. Only 16.8% of patients with M pay regular visits to physicians, while 36.3% never visited a physician. More than half of TTH patients have never visited a physician. The majority of patients are only partially satisfied with their current treatment, and almost one-third are not satisfied. Results of this study indicate that the treatment of primary headaches in Croatia should be improved.

Brainstem raphe lesion in patients with major depressive disorder and in patients with suicidal ideation recorded on transcranial sonography.

Recent transcranial sonography (TCS) studies showed that disruption of echogenic midbrain line, corresponding to basal limbic system and raphe nuclei (RN) within, might represent functional marker for the development of depression. Major depressive disorder (MDD) is one of the most common psychiatric disorders associated with suicidal ideation. We initiated this study to assess the usefulness of TCS recording in a group of MDD patients and in MDD patients who also reported suicidal ideation, on the assumption that TCS might serve as a screening method for differentiating patients at risk of suicide. Altogether 71 subjects: 17 patients with MDD, 14 patients with MDD who also reported suicidal ideation and 40 healthy controls, were studied using TCS by two independent physicians. Reduced raphe echogenicity was found in 8 of 17 (47%) of the patients with MDD but only in 6 of 40 (15%) controls. In patients with suicidal ideations that finding was even more pronounced (12 of 14, 86%) with the highest frequency of completely not visible TCS RN finding (10 of 14, 72%). Data showed that altered echogenicity of the RN is frequent in patients with suicidal ideation. Normal RN echogenicity in MDD patients was associated with less severe depressive symptoms and rarely with the presence of suicidal ideations. As far as we know, these are the first ever obtained results which show that TCS might help differentiating MDD patients with suicidal risk or eventually predict good disease recovery based on the findings of RN hypo- or normoechogenicity.

Women and stroke: how much do women and men differ? A review--diagnostics, clinical differences, therapy and outcome.

In this article, the authors have gathered data from epidemiological, observational, case-control and cohort studies to evaluate the differences between men and women in terms of ischemic events, mainly stroke. The authors are highlighting the differences that exist between men and women and play a role in terms of social diversities, and the pathophysiological differences that may be responsible at least in part for ischemic events. Studies show that male stroke patients are more likely to have a history of ischemic heart disease, smoking and alcohol consumption, whereas female stroke patients suffer from ischemic events at an older age, are more likely to have hypertension and atrial fibrillation. Women are more likely to arrive to an emergency room in a comatose state, with paralysis, aphasia, swallowing problems and urinary incontinence, which all indicates a more severe stroke. Also, women suffer from a higher level of disability than men, even though their survival rates are the same. Even though clear guidelines for the treatment of stroke exist, there are still differences in both diagnostic procedures and discharge destination between male and female patients.

Median nerve imaging using high-resolution ultrasound in healthy subjects.

Although electroneuro- and electromyography are still the leading diagnostic methods for investigation of peripheral nerve function, they do not provide information on their morphology. This study was conducted to evaluate the suitability of ultrasonography in visualization of median nerve in healthy volunteers. Twenty-five asymptomatic volunteers (17 women and 8 men), age range 21-47 years, participated in the study. Body height was measured and handedness ascertained, as well as average time spent daily working on a computer. The device used was Aloka Prosound Alpha10 Premier with a 13-MHz probe, using custom preset for musculoskeletal sonography. The following dimensions of median nerve at the pisiform bone level were measured bilaterally: cross-sectional area (CSA), circumference, and longer and shorter diameter. Using the latter values, the flattening ratio (FR) was calculated. Median nerve and the surrounding soft tissue structures were easily depicted in all study subjects. The mean median nerve CSA was 9.70 mm2 (range 5-15 mm2, SD 2.25 mm2), mean FR (longer/shorter diameter) 4.04 (range 2.16-6.08), and median height 172.72 cm. Only one subject was left-handed. The mean time spent daily working on a computer (overall mean of 3.2 h/day) did not correlate with either CSA or FR for the dominant hand. In four subjects, an aberrant artery accompanying median nerve was visualized. High-resolution sonographic imaging is a fast and noninvasive method for assessment of various morphological properties of median nerve and can be used to enhance diagnostic efficiency.

Blood flow velocity in middle cerebral artery during visuo-motor tasks using a mirror: a transcranial Doppler study.

