André Leite Gonçalves

Idiopathic intracranial hypertension with and without papilloedema in a consecutive series of patients with chronic migraine

Chronic migraine (CM) has been associated with idiopathic intracranial hypertension without papilloedema (IIHWOP), a significant percentage of these cases occurring in obese patients with intractable headache. A prospective study from February 2005 to June 2006 was made of 62 CM patients who fulfilled International Headache Society diagnostic criteria and had cerebral magnetic resonance venography (MRV) and lumbar puncture (LP) done. Two patients were excluded, six (10%) with elevated cerebrospinal fluid (CSF) open pressure (OP), five with body mass index (BMI) > 25. None of the patients had papilloedema or abnormal MRV. BMI and CSF OP were significantly correlated (r = 0.476, P < 0.001, Pearsons correlation test). Obesity (defined as BMI > 30) was a predictor of increase in intracranial pressure (defined as OP > 200 mmH2O) (f = 17.26, 95% confidence interval 6.0, 8.6; P < 0.001). From our study we strongly recommend that not only intractable CM patients with high BMI, but also first diagnosed patients with BMI > 30 should be systematically evaluated by a LP to rule out IIHWOP.

Randomized, proof-of-principle clinical trial of active transcranial magnetic stimulation in chronic migraine.

Background High-frequency repetitive transcranial magnetic stimulation of the left dorsolateral prefrontal cortex (rTMS-DLPFC) is an effective treatment for depression. Preliminary studies indicated beneficial effects of rTMS-DLPFC on pain relief in patients treated for depression, and in patients with chronic migraine. Methods In this randomized, double-blind, parallel-group, single-center, proof-of-principle clinical trial, we tested the hypothesis that 23 sessions of active rTMS-DLPFC delivered over eight weeks would be feasible, safe and superior to sham rTMS to decrease the number of headache days in 18 patients with chronic migraine without severe depression. Per-protocol analysis was performed. Results rTMS-DLPFC applied over eight weeks was feasible and safe in patients with chronic migraine. Contrary to our primary hypothesis, the number of headache days decreased significantly more in the sham group than in the group treated with active rTMS-DLPFC at eight weeks. Average decrease in headache days was >50% in the sham group, indicating a powerful placebo response. Pain intensity improved in both groups to a similar extent. Conclusions Positive results of M1 stimulation in other studies, and the absence of significant benefits of active high-frequency rTMS of the DLPFC in the present study, point to M1 as a more promising target than the DLPFC, for larger trials of noninvasive brain stimulation in patients with chronic migraine.

Increased variability of motor cortical excitability to transcranial magnetic stimulation in migraine: a new clue to an old enigma

Increased, decreased or normal excitability to transcranial magnetic stimulation (TMS) has been reported in the motor (M1) and visual cortices of patients with migraine. Light deprivation (LD) has been reported to modulate M1 excitability in control subjects (CS). Still, effects of LD on M1 excitability compared to exposure to environmental light exposure (EL) had not been previously described in patients with migraine (MP). To further our knowledge about differences between CS and MP, regarding M1 excitability and effects of LD on M1 excitability, we opted for a novel approach by extending measurement conditions. We measured motor thresholds (MTs) to TMS, short-interval intracortical inhibition, and ratios between motor-evoked potential amplitudes and supramaximal M responses in MP and CS on two different days, before and after LD or EL. Motor thresholds significantly increased in MP in LD and EL sessions, and remained stable in CS. There were no significant between-group differences in other measures of TMS. Short-term variation of MTs was greater in MP compared to CS. Fluctuation in excitability over hours or days in MP is an issue that, until now, has been relatively neglected. The results presented here will help to reconcile conflicting observations.

Misdiagnosis of hemicrania continua.

Hemicrania continua (HC) is a primary headache disorder that is characterized by a continuous unilateral headache of moderate severity, exacerbations of severe pain, and complete responsiveness to indomethacin. Misdiagnosis of HC is probably common in general neurology settings and other clinical specialties. This paper is an attempt to bridge the gap between the correct and misdiagnosis of this disorder. HC was once thought to be a rare headache disorder, but is, in fact, an underecognized headache syndrome. HC can be of continuous or remitting form. Variants such as HC with aura have been described and secondary cases may occur. Indomethacin is the best treatment, although HC could respond to other NSAIDs, such as the selective COX-2 inhibitors.

Primary diffuse leptomeningeal gliomatosis

Dr. Andre Leite Goncalves – Division of Child Neurology / Departamento de Neurologia e Neurocirurgia Rua Botucatu 720 – 04023-900 Sao Paulo SP Brasil. E-mail: goncalvesnp@yahoo.com.br Glioma arising primarily from the leptomeninges is extremely rare and often diagnosed only in postmortem examination. It is thought to derive from heterotopic nests of neuroglial tissue within the leptomeninges, which are present in 1% of necropsies. Primary leptomeningeal glioma can be in the form of a solitary tumour or a diffuse tumour involving intracranial or spinal cord leptomeninges. We report a case of primary diffuse leptomeningeal gliomatosis (PDLG) established by meningeal biopsy.

Interictal abnormal fMRI activation of visual areas during a motor task cued by visual stimuli in migraine

RESUMO Objetivo Avaliar mudancas na atividade cerebral por meio de ressonância magnetica funcional apos privacao luminosa comparada a exposicao a luz, em individuos com enxaqueca no estado interictal e em controles. Metodos Dez individuos com enxaqueca e dez controles participaram de duas sessoes de ressonância magnetica funcional. Em cada sessao, realizaram uma tarefa motora com a mao direita guiada por estimulos visuais. Foram colhidas imagens antes e apos 30 minutos de privacao luminosa ou exposicao a luz. Em individuos com [...]