André Palma da Cunha Matta

Cerebrovascular disorders in childhood: etiology, clinical presentation, and neuroimaging findings in a case series study

OBJECTIVE To describe the main etiologies, neurological manifestations and neuro-imaging findings among children with sequelae of cerebrovascular disorders. METHOD Case series study of children whose diagnosis was stroke sequelae. Variables studied were age at the time of first episode, number of episodes, etiology, motor deficits, epilepsy, and effected vascular territory. RESULTS Twenty three patients were studied. Average age at first episode was 6.91 (+/-2.08) years. Fourteen patients were female. The number of stroke events per patient ranged from one to five. The most frequent etiologies were heart disease and sickle cell anemia. The most frequent neurological deficit was right hemiparesis. Nine patients experienced seizures. The left middle cerebral artery was the most affected vascular area. CONCLUSION Our findings are similar to those described in the literature. Despite a careful investigation, some causes of stroke remain unidentified.

SINTOMAS DEPRESSIVOS E ANSIEDADE EM PACIENTES COM CEFALÉIA DO TIPO TENSIONAL CRÔNICA E EPISÓDICA

INTRODUCAO: A cefaleia do tipo tensional (CTT), dor cefalica mais comum, tem mecanismos fisiopatologicos, epidemiologia e apresentacao clinica pouco estudados. Depressao e ansiedade sao comorbidades especialmente enfocadas entre seus portadores. OBJETIVO: Estudar a ocorrencia de sintomas depressivos e ansiedade entre portadores de CTT episodica (CTTE) e cronica (CTTC). METODOLOGIA: Cinquenta pacientes com CTTE e cinquenta com CTTC preencheram os inventarios de depressao e de ansiedade de Beck. Somente foram considerados aqueles com escores moderado ou grave. RESULTADOS: Entre portadores de CTTE, ansiedade e sintomas depressivos foram encontrados em 60 e 32 % dos pacientes, respectivamente. Em pacientes com CTTC, ansiedade foi detectada em 44 % e sintomas depressivos foram observados em 40 % da amostra. CONCLUSAO: ambas as comorbidades sao importantes em pacientes com CTT. Negligencia-las significa risco de falencia no tratamento, contribuindo para queda na qualidade de vida .

Botulinum Neurotoxin Type A in Neurology: Update

This paper reviews the current and most neurological (central nervous system, CNS) uses of the botulinum neurotoxin type A. The effect of these toxins at neuromuscular junction lends themselves to neurological diseases of muscle overactivity, particularly abnormalities of muscle control. There are seven serotypes of the toxin, each with a specific activity at the molecular level. Currently, serotypes A (in two preparations) and B are available for clinical purpose, and they have proved to be safe and effective for the treatment of dystonia, spasticity, headache, and other CNS disorders in which muscle hyperactivity gives rise to symptoms. Although initially thought to inhibit acetylcholine release only at the neuromuscular junction, botulinum toxins are now recognized to inhibit acetylcholine release at autonomic cholinergic nerve terminals, as well as peripheral release of neuro-transmitters involved in pain regulation. Its effects are transient and nondestructive, and largely limited to the area in which it is administered. These effects are also graded according to the dose, allowing individualized treatment of patients and disorders. It may also prove to be useful in the control of autonomic dysfunction and sialorrhea. In over 20 years of use in humans, botulinum toxin has accumulated a considerable safety record, and in many cases represents relief for thousands of patients unaided by other therapy.

The real-life experience with cardiovascular complications in the first dose of fingolimod for multiple sclerosis

Fingolimod is a new and efficient treatment for multiple sclerosis (MS). The drug administration requires special attention to the first dose, since cardiovascular adverse events can be observed during the initial six hours of fingolimod ingestion. The present study consisted of a review of cardiovascular data on 180 patients with MS receiving the first dose of fingolimod. The rate of bradycardia in these patients was higher than that observed in clinical trials with very strict inclusion criteria for patients. There were less than 10% of cases requiring special attention, but no fatal cases. All but one patient continued the treatment after this initial dose. This is the first report on real-life administration of fingolimod to Brazilian patients with MS, and one of the few studies with these characteristics in the world.

Recommendations on diagnosis and treatment of depression in patients with multiple sclerosis

Multiple sclerosis (MS) is frequently associated with depression. Yet there are few clinical trials on treating depression in MS and no agreed recommendations for its assessment and follow-up. We present evidence-based recommendations for several aspects of depression in MS, including screening for depression, recognition of other concomitant psychiatric conditions, suicide risk, disability, fatigue, cognition, adherence to treatment, the effect of drugs used to treat MS on depression and possible pharmacological treatments for depression in MS.

CEFALÉIA DO TIPO TENSIONAL EPISÓDICA Avaliação clínica de 50 pacientes

A case series study of 50 consecutive patients with episodic tension type headache (ETTH) was conducted. Clinical aspects, family history and impact on work activities were studied. The casuistry was made up of 40 women and 10 men. The average age was 30 (±12) years. Constrictive pain was present in 40 patients (80%). Sickness was the most commonly reported related phenomenon (20%). As expected, bilateral pain predominated; however, unilateral location was also present (10%). Although classically described as a mild pain, we observed that ETTH can come in intense crisis (16%). Family history of tension type headache was positive in 12 patients. The impact on work activities was substantial (14%). Our findings regarding to clinical aspects are in agreement with the literature. It is important to mention that the impact of ETTH on the individual and society should be reconsidered, and is more substantial than has been reported to date.

