Application of the International Headache Society classification criteria in 652 cluster headache patients

We applied the International Headache Society (IHS) classification coding parameters to a study population of 652 cluster headache (CH) patients, in order to determine how many patients did not fulfil the diagnostic criteria for group 3.1 and to find out any diagnostic elements that could be changed in the upcoming revision of the classification to make it more relevant to current clinical practice. Ninety-nine patients were found to have cluster-like disorder (3.3), including 74 (74.7%) who did not fulfil the diagnostic criteria for CH, because either pain was not associated with any of the accompanying autonomic phenomena listed in the classification or it was not located orbitally, supraorbitally and/or temporally. A review of our total sample showed that 72.0% of patients reported frontal and occipital pain location; in 61.8%, 33.4% and 39.1% of cases, attacks were also accompanied by restlessness/agitation, nausea and photophobia, respectively. In a coding system that took into account the diagnostic elements that we considered in our study, group 3.1 of the existing IHS classification would actually include 51 of the 99 patients currently coded as 3.3.

A prospective study of migraine with aura attacks in a headache clinic population

In order to investigate the prevalence of migraine with aura (MA) attacks according to the criteria set by the International Headache Society (IHS) for diagnosis down to the three-digit level of classification, and to determine the recurrence and possible variability of MA attacks over time, we conducted a 6-15-month-long prospective study on 64 MA patients (42 women and 22 men) consecutively referred for the first time to the University of Parma Headache Centre. At the end of the follow-up period, diagnosis was the same as at the first visit for 80.0% of patients, while it was changed for 20.0%. Throughout the duration of the study, the average number of attacks for each patient was 5.3 +/- 6.2 (range 0-30). Attacks of migraine with typical aura were the most frequent (69.1% of patients), but migraine aura without headache (29.1%) and migraine with prolonged aura (20.0%) were also common; by contrast, basilar migraine and migraine with acute onset aura were reported only by one patient in either case. Migraine aura without headache was statistically significantly more frequent in males than in females. Our study results suggest that in most cases the frequency of recurrent MA attacks is relatively low and provide interesting indications about the prevalence of the different MA subtypes listed in the IHS classification, albeit in a headache clinic population.

Possible predictive factors in the evolution of episodic to chronic cluster headache

The purpose of our study was to identify general factors and distinctive clinical features differentiating patients with chronic cluster headache (CH) evolved from episodic CH and patients with episodic CH. Our study sample included 28 patients suffering from chronic CH evolved from episodic CH and 258 patients with episodic CH; all were referred to the Headache Center of Parma between December 1975 and June 1998. Patients with episodic CH were selected from all episodic CH referrals (n = 485) and selection was based on the duration of the disorder, which was to exceed the average period needed for an episodic form to turn into a chronic form (4.5 years for females and 7.0 years for males). At CH onset, the mean age for patients with chronic CH evolved from episodic CH was older than for those with episodic CH. Among patients with chronic CH, more were smokers or heavy drinkers, and had suffered a head injury. Clinically, episodic CH evolving into chronic CH was characterized by a high frequency of cluster periods, a larger proportion of patients with attacks not occurring strictly within cluster periods, and remission periods lasting less than 6 months. Possible predictive factors in the development of chronic CH appear to be CH onset from the third decade of life onward, the occurrence of more than one cluster period a year, and the short-lived duration of remission periods. The role played by head injury and cigarette smoking in the evolution of the disorder still cannot be established with certainty.

Primary and secondary chronic cluster headache: two separate entities?

The International Headache Society (IHS) classification divides chronic cluster headache (CH) into two subtypes: chronic CH unremitting from onset (CCHU) and chronic CH evolved from episodic (CCHE). The purpose of our study was to point out any similarities and differences between the two chronic CH subtypes and to determine whether or not they can be considered as two separate clinical entities. We reviewed data about 31 CCHE patients and 38 CCHU patients referred to the Parma Headache Centre between 1975 and 1999. Clinically, CCHE patients exhibited statistically significant differences from CCHU patients, i.e. earlier CH onset and duration of attacks varying more frequently between 120 and 180 min. From the point of view of lifestyle, heavy alcohol and coffee drinkers prevailed among CCHU patients, while CCHE patients were more frequently heavy smokers. Based on clinical features, it seems reasonable to suppose that chronic CH may occur as two distinct entities.

