Marcos Cristiano Lange

Prevalência e características da cefaléia idiopática em punhaladas em uma população de migranosos

Idiopathic stabbing headache is a quite unknown disorder. Its main features consist of brief stabbing pains, lasting few seconds. In most cases, idiopathic stabbing headache is underdiagnosed. We have followed up migraine patients during a period of 12 months, aiming to determine the prevalence and main features of idiopathic stabbing headache while occuring apart from migraine attacks. Two hundred and thirty-three of the 280 patients initially surveyed were included in the analysis of the results. Ninety-four patients presented idiopathic stabbing headaches (40.4%), being 72 of them females (76.5%). For migraine with idiopathic stabbing headaches, mean age, age of beginning of migraine and years with migraine were 33, 22.5 and 10.6 years, respectively. Mean duration of the idiopathic stabbing headaches was reported to be 1.42 seconds [ 1 second by 68 patients (72.4%), 2 seconds by 17 (18.1%), 3 seconds by 6 (6.3%), 4 seconds by 1 (1.05%) and 5 seconds by 2 (2.15%)]. Pain paroxysms were reported to be unilateral by 86 (91.4%) and bilateral by 8 (8.6%) of the cases. They were reported to be temporal by 56 patients (60%), occipital by 15 (15.6%), frontal by 8 (8.5%), temporo-occipital by 7 (7.4%), parietal by 5 (5.3%), fronto-temporal by 1 (1.06%), cervical by 1 (1.06%) and ocular by 1 patient (1.06%). The study confirms a high prevalence of idiopathic stabbing headaches in migraineurs. Its main clinical features could be well determined during the interval between migraine attacks.

Influence of NMDA and non-NMDA antagonists on acute and inflammatory pain in the trigeminal territory: a placebo control study

NMDA and non-NMDA receptors are involved in spinal transmission of nociceptive information in physiological and pathological conditions. Our objective was to study the influence of NMDA and non-NMDA receptor antagonists on pain control in the trigeminal system using a formalin-induced orofacial pain model. Motor performance was also evaluated. Male Rattus norvegicus were pre-treated with topiramate (T) (n=8), memantine (M) (n=8), divalproex (D) (n=8) or isotonic saline solution (ISS) (n=10) intraperitoneally 30 minutes before the formalin test. Formalin 2.5% was injected into the right upper lip (V2 branch) and induced two phases: phase I (early or neurogenic) (0-3 min) and phase II (late or inflammatory) (12-30 min). For motor behavior performance we used the open-field test and measured latency to movement onset, locomotion and rearing frequencies, and immobility time. Pre-treatment of animals with M and D only attenuated nociceptive formalin behavior for phase II. T increased locomotion and rearing frequencies and reduced immobility time. Treatment with M increased immobility time and with D reduced locomotion frequency. Our results showed that the NMDA antagonist (M) is more potent than the non-NMDA antagonists (D and T) in the control of pain in the inflammatory phase. The non-NMDA topiramate improved motor performance more than did D and M, probably because T has more anxiolytic properties.

Long-term evolution of papilledema in idiopathic intracranial hypertension: observations concerning two cases

Chronic headaches, associated with papilledema and pulsatile tinnitus without any neuroradiologic, cytobiochemical or cerebrospinal fluid abnormalities are suggestive of idiopathic intracranial hypertension (IIH). However the absence of the papilledema does not rule out this diagnosis. The reason why some patients do not develop papilledema in IIH is ignored, however there are some hypotheses concerning the structure of the optical nerve. In this study we described two female patients that presented diagnosis of IIH with papilledema, with subsequent resolution of papilledema without the due resolution of intracranial hypertension. The long-term behavior of the optic nerve (ON) facing an increased intracranial pressure was evaluated through repeated measurements of the intracranial pressure. We concluded that the ON submitted to high intracranial pressure for a certain length of time can adapt itself with subsequent disappearance of the papilledema. The presence or not of papilledema in IIH can be related to the period in which the diagnosis is accomplished.

