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 56,091 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Endovascular and cerebral bypass therapies are rarely used in children. The authors describe the treatment of a partially coiled giant distal vertebral artery (VA)-posterior inferior cerebellar artery (PICA) aneurysm in a child. They performed a side-to-side PICA-PICA anastomosis followed by endovascular VA aneurysm deconstruction with PICA preservation. A healthy 11-year-old boy developed progressive holocephalic headaches over the course of 2 months. Magnetic resonance imaging and magnetic resonance angiography revealed a large right PICA aneurysm causing brainstem compression. In November 2005, 2 Neuroform stents and Guglielmi detachable coils and Matrix were placed in the aneurysm at an outside institution. In 2006, angiography demonstrated aneurysm enlargement from which the PICA originated, coil compaction, and increased mass effect. The patient underwent a PICA-PICA bypass with intraoperative flow measurements followed by endovascular embolization of the aneurysm and parent VA. An angiogram obtained after the procedure demonstrated filling of the right PICA medullary branch through the bypass and obliteration of the aneurysm. The patient remained neurologically intact. Giant aneurysms of the posterior circulation are rare but do occur in children. With the aid of combined surgical and endovascular strategies the authors were able to safely eliminate the aneurysm from circulation with good outcome. Cerebral bypass and endovascular deconstructive therapies can be used safely in children but should be reserved for cases in which direct treatment carries significant risk. Careful surgical and endovascular planning with intraoperative flow assessment is essential for good outcome.
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PMID:Treatment of a complex posterior fossa aneurysm in a child using side-to-side posterior inferior cerebellar artery-posterior inferior cerebellar artery bypass. 1835 8

Increased incidence of cancers and the development of totally implanted venous access devices that contain their own port to deliver chemotherapy will lead to a greater than before numbers of central venous catheter-related thrombosis (CVCT). Medical consequences include catheter dysfunction and pulmonary embolism. Vessel injury caused by the procedure of CVC insertion is the most important risk factor for development of CVCT. This event could cause the formation of a fresh thrombus, which is reversible in the large majority of patients. In some cases, thrombus formation is not related to catheter insertion. The incidence of CVC-related DVT assessed by venography has been reported to vary from 30 to 60% but catheter-related DVT in adult patients is symptomatic in only 5% of cases. The majority of patients with CVC-related DVT is asymptomatic or has nonspecific symptoms: arm or neck swelling or pain, distal paresthesias, headache, congestion of subcutaneous collateral veins. In the case of clinical suspicion of CVC-related deep venous thrombosis (DVT), compressive ultrasonography (US), especially with doppler and color imaging, currently is first used to confirm the diagnosis. Consequently, contrast venography is reserved for clinical trials and difficult diagnostic situations. There is no consensus on the optimal management of patients with CVC-related DVT. Treatment of CVC-related VTE requires a five- to seven-day course of adjusted-dose unfractionated heparin or low molecular weight heparin (LMWH) followed by oral anticoagulants. Long-term LMWH that has been shown to be more effective than oral anticoagulant in cancer patients with lower limb DVT, could be used in these patients. The efficacy and safety of pharmacologic prophylaxis for CVC related thrombosis is not established and the last recommendations suggest that clinicians not routinely use prophylaxis to try to prevent thrombosis related to long-term indwelling CVCs in cancer patients. Additional studies performed in high risk populations with appropriate dosage and timing will help to define which patients could benefit from prophylaxis.
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PMID:[Venous thromboembolism associated with long-term use of central venous catheters in cancer patients]. 1839 94

Trigger point injections with different solutions have been studied mainly with regard to the management of myofascial pain (MFP) patient management. However, few studies have analyzed their effect in a chronic headache population with associated MFP. The purpose of this study was to assess if trigger point injections using botulinum toxin, lidocaine, and dry-needling injections for the management of local pain and associated headache management. Forty-five (45) myofascial pain patients with headaches that could be reproduced by activating at least one trigger point, were randomly assigned into one of the three groups: G1, dry-needling, G2, 0.25% lidocaine, at 0.25% and G3 botulinum toxin and were assessed during a 12 week period. Levels of pain intensity, frequency and duration, local postinjection sensitivity, obtainment time and duration of relief, and the use of rescue medication were evaluated. Statistically, all the groups showed favorable results for the evaluated requisites (p < or = 0.05), except for the use of rescue medication and local post injection sensitivity (G3 showed better results). Considering its reduced cost, lidocaine could be adopted as a substance of choice, and botulinum toxin should be reserved for refractory cases, in which the expected effects could not be achieved, and the use of a more expensive therapy would be mandatory.
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PMID:Botulinum toxin, lidocaine, and dry-needling injections in patients with myofascial pain and headaches. 1924 99

