F. Di Stani

Great occipital nerve blockade for cluster headache in the emergency department: case report

A 44-year-old man with a past medical history of episodic cluster headache presented in our ED with complaints of multiple daily cluster headache attacks, with cervico-occipital spreading of pain from May to September 2004. The neurological examination showed no abnormalities as well as brain and spine MRI. Great Occipital Nerve (GON) blockade, with Lidocaine 2% (5 ml) and betamethasone (2 mg), were performed in the right occipital region (ipsilaterally to cluster headache), during attack. GON blockade was effective immediately for the attack and the cluster period resolved after the injection. We suppose that the action of GON blockade may involve the trigemino-cervical complex and we moreover strongly suggest to use GON blockade in emergency departments for cluster headache with cervico-occipital spreading as attack abortive therapy, especially in oxygen and sumatriptan resistant cluster headache attacks, in patients who complaints sumatriptan side-effects or have contraindications to use triptans.

Carotid endarterectomy and gliofibrillar S100b protein release.

Abstract.Increased levels of the gliofibrillar S100b protein can be detected during carotid endarterectomy (CEA). Whether the S100b protein increase is marker of brain ischemic sufferance and predictor of cognitive decline is controversial. Twenty-eight patients underwent clinical assessment and cranial computed tomography (CT) 24–48 hours before and 3 months after CEA. S100b serum levels were evaluated before surgery, at cross-clamping, 10 minutes later, at declamping, and 24–48 hours and 10–12 weeks after CEA. Increased S100b levels were detected in 11 patients (39%); eight (73%) of these patients had symptomatic carotid artery disease. Increased S100b level correlated with history of TIA or stroke (p=0.005), low mini-mental state examination score (p=0.02), and ischemic infarctions at preoperative CT (p=0.03). Slight and transient increased S100b levels were detected in 39% of patients during CEA. The protein levels increased despite the absence of clinical events during surgery. Our findings suggest a failure of compensatory hemodynamic or metabolic mechanisms in peri-ischemic tissue, whose longterm effects on cognition remain to be investigated.

Cerebral effects of hyperbaric oxygen breathing: a CBF SPECT study on professional divers.

We investigated the effects on cerebral blood flow (CBF) of pure oxygen breathing exposure during dives in a group of professional divers, in both the normobaric (NBO) and the hyperbaric oxygen (HBO) breathing conditions. Using single photon emission computerized tomography (SPECT) and Tc‐99m hexamethylpropylenamine oxime (HM‐PAO), we studied 10 young divers and six normal volunteers. Divers were studied by SPECT in the NBO and HBO conditions, in two different sessions. The HBO state was obtained in a hyperbaric chamber at 2.8 ATA for 15 min. By ANOVA, we did not observe any significant difference in CBF distribution between controls and divers in both NBO and HBO conditions. By individual analysis, divers showed a decreased CBF in a total of 33 regions of interest (ROIs) during NBO and 46 ROIs during HBO with respect to control values. In particular, two divers showed a remarkable increase in the number of hypoperfused ROIs during HBO (+7 and +5 ROIs, respectively). Pure oxygen breathing exposure in young divers is associated with a patchy distribution of brain areas of hypoperfusion. This phenomenon is more pronounced in the HBO state than in the NBO state. Further studies on CBF are needed to help identify divers potentially prone to harmful oxygen effects.

Primary headache in Emergency Department: prevalence, clinical features and therapeutical approach

Headache is one of the most common reported complaints in the general adult population and it accounts for between 1% and 3% of admissions to an Emergency Department (ED). The overwhelming majority of patients who present to an ED with acute primary headache (PH) have migraine and very few of them receive a specific diagnosis and then an appropriate treatment. This is due, in part, to a low likelihood of emergency physicians diagnosing the type of PH, in turn due to lack of knowledge of the IHS criteria, and also the clinical condition of the patients (pain, border type of headache, etc.) In agreement with the literature, another interesting aspect of data emerging from our experience is that few of the ED PH patients are referred to headache clinics for diagnosis and treatment, especially if they present with high levels of disability. This attitude promotes the high–cost phenomenon of repeater patients that have already been admitted to the ED for the same reason in the past. This is statistically important because it involves about 10% of the population with PH.

Migraine in the Emergency Department: a psychometric study of a migraine "repeaters" sample.

To evaluate the influence of psychometric variables on the “repeater” phenomenon in an emergency department, 15 “repeaters” and 27 outpatient migraineurs were recruited. All patients were submitted to the Beck Depression Inventory (BDI), State and Trait Anxiety Inventory, Toronto Alexithymia Scale–20 (TAS–20), Tridimensional Personality Questionnaire and Migraine DIsability Assessment Scale (MIDAS). The “repeater” group showed higher MIDAS total scores (p=0.02) and higher scores in TAS–20 (p=0.02) than the outpatients. A higher frequency of alexithymic trait (p=0.02) and higher BDI scores (p=0.07) have also been observed in the “repeater” group than the outpatients. Alexithymia and depressive mood associated with high disability may be a specific psychosocial pattern of “repeater” migraineurs. The psychometric evaluation of this population may be important to explain the “repeaters” phenomenon.

Atypical primary headache responding to finger pressure: possible involvement of the vagus nerve?

We describe a case of atypical primary headache strongly responsive to prolonged pressure in the anterior aspect of the neck. We hypothesize that, at least in this case, the trigemino-cervical system and its connections with the vagus nerve are involved.

Neuroprotection and Stroke

The current goal of acute stroke therapy is to restore cerebral perfusion and to protect cerebral tissue before the development of an irreversible damage. This latter is due to the duration and the severity of cerebral ischemia [1]. Recanalization operated by thrombolysis represents the most intuitive and effective treatment of acute cerebral ischemia. Unfortunately, because of the strictly clinical criteria that make thrombolysis feasible, this approach is limited only to few patients, and it is estimated that only about 5% of all acute cerebrovascular patients are suitable for rtPA treatment [2]. The need for new therapeutic strategies appropriate for the majority of acute stroke patients is therefore evident, in order to save as much ischemic brain tissue as possible.