Hamit Macit Selekler

Cutaneous Allodynia During Cluster Headache Attacks

Cutaneous allodynia occurs in > 60% of patients with episodic migraine, either solely within the referred pain area on the ipsilateral head or within and outside the ipsilateral head (1, 2). Burstein et al. (3) have described a patient in whom, 1 h after migraine pain onset, mechanical and cold allodynia started to develop in the ipsilateral head and after 2 h allodynia spread to the contralateral head and the ipsilateral forearm. The authors hypothesized that allodynia on the ipsilateral head reflects sensitization of second-order neurons in trigeminal nucleus caudalis, and allodynia outside this area is related to sensitization of third-order neurons in the thalamus (3). In cluster headache (CH), data are limited to two studies, one showing cutaneous allodynia in four of 10 patients, and the other study reporting absence of allodynia in 16 patients (4, 5). Apart from allodynia, primary headaches may be associated with spontaneous limb pain (6–9), both of which were considered to be the result of central sensitization. In the current literature, there is no report on spontaneous limb pain in CH patients. We present two CH patients who rapidly developed allodynia in trigeminal areas and in ipsilateral limbs, in one of whom accompanied by ipsilateral limb pain.

Prevalence and clinical characteristics of an experimental model of 'ice-cream headache' in migraine and episodic tension-type headache patients

This study was designed to compare the prevalence and clinical characteristics of ‘cold-induced headache’ between migraine and episodic tension-type headache patients. Seventy-six migraine and 38 episodic tension-type headache patients were included in the study. An experimental model of an ‘ice-cream headache’ was developed for the study. The pain occurrence period, its location and quality were recorded for each patient who felt pain in their head during the test procedure. Pain in the head occurred in 74% of migraine and 32% of ‘tension-type headache’ patients. Although the most frequent pain location was the temple in both groups of patients, this rate was greater than twofold in migraine patients when compared with episodic tension-type headache patients. While headache quality was throbbing in 71% of migraine patients, it was so in only 8% of the episodic tension-type headache patients. Considering all the results, it seems that ‘cold-stimulus headache’ is not only more frequent in migraine patients, but also its location and quality differ from ‘tension-type headache’.

Does metoprolol inhibit the cortical spreading depression? Acute effects of systematic metropol on CSD in rats

Cortical spreading depression (CSD) is supposed to be the underlying biological basis of the migraine aura. Metoprolol was proven to be effective in migraine prophylaxis in clinical trials, but its mechanism of action has not been clarified yet. We studied direct effects of metoprolol on a continuous CSD induction model in rats. Six adult Wistar rats were anaesthetized with intraperitoneal thiopental (50 mg/kg). CSD was induced with application of 1 M KCL through a burr hole into the left frontal dura-mater, and recorded by an Ag/AgCl DC electrode on the left parietal dura-mater. After a basal recording of CSD induction during the first 40-min period, metoprolol (5 mg/kg) was infused within 4 min. Then DC recordings were maintained for a further 120 min. Any significant differences in total number and duration of CSDs before and after metoprolol administration were not detected. This study suggests that the mode of action of metoprolol in prophylaxis is not via direct CSD inhibition.

Influence of the long term use of a computer on median, ulnar and radial sensory nerves in the wrist region

ObjectivesRepetitive microtrauma or overuse injuries may often affect upper extremities of the long term computer users. The aim of this study was to compare sensory nerve conduction velocities (SNCV) for median, radial and ulnar nerves in the wrist of computer users with the same parameters in controls who do not use computers regularly.Material and MethodsTwenty one male computer users (age: mean (M) = 28.3 years ± standard deviation (SD) = 7.5 years) and 21 male control subjects (age: M±SD = 24.1±4.6 years) were recruited for the study. Limb length and the perimeters of the dominant arm and forearm were measured for each subject. The neurophysiological study consisted of measuring sensory nerve conduction of the median, ulnar and radial nerves.ResultsThe sensory conduction velocities of both median and ulnar nerves were significantly delayed in the dominant arm of the computer users compared to the controls. In addition, sensory conduction velocity of the median nerve was significantly delayed in the dominant extremity of the computer users compared to their non-dominant extremity.ConclusionsThis study shows that computer users have a tendency toward developing median and ulnar sensory nerve damage in the wrist region. Mechanism of delayed SNCV in the median and ulnar nerves may be due to sustained extension and ulnar deviation of the wrist during computer mouse use and typing. Reduced SNCV changes were more apparent on the dominant side of the median nerve. This may indicate the increased neural deficits related to an increased use of the dominant side. Further investigation is needed to determine how to reduce potential risk factors at this stage in order to prevent development of median or ulnar neuropathy in the long term computer users.

Isolated abducens nerve palsy associated with retinoic acid therapy: a case report.