Possible predictive factors in the prognosis of migraine with aura

In order to identify possible predictive factors in the prognosis of migraine with aura (MA), we conducted a review at 10 to 20 years from referral on a sample of 77 MA patients (51 F, 26 M) consecutively seen for the first time at the University of Parma Headache Center. Based on the date of the last MA attack reported by these patients, we divided them into two study groups: a group of 22 patients "with remission of the disease," i.e. attack-free for at least 2 years at the end of the follow-up study; and a group of 55 patients "without remission of the disease," i.e. still having attacks in the last 2 years of the follow-up study. A comparative analysis of the MA clinical features observed in the two groups at the time of the patients' first visit to our Center enabled us to identify a number of favorable prognostic indicators, namely: a family history of parents with MA, the absence of other associated forms of primary headache, and the absence of both natural and artificial light stimulation as trigger factors.

Weekend headache: a possible role of work and life-style

The purpose of our study was to determine whether or not patients reporting weekend headache exhibit distinctive features in their work habits, family life, and leisure on workdays and on weekends as compared to other headache sufferers, and whether or not they are inclined to change their living habits at the weekend. The study was done on an initial sample of 50 patients referred to the University of Parma Headache Centre between October 1996 and April 1997. These patients completed a specially designed questionnaire which, in addition to demographics, contained specific questions relevant to the subject matter being investigated. They were also given a diary which they had to complete for 8 consecutive weeks in order to determine the actual frequency of headache attacks over different days of the week. The questionnaire data were only analyzed for the 38 women in the sample, because there were too few male controls for an accurate comparison with weekend headache sufferers. Among the women with weekend headache, work habits, family life, and leisure were such as to suggest a possible increase in stress and frustration on weekends, which might have made them perceive the headaches occurring on Saturdays and Sundays as more severe. No changes were found in the intake of substances such as coffee and alcohol, nor in cigarette smoking over the different days of the week. Finally, analysis of the diaries showed an increased frequency of headache attacks on weekends only among the men, which seems to corroborate the hypothesis of weekend headache as a disorder typically affecting men.

Migraine with aura: a review of 81 patients at 10-20 years' follow-up

We investigated the evolution over time of migraine with aura (MA) in a number of MA patients consecutively referred to the University of Parma Headache Center in the period 1976-86. The follow-up period chosen for our review of the clinical condition of patients varied from a minimum of 10 years to a maximum of 20 years. The study group comprised 81 patients (55F, 26M), 21 of them (14.2%) with at least one parent with MA. Migraine without aura (MO) was also present in 29.6% of the patients studied. Currently, 35% of patients (29.4% F, 46.1% M) have been free from attacks for at least 1 year and 19.4% (13.6% F, 30.8% M) for over 5 years. Moreover, the frequency of attacks has decreased considerably in 54.4% of cases (50% F, 63.7% M); it has increased in only 25% (26.1% F, 22.7% M). The headache has disappeared completely in 11.1% of patients (8.0% F, 18.2% M); it has become less severe in 36.2% and more severe in only 5.5%. The results of our investigation point to a favorable evolution of MA over time.

[Our experience with the surgical treatment of carcinoma of the colon]

The Authors analyze a series of 441 patients affected by carcinoma of the colon operated on between June 1980 and November 1993. The incidence of the different stages of the disease according to Dukes resulted comparable to that reported in the literature as well as the incidence of morbidity and mortality. Recostruction was performed in all cases with mechanical sutures (T-L for the right colon and L-T for the left colon) and without protection enterostomy. Long-term results evaluated by actuarial methods were influenced by the stage of the disease, and not by sex or duration of symptoms. The need of early diagnosis as well as oncologically correct surgical technique is furthermore confirmed. The importance of clinical trials on adjuvant chemotherapy is emphasized in order to improve survival in patients operated for stage B and C colon cancer.

[The therapy of the liver metastases of colorectal carcinoma]

The treatment of liver metastases should be addressed in a multidisciplinary way, considering the manifold therapeutic options available, for each of which corresponds a particular indication. The best results are obtainable with resective surgery in cases in which there is a partial involvement of the liver (25-50%) and a variable intra-hepatic distribution (monolobar), situations that correspond to Gennari stages I and II. In the authors' experience, the extent of the liver resection does not influence possible survival and oncologically correct resections should be carried out such as segmentectomies, pluri-segmentectomies or wedge resection in compliance with the principle of removing at least 1.5 cm of healthy perineoplastic tissue. The authors reserve major hepatectomies to special situations: voluminous metastases, diffuse involvement of a single lobe, topographic localisation contraindicating segmentary resection.