Continuous spinal anesthesia (CSA) is an underutilized technique in modern anesthesia practice. Compared with other techniques of neuraxial anesthesia, CSA allows incremental dosing of an intrathecal local anesthetic for an indefinite duration, whereas traditional single-shot spinal anesthesia usually involves larger doses, a finite, unpredictable duration, and greater potential for detrimental hemodynamic effects including hypotension, and epidural anesthesia via a catheter may produce lesser motor block and suboptimal anesthesia in sacral nerve root distributions. This review compares CSA with other anesthetic techniques and also describes the history of CSA, its clinical applications, concerns regarding neurotoxicity, and other pharmacologic implications of its use. CSA has seen a waxing and waning of its popularity in clinical practice since its initial description in 1907. After case reports of cauda equina syndrome were reported with the use of spinal microcatheters for CSA, these microcatheters were withdrawn from clinical practice in the United States but continued to be used in Europe with no further neurologic sequelae. Because only large-bore catheters may be used in the United States, CSA is usually reserved for elderly patients out of concern for the risk of postdural puncture headache in younger patients. However, even in younger patients, sometimes the unique clinical benefits and hemodynamic stability involved in CSA outweigh concerns regarding postdural puncture headache. Clinical scenarios in which CSA may be of particular benefit include patients with severe aortic stenosis undergoing lower extremity surgery and obstetric patients with complex heart disease. CSA is an underutilized technique in modern anesthesia practice. Perhaps more accurately termed fractional spinal anesthesia, CSA involves intermittent dosing of local anesthetic solution via an intrathecal catheter. Where traditional spinal anesthesia involves a single injection with a somewhat unpredictable spread and duration of effect, CSA allows titration of the block level to the patient's needs, permits a spinal block of indefinite duration, and can provide greater hemodynamic stability than single-injection spinal anesthesia.
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PMID:Continuous spinal anesthesia. 1954 4

Migraine is Europe and North America's most frequent neurological illness. Its prevalence is about 12%, affecting women twice more than men. Migraine illness is defined by the occurrence of several episodes of pulsatile headaches, uni- or bilateral, accompanied or preceded by signs of central and autonomic nervous system dysfunction. Considered benign, it can lead to non negligible social and professional handicap. Its social and economic repercussions are serious, due to consequences in terms of work incapacity. Essentially relying on drugs, therapeutic divides itself into migraine attack treatment and migraine prophylaxis. Migraine attack treatment relies essentially on acetaminophen and non-steroidal antiinflammatory agents, associated or not with antiemetics like domperidone and metoclopramide, accessorily on ergot derivatives and triptans. Migraine prophylaxis is best provided by propranolol, valproic acid and amitryptiline, anti-serotoninergic agents, topiramate, flunarizine and other agents should be reserved to particular cases. In some cases, children in particular, non-drug approaches such as relaxation, biofeedback or behavioral therapy can be privileged although relying on weak scientific evidences.
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PMID:[Migraine in 2009: from attack to treatment]. 1989 87

Daily headache affects an estimated 3% to 6% of the general population and affects women 2 to 3 times more frequently than men. The vast majority of daily headache is nonparoxysmal, or chronic daily headache. In the general population, the distribution of chronic tension-type headache and chronic migraine is fairly equal, but in medical practice chronic migraine accounts for the vast majority of nonparoxysmal daily headache. The first step in the management of chronic daily headache is to identify potential overuse of analgesic and vasoconstrictor medications. Preventive treatment is then initiated with a tricyclic antidepressant, beta-blocker, calcium-entry blocker, and/or anticonvulsant. Chronic migraine patients who are refractory to specific headache treatment may take a triptan frequently, if not daily, or a (long-acting) opioid. Both management strategies of refractory daily headache are controversial but appear safe and effective, although daily opioid treatment should be reserved for a relatively small, selected subpopulation. Through a practice survey, we looked at potential differences between daily (long-acting) opioid and daily triptan treatment in 53 patients. We found patient satisfaction with either treatment to be relatively favorable, although there was an implication that triptans outperform opioids in providing headache relief. However, it was also evident that in both treatment groups, despite the relatively positive patient satisfaction results, chronic migraine patients clearly continued to experience a negative impact from their headaches.
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PMID:Management of daily headache unresponsive to preventive treatment: daily triptans versus daily opioids. 2006 22

Schistosomiasis (bilharzia) is a neglected tropical disease caused by digenetic trematode platyhelminths of the genus Schistosoma. Neuroschistosomiasis is one of the most severe clinical outcomes associated with schistosome infection. Neurological complications early during the course of infection are thought to occur through in situ egg deposition following aberrant migration of adult worms to the brain or spinal cord. The presence of eggs in the CNS induces a cell-mediated Th2-driven periovular granulomatous reaction. The mass effect of thousands of eggs and the large granulomas concentrated within the brain or spinal cord explain the signs and symptoms of increased intracranial pressure, myelopathy, radiculopathy and subsequent clinical sequelae. Myelopathy (acute transverse myelitis and subacute myeloradiculopathy) of the lumbosacral region is the most common neurological manifestation of S. mansoni or S. haematobium infection, whereas acute encephalitis of the cortex, subcortical white matter, basal ganglia or internal capsule is typical of S. japonicum infection. Cerebral complications include encephalopathy with headache, visual impairment, delirium, seizures, motor deficits and ataxia, whereas spinal symptoms include lumbar pain, lower limb radicular pain, muscle weakness, sensory loss and bladder dysfunction. The finding of eggs in the stool or a positive serology, provides supportive but not direct evidence of neuroschistosomiasis. A definitive diagnosis can only be made with histopathological study showing Schistosoma eggs and granulomas. Schistosomicidal drugs (notably praziquantel), steroids and surgery are currently used for the treatment of neuroschistosomiasis. During the 'acute phase' of the disease, neuroschistosomiasis is treated with corticosteroids which are augmented with a course of praziquantel once female worm ovipositioning commences. Surgery should be reserved for special cases such as in those with evidence of medullary compression and in those who deteriorate despite clinical management.
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PMID:Neuroschistosomiasis. 2167 95