Mirror illusion means that standing in front of a mirror placed in sagittal plane, with the head tilted on one side and one arm stretched forward, one side of the body is reflected as if it were the other side by mirror visual feedback. The aim of this study was to monitor blood flow changes in middle cerebral artery (MCA) by use of transcranial Doppler (TCD) in individuals during motor tasks and tasks using mirror visual feedback. Eight young healthy volunteers (four male and four female) were included in the study. TCD recording in MCA was done during each task consisting of various motor and visuomotor activities using mirror illusion. Both MCA mean blow flow velocity (MBFV) was measured while the subjects were seated in a comfortable chair. The MCA MBFV recordings are presented as baseline values. During the illusion of motor hand activation, when the subject was making right hand flexions and watching its reflection in the mirror, with the left hand immobile, an increase was observed the contralateral MCA MBFV (task 3, +4.5% baseline value; P = 0.017). Furthermore, when the subject made left hand flexions while watching the reflection of the immobile right hand in the mirror, there was an increase in the right MCA MBFV (+5.6% baseline value; P = 0.044), which was more pronounced than during the illusion of motor hand activation (task 3) and less than during direct vision of hand flexion (task 2, +6.3% baseline value; P = 0.005). Our data showed that visual illusion of action, as well as direct action observation could increase the MCA MBFV, which brings forward the possible usage of mirror illusion as a tool in motor neurorehabilitation.

Gabapentin in the prophylaxis of cluster headache: an observational open label study.

Cluster headache is an extremely painful syndrome that occurs more frequently in men. Although periodic in most cases, cluster headache has a considerable impact on the patient quality of life. Acute therapy is usually not sufficient and most patients warrant prophylactic treatment. The aim of this study was to evaluate the efficacy and safety of gabapentin as prophylaxis in patients with cluster headache previously successfully or unsuccessfully treated with other prophylactic medications. The study included 14 patients, 9 men and 5 women (mean age 42 +/- 15 years). Gabapentin was gradually introduced; the maintenance dose was in the range from 900 mg to 2400 mg: 900 mg/day in 6, 1200 mg/day in 2, 1800 mg/day in 4 and 2400 mg/day in 2 patients. The mean duration of treatment was 3.5 (range 2-5) months. Within 1-2 weeks, patients reported response to treatment. The mean number of headache days/4 weeks was reduced from 378 (mean 27) at baseline to 210 (mean 15) at the end of follow up, yielding a reduction by 12 headache days/4 weeks or by 44.94% in headache frequency. Pain intensity was decreased by 25% in 1 (7.14%) patient, by 50% in 8 (57.14%) and by 75% in 3 (21.4%) patients, whereas 2 (14.28%) patients were non-responders. Upon completion of gabapentin therapy, there were no recurrent in treated patients. Adverse events were reported in 8/14 (57.14%) patients and were generally of mild to moderate severity. The most frequently reported adverse events were drowsiness, dizziness, slowness and constipation. There were no drop-outs due to adverse events.

Pineal gland cysts--an overview.

Pineal cysts occur in all ages, predominantly in adults in the fourth decade of life. In series of magnetic resonance imaging (MRI) studies, the prevalence of pineal cysts ranged between 1.3% and 4.3% of patients examined for various neurologic reasons and up to 10.8% of asymptomatic healthy volunteers. The diagnosis of pineal cyst is usually established by MRI with defined radiological criteria to distinguish benign pineal cyst from tumors of this area. A recent study demonstrated the findings obtained by transcranial sonography to correspond to those obtained by MRI in the detection of both pineal gland cyst and pineal gland itself, and could be used in the future mainly as follow up examination. Pineal cysts usually have no clinical implications and remain asymptomatic for years. The most common symptoms include headache, vertigo, visual and oculomotor disturbances, and obstructive hydrocephalus. Less frequently, patients present with ataxia, motor and sensory impairment, mental and emotional disturbances, epilepsy, circadian rhythm disturbances, hypothalamic dysfunction of precocious puberty, and recently described occurrence of secondary parkinsonism. Symptomatic cysts vary in size from 7 mm to 45 mm, whereas asymptomatic cysts are usually less than 10 mm in diameter, although a relationship between the cyst size and the onset of symptoms has been proved to be irrelevant in many cases. There is agreement that surgical intervention should be undertaken in patients presenting with hydrocephalus, progression of neurologic symptoms, or cyst enlargement. Tissue sample of the pineal lesion can be obtained by open surgery, stereotaxy and neuroendoscopy.

Parkinson's disease.