[Excessive reabsorption of irrigation fluid during operative hysteroscopy for uterine myoma]

Operative hysteroscopy procedures can present complications connected to necessity of kneeping, usually with low viscosity fluids, an uniform distension of uterine cavity. The instilled solutions are reabsorbed through the peritoneum and open uterine venous channels producing a hyperhydration syndrome. The case report shows the rising up of tis syndrome during a hysteroscopy for an uterine myoma resection. The physiopathology includes cardiovascular overload and haemodilution, causing pulmonary, cerebral and tissutal oedema. In this case report the volumes of arterial oxygen saturation and end tidal carbon dioxide obtained on line were the first warning signals. A high CVP value, a plasmatic reduction of Na, albumin, proteins, haemoglobin, haematocrit and osmolarity reflected the excessive fluid reabsorption. For this reason the necessity, during these surgical methods, of considering some practical indications and the absolutely necessary use of clinical and biochemical monitoring systems for these patients.

[The surgical treatment of malignant neoplasms of the pancreas: resection or palliative intervention?]

The authors retrospectively evaluate their 10-year experience in the surgical management of pancreatic cancer, and analyze their results in terms of morbidity and long-term survival. The comparison between curative and palliative surgery shows, in this series, a better long-term survival and a better performance status for the patients in the curative group, although postoperative morbidity and mortality are higher. The difficulty of an early diagnosis as well as a correct preoperative staging is confirmed. Finally, the authors propose a personal, totally mechanic technique of digestive tract restoration after gastric resection during pancreatic surgery underlining this procedure is easy, safe, fast and functional.

Intrahepatic epidoxorubicin in metastatic and primary liver tumours: a phase II study

Primary and metastatic gastrointestinal tumours in the liver have been treated by intrahepatic artery infusion of chemotherapeutic drugs in an attempt to increase the efficacy of the administered agents. Among the several active agents, 4' epidoxorubicin, an anthracycline analogue, was selected for this study because of the therapeutic level reached in the liver by this drug. Seven patients with primary hepatic carcinoma and twenty with metastatic adenocarcinoma of the colon to the liver received intraarterial hepatic infusion of epidoxorubicin at the dosage of 30 mg weekly. No haematological or gastrointestinal grade 3-4 toxicity was recorded, only one patient experienced transient cardiac toxicity. No objective response was observed in primary hepatic carcinoma and six objective responses, 1 complete and 5 partial (30%), were achieved in metastatic colorectal cancer patients. This results is not far from those reported with FUDR, but does not justify epidoxorubicin in colorectal cancer patients as first line intraarterial treatment.

[Cardiac tamponade caused by vascular erosion. A case report]

Cardiac tamponade may be caused by erosion of the right cardiac walls or of the intrapericardial superior vena cava in subjects with a central venous catheter. The underlying cause of this rare complication is direct parietal trauma by the catheter and endarterial damage produced by infused hyperosmolar solutions. High mortality is closely related to erroneous or late diagnosis. Both correct positioning techniques and the use of soft venous catheters are fundamentally important in preventing this complication.

[Rare primary hepatic neoplasms. Our experience in 2 cases: a primary lymphoma and a leiomyosarcoma of the liver]

In a review of personal experience of major liver surgery, 2 very rare cases of primary liver tumours, one lymphoma and one leiomyosarcoma are presented. The world literature on the subject is also reviewed and follow-up results are reported after indicating the surgical techniques adopted.

[Value of the use of tissue adhesive (Braun Histoacryl) and its importance as a safety measure in difficult anastomoses]

In an experimental and then clinical investigation, the intention has been to demonstrate that tissue adhesive (Histoacryl Braun) is a useful safety factor in a wide variety of difficult intestinal sutures, in both emergency surgery and in that of choice. Experiments were carried out on about a hundred rabbits which received colic anastomosis, after clean, complete section, anastomosis of the viscera, with four cardinal sutures in 000 silk and the remaining suture of a diameter of about 3 cm with adhesive. This stage having been surmounted with excellent results, work continued with the experiment in emergency surgery and surgery of choice, on the basis of the criterion of greater safety as a complement of the traditional high dehiscence risk suture technique. The clinical results obtained thus far have been encouraging enough to suggest its experiments.