The focus of this review is on the efficacy of antidepressants as preventive treatments for migraine and chronic tension-type headache (TTH). Pharmacologic prophylaxis may be indicated for patients with frequent headaches, who respond insufficiently to acute therapies, or for whom medication overuse is a concern. The well-documented efficacy of the tricyclic antidepressant amitriptyline, both for migraine and chronic TTH, has been followed by widespread use of other antidepressants for headache prophylaxis. Although antidepressants in general share comparable efficacy for the treatment of depressive disorders, their efficacy as headache preventives varies widely. Evidence supporting use of the selective serotonin reuptake inhibitors as headache preventives is poor; their use should be reserved for treating comorbid depression in a patient who also has a headache disorder. Small randomized trials of venlafaxine indicate preliminary efficacy both for migraine and tension-type headache. Evidence for other antidepressants is lacking. Although antidepressants are often prescribed to headache patients under the assumption that the prescribed agent also will be effective in reducing symptoms of comorbid depression, the majority of studies have failed to find a strong relationship between depression symptoms and headache improvement. Suggestions for future research are discussed.
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PMID:The use of antidepressants for headache prophylaxis. 2195 70

Pituitary apoplexy is rare endocrine emergency which can occur due to infarction or haemorrhage of pituitary gland. This disorder most often involves a pituitary adenoma. Occasionally it may be the first manifestation of an underlying adenoma. There is conflicting data regarding which type of pituitary adenoma is prone for apoplexy. Some studies showed predominance of non-functional adenomas while some other studies showed a higher prevalence in functioning adenomas amongst which prolactinoma have the highest risk. Although pituitary apoplexy can occur without any precipitating factor in most cases, there are some well recognizable risk factors such as hypertension, medications, major surgeries, coagulopathies either primary or following medications or infection, head injury, radiation or dynamic testing of the pituitary. Patients usually present with headache, vomiting, altered sensorium, visual defect and/or endocrine dysfunction. Hemodynamic instability may be result from adrenocorticotrophic hormone deficiency. Imaging with either CT scan or MRI should be performed in suspected cases. Intravenous fluid and hydrocortisone should be administered after collection of sample for baseline hormonal evaluation. Earlier studies used to advocate urgent decompression of the lesion but more recent studies favor conservative approach for most cases with surgery reserved for those with deteriorating level of consciousness or increasing visual defect. The visual and endocrine outcomes are almost similar with either surgery or conservative management. Once the acute phase is over, patient should be re-evaluated for hormonal deficiencies.
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PMID:Pituitary apoplexy. 2202 23

Nasal polyps are inflammatory outgrowths of paranasal sinus mucosa caused by chronic mucosal inflammation that typically arise from the middle meatus and ethmoid region. The main symptoms of nasal polyps are perennial nasal congestion, nasal obstruction, and anosmia or hyposmia. Unlike patients with chronic rhinosinusitis (CRS) without nasal polyps who present with headache and facial pain, patients with nasal polyps typically do not complain of those symptoms. Nasal polyps appear as semitranslucent, pale gray growths in the nasal cavity in contrast to pink or erythematous adjacent mucosa. Nasal polyps occur more frequently in patients with persistent asthma, aspirin-exacerbated respiratory disease (AERD), CRS, and cystic fibrosis. Children with nasal polyps should be evaluated for cystic fibrosis. Churg-Strauss syndrome and ciliary dyskinesia also may be associated with nasal polyps. Nasal polyps have increased numbers of activated eosinophils, mast cells, and IgE. Staphylococcal superantigens may play a role in the Th2 type of chronic eosinophilic inflammation observed in nasal polyps. Dysfunction of the epithelial barrier in nasal polyps causing reduced levels of antimicrobial proteins has been described. Topical nasal steroids are the treatment of choice. They significantly decrease polyp size, nasal congestion, rhinorrhea, and increase nasal airflow. Short courses of oral steroids may be needed to reduce polyp size followed by maintenance therapy with intranasal steroids. Surgery is reserved for cases when polyps cause severe obstruction, recurrent sinusitis, and for patients who have failed medical therapy. Aspirin desensitization may decrease the requirement for polypectomies and sinus surgery in patients with AERD.
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PMID:Chapter 7: Nasal polyps. 2279 80


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