Prevalence and clinical features of migraine in a population of visually impaired subjects in Curitiba, Brazil

To investigate the relevance of lacking or diminished visual input on the expression of migraine, we evaluated its prevalence and clinical features in a population of visually impaired subjects. Between September 1999 and April 2000, 203 visually impaired subjects with a headache inventory were surveyed. Those with headache were assessed according to IHS criteria for the presence of migraine. Migraineurs had their symptoms further detailed through an interview and a headache diary. Of the 104 subjects reporting headaches during the last 6 months, 29 had migraine (14.2%). The prevalence of migraine was not influenced by whether the visual impairment was complete or partial. Mean frequency of migraine attacks was 2.7/month. Most subjects (96%) reported severe and/or moderate attacks. Nausea, vomiting, aggravation by activity and phonophobia were reported by 62%, 37.9%, 86.2% and 96.6% of the subjects, respectively. Visual impairment does not seem to influence prevalence of migraine or its clinical features.

Utilização da algometria de pressão na determinação dos limiares de percepção dolorosa trigeminal em voluntários sadios: um novo protocolo de estudos

Algometria de pressao e uma tecnica que mensura a fisiologia do sistema nociceptivo. Atuando diretamente sobre os nociceptores perifericos responsivos aos estimulos pressoricos esta tecnica permite o estudo da integridade nociceptiva em individuos normais ou portadores de diferentes sindromes algicas. Foram testados 29 voluntarios assintomaticos em que pesquisamos os limiares de percepcao dolorosa, mensurando-os de forma direta sobre a emergencia dos nervos supra-orbital, infra-orbital, mental. Registramos os seguintes valores medios algometricos: nervo mental direito 46,2 Kg/cm2 e esquerdo 48,6 Kg/cm2; nervo supra-orbital direito 47,7 Kg/cm2 e esquerdo 45,2 Kg/cm2; nervo infra-orbital direito 53,9 Kg/cm2 e esquerdo 55,4 Kg/cm2. Apos revisao dos principios de utilizacao da algometria, validamos este protocolo apresentando os valores medios obtidos pela mensuracao do sistema trigeminal comparando-os posteriormente com uma regiao inervada pelos primeiros ramos cervicais (nervo occipital maior) e regiao do musculo temporal.

Episodic migraine associated with postural orthostatic tachycardia syndrome and vasovagal syncope: migraine triggers neuromediated syncope

Dr. Elcio Juliato Piovesan – Hospital de Clínicas da UFPR Rua General Carneiro 181 / 12 andar / Sala 1236 80060-900 Curitiba PR Brasil. E-mail: piovesan@avalon.sul.com.br Migraine is a common episodic headache disorder characterized by attacks consisting of various combinations of headache, neurologic, gastrointestinal and autonomic symptoms. Autonomic symptoms, such as a cold feeling, increased urination, anorexia, diarrhea, constipation and fluid retention, can occur during the premonitory phase, and nausea, vomiting, diarrhea, cutaneous vasoconstriction (pallor), vasodilation (flushing), piloerection and diaphoresis can occur during the pain phase. Migraine patients with accompanying autonomic symptoms seem to experience their pain more unilateral and more severe than non autonomic migraine patients. Studies of autonomic nervous system dysfunction in migraine have been performed. Cardiovascular tests, vasomotor reactions to temperature changes and responses to pharmacological tests, and changes in biochemical parameters suggest abnormalities (hypoor hyperfunctioning) of both the sympathetic and parasympathetic nervous systems. These inconsistent findings may be explained by different types of autonomic dysregulation. Syncope and migraine are both highly prevalent in the general population. Both disorders occur together more frequently than chance would predict, i.e., they are comorbid. Studies using the orthostatic (tilt) test suggest that migraine patients have vagal hyperactivity and α-sympathetic system hypoactivity. Migraineurs may have a genetic predisposition leading to autonomic nervous system (ANS) dysfunction. The link between migraine and abnormal ANS function is unclear. ANS dysfunction may be involved in both increased susceptibility to migraine headaches and increased response to triggers. Migraine patients with typical autonomic symptoms, such as postural orthostatic tachycardia syndrome (POTS) and vasovagal syncope (VS), as well as patients with migraine with prolonged aura, are potential candidates for genetic studies. Mitochondrial dysfunction may play a role in migraine pathophysiology. It is not known whether the mitochondrion (encoded by the nuclear and mitochondrial genomes) is the primary site of the dysfunction, or whether the mitochondrial disturbance occur secondary to another cause. Mitochondria may play a role in the genesis of migraine, especially in these groups (migraine plus autonomic symptoms). Connecting networks exist between pain and autonomic functions in the brain (Fig 1); thus pain can produce autonomic symptoms. We describe a group of patients in whom autonomic symptoms (POTS and VS) occurred only during migraine attacks. We also studied the presence of the mitochondrial DNA (mtDNA) A3243G point mutation, common in patients with mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes (MELAS).