Isolated abducens nerve palsy is a rare complication of treatment with various drugs. Here, the authors report the case of a 23-year-old female with isolated left abducens nerve palsy after long-term retinoic acid therapy. The association is based on the temporal relationship and the exclusion of other possible etiologic factors following extensive laboratory and imaging diagnostics. The authors suggest that isolated abducens nerve palsy may be a presenting sign of a toxic neuropathy associated with retinoic acid therapy. After the exclusion of other organic lesions, especially idiopathic intracranial hypertension, and an assessment of the risk-benefit ratio, discontinuation of treatment must be considered in such cases.

The importance of EEG and variability of MRI findings in acute hemorrhagic leukoencephalitis.

Sir, Acute haemorrhagic leukoencephalitis (AHLE) is a lethal haemorrhagic variant of acute disseminated encephalomyelitis (ADEM), a rare demyelinating disorder of central nervous system. A 22-year-old woman was referred to our hospital with status epilepticus. Her seizures were treated with phenytoin infusion. In the next day, neurological examination revealed global aphasia and right-sided hemiplegia. High degree of fever and leukocytosis (22.000/mm) were detected suggesting a preceding infection. Antibiotic and antiviral agents were introduced. Magnetic resonance imaging (MRI) of brain showed large hyperintense areas including some isointense regions on diffusion-weighted signal intensity (DWI). These areas were observed as hypointense on apparent diffusion coefficient (ADC) again including some isointense regions (Fig. 1). T1 and T2-weighted images were completely normal. In spite of mannitol and dexamethasone treatment, total quadriplegia and increased muscle tonus prominent in neck and face muscles were observed during the follow up. Electroencephalogram (EEG) revealed slow background activity and a rhythmic focal delta activity in left hemispheric derivations (Fig. 2). A new MRI scan was performed and large hyperintense lesions scattered in both hemispheres in T1 and T2-weighted images with partial contrast enhancement were detected (Fig. 3). Findings in DWI and ADC mapping were completely reversed. Diagnosis of AHLE was made and 1000 mg/day intravenous methylprednisolone treatment was introduced. All neurological impairments, MRI and EEG findings were resolved within 10 days. Acute disseminated encephalomyelitis typically begins within 6 days to 6 weeks after an infection or vaccination. Long-tract signs and impairment of consciousness are the most common features. Seizures, aphasia and extrapyramidal signs like hemidystonia or rigidity could be occurred infrequently. The diagnosis is usually based on MRI studies. Most common abnormalities are bilateral asymmetric multiple small lesions (<5 mm) and large confluent white matter lesions. AHLE (some degree of

A non-traumatic interhemispheric subdural haematoma: presented with headache as the sole complaint

Due to their localisations and symptoms, interhemispheric subdural haematomas (ISH) compose a distinct category. Altered level of consciousness and hemiparesis are the most frequent symptoms. We report a case of ISH who presented with headache as the sole complaint. Left cerebellar haematoma and ISH were found in cranial MRI and cranial computed tomography Cranial MR angiogram was normal. Haemogram and coagulation parameters were within normal limits. ISH should be considered among the diagnostic possibilities in elderly patients who present with headache as the sole symptom without other clinical features such as meningeal irritation signs, focal neurological symptoms and alteration of consciousness. Cranial imaging studies should be done in such cases.

Short-lasting unilateral neuralgiform headache with severe lacrimation and mild conjunctival injection

Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) were first described by Sjaastad et al. (1). It has been accepted as unilateral orbital, supraorbital or temporal or pulsating pain lasting 5–240 s. Pain is accompanied by ipsilateral conjunctival injection and lacrimation. Attacks occur with a frequency from 3 to 200 per day (2). Some clinical features in SUNCT, such as attack duration, pain profile as well as the precipitating mechanisms, are suggestive of a link with first division (V1) trigeminal neuralgia (TN) (3). From a nosological perspective, attacks changing from TN to SUNCT have been reported (4). Sesso (5) suggested that the autonomic features occur just above a ‘certain pain threshold’ and proposed that many cases diagnosed as SUNCT are TN in reality. Sjaastad et al. (6) emphasized that, V1 trigeminal neuralgia resembles to SUNCT only in later stages of the disease, during severe and long-lasting attacks. Even during these attacks, conjunctival injection and lacrimation, hallmarks of SUNCT, are mostly mild. Neurosurgical literature contains many references to atypical TN (7). Some neurosurgeons believe that current concept of the pathophysiology of TN may have been artificially constrained by clinical classification of the disorder (8). A typical form of TN may, in prolonged cases, develop atypical signs. In contrast, many cases of TN start with pain lacking the typical characteristics of TN, and later develop all the hallmark signs of TN (9). In this article, we presented a case with shortlasting unilateral neuralgiform headache attacks which did not fit into classical descriptions of TN and SUNCT. Our main focus was the accompanying autonomic symptoms of attacks; thus, we analysed laterality, timing and degree of each autonomic symptom. Case report