Parkinson's disease is one of the most common neurodegenerative diseases caused by degeneration of dopaminergic neurons in substantia nigra. The neuropathologic hallmark of Parkinson's disease is the presence of Lewy bodies composed mostly of alpha-synuclein and ubiquitin. It is believed that the occurrence of Parkinson's disease is due to a combination of genetic and environmental factors, but the exact mechanism of Parkinson's disease development is not fully elucidated. The most characteristic motor symptoms for Parkinson's disease include bradykinesia, rigidity, resting tremor and postural instability, while many patients also have non-motor signs and symptoms. The key therapeutic agent in the treatment of Parkinson's disease is L-dopa, and the others are dopaminergic agents, monoamine oxidase-B (MAO-B) inhibitors, catechol-O-methyltransferase (COMT) inhibitors, amantadine and anticholinergic agents.

[Transcranial sonography (TCS) in evaluation of patients with essential tremor]. / Transkranijska sonografija (TCS) u procjeni bolesnika s esencijalnim tremorom (ET).

Essential tremor is one of the most common movement disorders characterized by combination of postural bilateral action tremor with frequency 4-12MHz. Diagnosis is based on clinical examination, while neuroimaging methods so far have limited role. Recent reports showed that substantia nigra (SN) hyperechogenicity detected by transcranial sonography (TCS) is a specific finding of Parkinsons disease (PD). Usefulness of TCS in distinguishing some basal ganglia disorders is well documented. However, only a few studies showed its usage in the differentiation of the ET as a potential misdiagnosis of the PD. The aim of this study was to determine the reliability of TCS in the differentiation of patients with ET, PD and healthy controls. TCS and clinical examination was performed on 120 individuals, including 40 PD patients, 40 patients suffering from ET and 40 matched controls. Bilateral SN hyperechogenicity over the margin of 0.20 cm2 was found in 90% of PD patients, 10% of healthy subjects and in 17% patients with ET. Interobserver agreement for this method was significant. TCS may serve as a practical and sufficiently sensitive neuroimaging tool in ET diagnosing and in distinguishing it from PD, its repeatability and accuracy might add to its practical value.

Transcranial sonography in the evaluation of pineal lesions: two-year follow up study.

We have recently reported that transcranial sonography (TCS) is a method competitive to magnetic resonance neuroimaging (MRI) in the evaluation of pineal gland lesions. The aim of the present is study was to assess the usefulness of TCS in a larger patient sample during a two-year follow up. Twenty patients with incidental pineal gland cyst (PGC) detected by MRI scan of the brain and 40 healthy controls without any previous documented data on a disease related to pineal gland were evaluated by TCS and compared with MRI scans. There were no statistically significant differences in PGC size measured by TCS by two observers (p = 0.475), PGC size measured by TCS and MRI (first observer, p = 0.453; and second observer, p = 0.425), size of the pineal gland measured by TCS and MRI in control group (first observer, p = 0.497; and second observer, p = 0.370), and pineal gland size measured by TCS by two observers in control group (p = 0.473). Study results suggested TCS to be a suitable method in the evaluation of pineal gland lesions. Although its resolution cannot match the MRI resolution, its repeatability and accuracy might add to its practical value. We suggest that the repeat MRI scan of such lesions might be replaced by clinical and TCS follow up.

Prevalence of vertigo, dizziness, and migrainous vertigo in patients with migraine.

OBJECTIVE: The aim of this study was to determine the lifetime prevalence of vertigo and dizziness in patients with migraine as compared with controls and to establish the lifetime prevalence of migrainous vertigo. BACKGROUND: Dizziness and vertigo are relatively frequent complaints in general population; however, the prevalence of migrainous vertigo has not been extensively studied so far. METHODS: The study included 327 migraine patients and 324 controls who do not suffer from frequent headaches. The study and control group were assessed clinically and through diagnostic workup for having vertigo, dizziness, hypotension, and sideropenic anemia. RESULTS: Vertigo or dizziness was experienced by 51.7% of migraine patients (MVL group) and 31.5% in the control group (CVL group), P < .0001. Among the MVL group, 23.2% of patients met the criteria for migrainous vertigo. There was no difference between the MVL group and CVL group in frequency of attacks or the pattern of symptom appearance in relation to head movement. Patients in the MVL group more frequently had hypotension, P = .011. Patients with migraine with aura significantly more often had migraine attacks in association with vertigo or dizziness, P < .0001. CONCLUSION: The lifetime prevalence of migrainous vertigo is relatively frequent in migraine patients, especially in migraine with aura.