Structural and functional analyses of the occipital cortex in visual impaired patients with visual loss before 14 years old

Single photon emission tomography (SPECT) perfusion images of the brain of individuals with complete visual loss before the age of 14 were carried out and compared to those of visually normal subjects, in order to assess hypothetical differences in brain structural and metabolism between the two groups. Study group was comprised by 2 females and 3 males, aged 30 +/- 10 years. Controls were composed by 6 females and 5 males aged 41.5 +/- 3.8 years. All individuals were submitted to physical and neurological examinations, and to MRI and to SPECT. Blind subjects presented larger perfusion measurements bilaterally in their medial temporal lobes (p=0.030, right side; p=0.01, left side), but smaller perfusion measurements in their left frontotemporal area than controls (p=0.026). Intragroup analysis of the study group disclosed asymmetric perfusion, lesser in the left temporal and parietal areas (p=0.026 and p<0.0001, respectively) compared to the right side. In the healthy controls, reduced perfusion was also noted at the left parietal areas when compared to the right side (p=0.035). The study revealed that completely blind patients that became visually impaired before the age of 14 in spite of not having MRI detectable changes in their brains anatomy do present increases in perfusion of their left and right medial temporal lobes, and a reduction in the perfusion of the left frontotemporal area, as compared to normal controls. While the increases in blood flow may reflect compensatory mechanisms for visual deprivation, the significance of the diminished perfusion in the left frontotemporal area remains elusive.

Mudança no padrão biológico da migrânea com aura após a utilização da tetrabenazina: relato de caso

The influence of the dopaminergic system on the pathophysiology of migraine has been suggested as a result of recent genetic discoveries. A possible hyper-reactivity of the dopaminergic receptors DRD2 reinforced the evidence regarding this. We describe a 31 years-old male patient affected by a generalized dystonia secondary to perinatal hypoxia. At age 16, the patient started having headache crises that met the criteria for migraine with aura. After three years of treatment for dystonia with tetrabenazine, a clear reduction in the frequency, intensity and duration of the crises was perceived. During two periods longer than two months, the interruption of the treatment with tetrabenazine brought about an aggravation of the migraine crises. We present this case as being the first description in the literature showing the beneficial effects of tetrabenazine, a blocker of dopaminergic receptors, on the behavior of migraine with aura.

Program to Diagnose Probability of Aspiration Pneumonia in Patients with Ischemic Stroke

Introduction Stroke is a major cause of death and disability worldwide, with a strong economic and social impact. Approximately 40% of patients show motor, language, and swallowing disorders after stroke. Objective To evaluate the use of software to infer the probability of pneumonia in patients with ischemic stroke. Methods Prospective and cross-sectional study conducted in a university hospital from March 2010 to August 2012. After confirmation of ischemic stroke by computed axial tomography, a clinical and flexible endoscopic evaluation of swallowing was performed within 72 hours of onset of symptoms. All patients received speech therapy poststroke, and the data were subsequently analyzed by the software. The patients were given medical treatment and speech therapy for 3 months. Results The study examined 52 patients with a mean age of 62.05 ± 13.88 years, with 23 (44.2%) women. Of the 52 patients, only 3 (5.7%) had a probability of pneumonia between 80 and 100% as identified by the software. Of all patients, 32 (61.7%) had pneumonia probability between 0 and 19%, 5 (9.5%) between 20 and 49%, 3 (5.8%) between 50 and 79%, and 12 (23.0%) between 80 and 100%. Conclusion The computer program indicates the probability of patient having aspiration pneumonia after ischemic stroke.

Hamartoma fibrolipomatoso de nervo mediano: relato de caso

Fibrolipomatous hamartoma is a rare benign neoplasm that in some cases is associated with macrodactylia. We describe a 31-year-old man who had a tissue enlargement in the wrist, second and third fingers of the left hand since infancy. At 23-years-old he began with continuous, progressive and high intensity pain that occurred more frequently at night, localized in the left hand. It was associated with paraesthesias and hypostesias predominantly at the fingers described above. Investigation with X-ray, ultrasonography, electrodiagnosis, magnetic resonance image of the left wrist and hand showed carpal tunnel syndrome with macrodactylia by fibrolipomatous hamartoma of the median nerve. The patient did not a have good response to clinical therapy, so he was submitted to a surgical decompression of the left carpal tunnel, and after three months of follow up is asymptomatic.