Post-transfusion severe headache in a patient with thalassemia with superficial siderosis of the central nervous system: a case report and literature review

BACKGROUND

Patients with severe thalassemia may experience adverse effects from transfusion such as fever, rash, and iron overload after long-term transfusion therapy. Severe headaches as a side effect of blood transfusion in patients with thalassemia are not commonly observed, especially when combined with superficial siderosis of the central nervous system, which is easily misdiagnosed and requires excessive examination and treatment.

CASE PRESENTATION

A 31-year-old woman was admitted with severe headache and vomiting over 3 days following blood transfusion. She was diagnosed with intermediate α-thalassemia at 2 years of age and had a history of irregular blood transfusions. Physical examination revealed horizontal nystagmus with no other abnormal neurological signs. Magnetic resonance (MR) imaging, MR venography, MR arteriography, and cerebrospinal fluid analysis were normal. However, susceptibility-weighted imaging showed abnormal signals in the bilateral and fourth ventricles. Initial antibiotics, antivirals, decompression of intracranial pressure, iron chelation, and symptomatic treatments were administered; subsequently, small intermittent blood transfusions were cautiously administered for severe anemia. The patient's headache was gradually relieved, and she was discharged on day 9. At the 5-month follow-up, the patient's headache recurred following another transfusion.

CONCLUSIONS

Severe post-transfusion headache in patients with thalassemia has not been fully recognized and is easily misdiagnosed, leading to excessive examination and treatment. Understanding the clinical features of transfusion-related headaches can help identify this complication, but the exact pathophysiological mechanism requires further research.

Neural Interruption by Unilateral Labyrinthectomy Biases the Directional Preference of Otolith-Related Vestibular Neurons

Background: The directional preference of otolith-related vestibular neurons elucidates the neuroanatomical link of labyrinths, but few direct experimental data have been provided. Methods: The directional preference of otolith-related vestibular neurons was measured in the vestibular nucleus using chemically induced unilateral labyrinthectomy (UL). For the model evaluation, static and dynamic behavioral tests as well as a histological test were performed. Extracellular neural activity was recorded for the neuronal responses to the horizontal head rotation and the linear head translation. Results: Seventy-seven neuronal activities were recorded, and the total population was divided into three groups: left UL (20), sham (35), and right UL (22). Based on directional preference, two sub-groups were again classified as contra- and ipsi-preferred neurons. There was no significance in the number of those sub-groups (contra-, 15/35, 43%; ipsi-, 20/35, 57%) in the sham (p = 0.155). However, more ipsi-preferred neurons (19/22, 86%) were observed after right UL (p = 6.056 × 10⁻⁵), while left UL caused more contra-preferred neurons (13/20, 65%) (p = 0.058). In particular, the convergent neurons mainly led this biased difference (ipsi-, 100% after right UL and contra-, 89% after left UL) (p < 0.002). Conclusions: The directional preference of the neurons depended on the side of the lesion, and its dominance was mainly led by the convergent neurons.

Incidence of peripheral vestibular disorders in individuals with obstructive sleep apnea

BACKGROUND

Obstructive sleep apnea(OSA) could influence peripheral vestibular function adversely via intermittent hypoxia and its consequences.

OBJECTIVE

This study aimed to evaluate the risk of peripheral vestibular disorders in OSA using a nationwide population-based retrospective cohort study.

METHODS

The National Health Insurance Service-National Sample Cohort represents the entire Korean population from 2002 to 2015. OSA was defined as individuals who had used medical services twice or more under a diagnosis of OSA(G47.33 in ICD-10). A comparison cohort consisted of socio-demographically matched non-OSA subjects in a ratio of 1:4. The incidences of benign paroxysmal positional vertigo(BPPV), Meniere's disease, and vestibular neuritis were evaluated in each cohort.

RESULTS

A total of 2,082 individuals with OSA and 8,328 matched non-OSA subjects were identified. The incidence rates(IRs) of peripheral vertigo in OSA and non-OSA were 149.86 and 23.88 per 10,000 persons, respectively (Ratio of IR, IRR = 6.28, 95%CI 4.89 to 8.08). In multivariable analysis, the risk of peripheral vertigo was significantly higher in OSA(adjusted HR = 6.64, 95%CI 5.20 to 8.47), old age(adjusted HR = 1.03, 95%CI 1.02 to 1.04), female sex(adjusted HR = 1.92, 95%CI 1.48 to 2.50), and comorbidities(adjusted HR = 1.09, 95%CI 1.003 to 1.19). The IRRs of each vestibular disorder in the two groups were 7.32(95%CI 4.80 to 11.33) for BPPV, 3.61(95%CI 2.24 to 5.81) for Meniere's disease, and 9.51(95%CI 3.97 to 25.11) for vestibular neuritis.