No evidence of disease activity in multiple sclerosis patients

ABSTRACT Introduction: Multiple Sclerosis is a chronic inflammatory demyelinating disease that affects 2.5 million people in the world. NEDA (No evidence of disease Activity) −4 is a new concept related to absence of disease activity in the context of MS. It takes into account the following four parameters: relapses; disability progression; lesion load and brain atrophy. Areas covered: The purpose of this paper is to visit the new emerging concepts of NEDA. Although it is considered important and attractive, there is a lack of uniformity. Expert commentary: Although NEDA-4 embraces important markers of disease activity and degeneration, this definition is still evolving and other parameters apart from the loss of brain volume might be included, especially those related to disability, such as cognitive problems, visual function, fatigue and pain.

Motor Imagery and Its Effect on Complex Regional Pain Syndrome: An Integrative Review.

The motor imagery (MI) has been proposed as a treatment in the complex regional pain syndrome type 1 (CRPS-1), since it seems to promote a brain reorganization effect on sensory-motor areas of pain perception. The aim of this paper is to investigate, through an integrative critical review, the influence of MI on the CRPS-1, correlating their evidence to clinical practice. Research in PEDro, Medline, Bireme and Google Scholar databases was conducted. Nine randomized controlled trials (level 2), 1 non-controlled clinical study (level 3), 1 case study (level 4), 1 systematic review (level 1), 2 review articles and 1 comment (level 5) were found. We can conclude that MI has shown effect in reducing pain and functionality that remains after 6 months of treatment. However, the difference between the MI strategies for CRPS-1 is unknown as well as the intensity of mental stress influences the painful response or effect of MI or other peripheral neuropathies.

The influence of fear of falling on orthostatic postural control: a systematic review

Posture is a complex sensory-motor behavior that can be influenced by the fear of falling (FoF) during environmental changes. The aim of this paper is to investigate the influence of FoF on orthostatic postural control in healthy individuals by a systematic review. Thirteen articles were selected. Some other articles (31 references) were used to contextualize and discuss the topic. Studies in the environment made changes on the environment, in which participants were positioned in high hydraulic platforms at different heights, showed a decrease in the center of pressure in the anteroposterior oscillation where the platform was higher. This change in postural control strategy and the FoF are correlated. It can modulate the activity of the muscle spindle (H-reflex) and probably induce postural freezing phenomenon (anticipated postural anxiety). We can conclude that further studies are needed to understand the physiological echanisms involved in FoF and its relation to changes in postural control strategy.

Persistent Headache in Patients With Multiple Sclerosis Starting Treatment With Fingolimod

It is difficult to think of a medication that does not have “headache” as a potential adverse event listed by the manufacturer. However, this symptom is not described in detail by the pharmaceutical companies, and no considerations are made regarding the acceptable duration of this side effect or how to manage it, should it occur. This letter concerns 12 potential cases of headache associated with use of fingolimod, a new and very efficient drug for treating multiple sclerosis (MS). Upon starting with fingolimod, these patients presented persistent headache that resembled new daily persistent headache (NDPH) but were, in fact, attributable to a new substance. Fingolimod is an orally bioavailable compound that antagonizes the sphingosine 1-phosphate (SP1) receptor. In vivo, fingolimod is phosphorylated to fingolimod-phosphate, which resembles naturally occurring S1P. Through binding to SP1 sites in lymphocytes, fingolimod prevents these cells from leaving the lymph nodes. The first dose of fingolimod may be associated with bradycardia, fatigue, gastrointestinal disturbance, headache, and upper respiratory tract infection. Other adverse events in patients using fingolimod that are more serious but rare include atrioventricular block, herpetic viral infections, and macular edema. Although headache is described as a potential side effect of fingolimod and many other drugs for the treatment of MS, the present cases caught our attention because of the characteristics that these patients presented. These patients comprised 8 males and 3 females, of mean age 33.5 years (range 23 to 46 years), who are undergoing treatment for MS. Fingolimod was prescribed due to suboptimal response to other drugs. One patient had a previous history of episodic migraine. They were not using any drugs other than immunomodulatory treatments for MS. In all patients, their headache started within the first week of use of fingolimod and persisted for at least 3 months. In all cases, the pain was bilateral, non-pulsatile, of moderate intensity, and persistent From the MS Reference Center, Universidade Metropolitana de Santos, SP, Brazil (Y.D. Fragoso); MS Reference Center, Hospital Sirio-Libanes, Sao Paulo, SP, Brazil (T. Adoni); Department of Neurology, Hospital Beneficencia Portuguesa de Sao Paulo, Sao Paulo, SP, Brazil (S. Gomes); MS Unit, Centro Hospitalar Unimed, Joinville, SC, Brazil (M.V.M. Goncalves); Department of Neurology, Hospital Universitario Antônio Pedro, Universidade Federal Fluminense, Niterói, RJ, Brazil (A.P.C. Matta); Department of Neurology, Medical School, Irmandade de Misericordia da Santa Casa de Sao Paulo, Sao Paulo, SP, Brazil (M.F. Mendes); Department of Neurology, Universidade Regional de Blumenau, Blumenau, SC, Brazil (F. Siquineli).