Successful endovascular thrombectomy 90h after stroke onset.

Endovascular thrombectomy (EVT) has extended the conventionally accepted time window of treatment, from 4.5h (ECASS III trial) for intravenous thrombolysis, to 7.3h for EVT (HERMES collaboration). More recent evidence suggests EVT times could be extended to 24h in carefully selected patients (DAWN trial). Some patients present after these time windows with large areas of ischemia but little established infarction on imaging. They represent a major dilemma with much to gain from EVT but at theoretically higher risk of a poor outcome. We present a case of near-complete left M1 occlusion in which EVT achieved reperfusion 90h 41min after stroke onset with excellent clinical outcome. Current guidelines on treatment windows for EVT according to HERMES collaboration do not reflect individual patient factors. In appropriate patients delayed EVT may give positive clinical outcomes.

Levetiracetam in chronic daily headache: a double-blind, randomised placebo-controlled study. (The Australian KEPPRA Headache Trial [AUS-KHT]).

INTRODUCTION: Chronic daily headache (CDH) represents a temporal profile of headache (15+ days/month; 4+ hours/day; >6 months). We report the first comprehensive and largest levetiracetam (LEV) trial in CDH. METHODS: A 27-week, multi-centre, randomised, placebo-controlled, cross-over, phase III B study assessed efficacy of a target of 3 g/day LEV of 6 placebo tablets/day in CDH. Primary efficacy was headache-free rate (HFR) while secondary parameters were loss of diagnostic criteria; severity; duration; disability; associated features; pain; and quality of life. RESULTS: Ninety-six patients were recruited (baseline HFR 10.4 ± 14.6%; median 0%). At onset of history 73 (74.1%) had migraine +/- aura and 35 (36.5%) had tension-type headache (TTH). Over the six months preceding recruitment 54 (56.3%) had migraine and 42 (43.8%) had TTH. Headache history was 22.6 ± 15.0 years (median 20.0). Eighty-eight received placebo and 89 received LEV with >80 receiving stable dose in either arm. LEV achieved 3.9% increased HFR over placebo, showing a trend but not significance. There was 9.9% increase in loss of CDH diagnostic criteria re: headache days/month for LEV over placebo (p = .0325), reduced disability (p = .0487) and reduced pain severity for LEV (p = .0162). The Short-Form Quality of Life assessment instrument (SF-36) showed impaired mental health on LEV (p = .001). DISCUSSION: These findings conflict with reports of LEV efficacy, mandating placebo control in headache trials. Primary efficacy equated to one extra headache-free day/month with reduced disability and pain intensity. Mental health was reduced on LEV. The 10% loss of diagnostic criteria, decreased intensity and disability suggest a subpopulation with CDH where LEV remains a therapeutic option.

Gabapentin in the prophylaxis of chronic daily headache: a randomized, placebo-controlled study.

OBJECTIVE: To compare efficacy and safety of gabapentin (GPT) versus placebo for prophylaxis of chronic daily headache (CDH) (headache at least 15 days/month of greater than 4 hours duration over preceding 6 months). METHODS: This is a multicenter randomized placebo-controlled crossover study. After 4-week baseline, subjects, aged 18 to 65, were randomized to GPT 2,400 mg/day or placebo. There was 2 weeks titration, 6-week stable dosage, and 1 week washout period between treatment arms. The primary efficacy measure was the difference between the percentage of headache-free days per treatment period. Secondary efficacy measures included headache duration and severity, degree of disability, associated symptoms, concomitant medications, Visual Analogue Scale (VAS) scores, and quality of life (QOL). RESULTS: A total of 133 patients were enrolled (41 men, 92 women, mean age 43 years). All were eligible for safety analysis. Ninety-five received sufficient treatment to allow evaluation of efficacy. There was a 9.1% difference in headache-free rates favoring GPT over placebo (p = 0.0005). Benefits for GPT were also demonstrated for headache-free days/month (p = 0.0005), severity (p = 0.03), VAS (p = 0.0006), headache-associated symptoms of nausea (p = 0.03) and photophobia/phonophobia (p = 0.04), disability affecting normal activities (p = 0.02), attacks requiring bed rest (p = 0.001), and QOL related to bodily function (p = 0.01), health/vitality (p = 0.0001), social function (p = 0.006), and health transition (p = 0.0002). Reduction in headache days/month was seen across the spectrum of prerandomization headache frequencies. CONCLUSION: Gabapentin represents a therapeutic option for chronic daily headache.

Wernicke's encephalopathy presenting with upbeating nystagmus.

The case of a 49-year-old woman with Wernicke's encephalopathy is described, in which primary position upbeating nystagmus was the chief ocular sign. Although there was no history of excessive alcohol consumption, Wernicke's encephalopathy was diagnosed on a background of anorexia nervosa. The diagnosis was supported by the patient's symptomatic and clinical recovery following thiamine therapy.