CONCLUSIONS

Subjects diagnosed with OSA had a higher incidence of peripheral vestibular disorders than those without OSA, according to national administrative claims data. It is recommended to take peripheral vertigo into account when counseling OSA.

Biomarkers of Oxidative Stress and Endogenous Antioxidants for Patients with Chronic Subjective Dizziness

As a neurotologic disorder of persistent non-vertiginous dizziness, chronic subjective dizziness (CSD) arises unsteadily by psychological and physiological imbalance. The CSD is hypersensitivity reaction due to exposure to complex motions visual stimuli. However, the pathophysiological features and mechanism of the CSD still remains unclearly. The present study was purposed to establish possible endogenous contributors of the CSD using serum samples from patients with the CSD. A total 199 participants were gathered and divided into two groups; healthy (n = 152, male for 61, and female for 91) and CSD (n = 47, male for 5, female for 42), respectively. Oxidative stress parameters such as, hydrogen peroxide and reactive substances were significantly elevated (p < 0.01 or p < 0.001), whereas endogenous antioxidant components including total glutathione contents, and activities of catalase and superoxide dismutase were significantly deteriorated in the CSD group (p < 0.01 or p < 0.001) as comparing to the healthy group, respectively. Serum levels of tumor necrosis factor -α and interferon-γ were significantly increased in the CSD participants (p < 0.001). Additionally, emotional stress related hormones including cortisol, adrenaline, and serotonin were abnormally observed in the serum levels of the CSD group (p < 0.01 or p < 0.001). Our results confirmed that oxidative stress and antioxidants are a critical contributor of pathophysiology of the CSD, and that is first explored to establish features of redox system in the CSD subjects compared to a healthy population.

Focused Neuro-Otological Review of Superficial Siderosis of the Central Nervous System

Background

Infratentorial siderosis (iSS) is a progressive degenerative disorder targeting primarily the cerebellum and cranial nerve eighth; therefore, progressive ataxia and its neuro-otological findings are common. Toxicity from hemosiderin involves selectively vulnerable neurons and glia in these posterior fossa structures. Other neurologic findings may be present, though our focus relates to the cochlea-vestibular cerebellar involvement. Radiographic evidence of siderosis may be the result of recurrent, albeit covert bleeding in the subarachnoid space, or the consequence of an overt post-traumatic or aneurysmal subarachnoid hemorrhage (SAH). The radiographic iSS appearance is identical regardless of the SAH cause. A recent study provides compelling evidence to search and correct possible hemorrhage sources in the spinal canal. The removal of residual existing hemosiderin deposits that may potentially cause clinical symptoms remains as a major therapeutic challenge.

Methods

We reviewed large data sources and identified salient papers that describe the pathogenesis, clinical and neurotologic manifestations, and the radiographic features of iSS.

Results

The epidemiology of iSS is unknown. In a recent series, clinically evident iSS was associated with recurrent SAH; by contrast, in a follow-up period ranging from weeks up to 11 years after a monophasic episode of SAH, radiographic siderosis was clinically silent. However, the post-aneurysmal or post-trauma SAH sample size in this single study was small and their observation period relatively short; moreover, the burden of intraneuronal hemosiderin is likely greater with recurrent SAH. There are a few reports of late iSS, several decades after traumatic SAH. A recent report found subjective hearing loss in aneurysmal SAH individuals with radiographic siderosis. Only in recent years, it is safe to perform magnetic resonance imaging (MRI) in post-aneurysmal SAH, because of the introduction of titanium, MRI-compatible aneurysm clips.

Conclusion

iSS can be associated with significant neurotologic and cerebellar morbidity; the recurrent SAH variant is frequently clinically symptomatic, has a shorter latency and greater neurotologic disability. In these cases, a thorough search and management of a covert source of bleeding may stop clinical progression. The frequency and clinical course of radiographic iSS after traumatic and post-aneurysmal SAH is largely unknown. Detection of radiographic iSS after trauma or aneurysm bleeding suggests that the slower clinical course could benefit from an effective intervention if it became available. The use of cochlear implants is a valid alternative with advanced hearing impairment.