Characteristics of headache during and after digital substraction angiography: A critical re-appraisal of the ICHD-3 criteria

Introduction Headache is a frequent but neglected side effect of angiography, and the criteria for angiography related headache have been based on only a few studies. Methods One-hundred and thirty nine patients who underwent cerebral angiography and 30 controls who underwent peripheral angiography participated in this prospective, non-randomized, case-control study. Participants were instructed to tell the angiography staff in case a headache developed and were questioned about their headache just after, 24 hours after, and one week after angiography. Results In the cerebral angiography group 42 patients (30.2%) had procedural headache compared to three of the controls (10%). Two different types of headache related to angiography were observed: one during angiography, which was related to contrast injection, and the other occuring within 24 hours. Both headaches were more frequent in patients with a history of primary headache, but were distinctly different from the premorbid headache. Headache characteristics are described in detail. Discussion Both types of headache related to angiography did not match the ICHD-3beta criteria for angiography headache, but were similar to headaches reported in studies that were not included in the current criteria. The timing and characteristics of these headaches are discussed in the light of our and previous reports. We suggest that the present ICHD-3 beta criteria are inadequate in properly defining angiography headache and should be revised in the light of the present literature.

A Randomized Prospective Placebo-Controlled Study of Intravenous Magnesium Sulphate vs. Metoclopramide in the Management of Acute Migraine Attacks in the Emergency Department

The objective of this randomized, placebo-controlled, double-blind study was to determine the effectiveness of intravenous magnesium sulphate and intravenous metoclopramide in the treatment of acute migraine attacks in the Emergency Department when compared with placebo. Adult patients who presented to the Emergency Department with a headache that met International Headache Society (IHS) criteria for acute migraine were infused with either 10 mg of intravenous metoclopramide, 2 g of intravenous magnesium sulphate or normal saline over 10 min. At 0, 15, and 30 min, patients were asked to rate their pain on a standard visual analogue scale. At 30 min, patients were asked in a standard manner about the need for rescue medication. Adverse affects were also recorded. Patients were followed up by telephone within 24 h for any recurrence after discharge. The primary endpoint of the study was the difference in pain relief between the groups at 30 min. Of the 120 patients who met IHS criteria, seven were excluded from the study due to insufficient data. The number of patients, gender, age and initial visual analogue scale (VAS) scores were comparable between groups. Each group experienced more than a 25-mm improvement in VAS score at 30 min. However, there was no significant difference detected in the mean changes in VAS scores for pain. The rescue medication requirement was higher in the placebo group. The recurrence rate in 24 h was similar between the groups. Although patients receiving placebo required rescue medication more than the others, metoclopramide and magnesium have an analgesic effect similar to placebo in migraine attacks.

Tunable band gap in hydrogenated quasi-free-standing graphene

We show by angle-resolved photoemission spectroscopy that a tunable gap in quasi-free-standing monolayer graphene on Au can be induced by hydrogenation. The size of the gap can be controlled via hydrogen loading and reaches approximately 1.0 eV for a hydrogen coverage of 8%. The local rehybridization from sp(2) to sp(3) in the chemical bonding is observed by X-ray photoelectron spectroscopy and X-ray absorption and allows for a determination of the amount of chemisorbed hydrogen. The hydrogen induced gap formation is completely reversible by annealing without damaging the graphene. Calculations of the hydrogen loading dependent core level binding energies and the spectral function of graphene are in excellent agreement with photoemission experiments. Hydrogenation of graphene gives access to tunable electronic and optical properties and thereby provides a model system to study hydrogen storage in carbon materials.

Transcranial Doppler ultrasonographic evaluation of cerebral circulation during passive tilting in patients with Parkinson's disease

PURPOSE

To assess the effects of the tilt test on cerebral blood flow velocity (CBFV), blood pressure, and heart rate in patients with Parkinson's disease (PD) without symptomatic orthostatic dysautonomia.

METHODS

Thirty patients with idiopathic PD and 15 healthy controls were included. Mean middle cerebral artery blood flow velocity (CBFV) was recorded with transcranial Doppler sonography, while systolic (SBP), diastolic (DBP), and mean (MBP) blood pressure and heart rate were measured in the supine position and after passive tilting.

RESULTS

There was no difference in resting SBP, DBP, or MBP between patients and controls. CBFV was lower at rest in patients than in controls and dropped significantly and similarly after tilting in both groups. SBP decreased in patients during the first 5 minutes of tilting (p < 0.05), whereas it increased progressively after the first minute in controls. In patients, DBP decreased slightly and MBP dropped during the first 2 minutes, then increased. Baseline heart rate was higher in patients than in controls (p < 0.05) and increased in both groups during tilting.

CONCLUSION

Our results suggest that cardiovascular responses to tilting are delayed in PD patients and that subclinical autonomic dysfunction may be present even in the absence of symptomatic orthostatic dysautonomia.

Orthostatic heart rate variability analysis in idiopathic Parkinson's disease

OBJECTIVES

We evaluated time and spectral analyses of 24-h heart rate variability (HRV) and the heart rate responses to passive tilt in patients with idiopathic Parkinson's disease (IPD) in order to investigate cardiovascular autonomic functions.

MATERIAL AND METHODS

Twenty-three subjects with IPD without autonomic symptoms and 15 age-matched healthy controls were enrolled. Frequency- and time-domain HRV parameters were studied during resting and passive head-up tilt (HUT) test.

RESULTS

All time-domain parameters were found to be low in patients with IPD. In patients with IPD, both low frequency (LF) and high frequency (HF) decreased during HUT period and no significant change in LF to HF ratio was noted. Both time- and frequency-domain HRV indices showed no correlation with age, disease severity and duration, and with l-dopa medication.

CONCLUSION

The results indicate that impairment of autonomic nervous system function in IPD without autonomic symptoms is frequent, and does not show clear association with clinical stage and the age of the patients.

Factors affecting one year mortality and functional outcome after first ever ischemic stroke in the region of Antalya, Turkey (a hospital-based study)

In order to establish good health politics for stroke survivors, regional differences in factors affecting the outcome of patients have to be known. For this purpose we investigated factors affecting 1 year mortality and functional outcome in patients with first-ever-in a lifetime stroke in the region of Antalya, Turkey. One-hundred and forty-seven patients with a first ever stroke were included and followed up for at least one year. The modified Rankin Scale was used for evaluation of handicap. Several factors known to affect prognosis such as demographic features, socioeconomic status, stroke subtype, neurological findings and stroke risk factors were compared between patients who died during follow-up and survivors. Of the 147 patients 35 (23.8%) died during the course of the study. Multivariate logistic regression analysis showed that only illiteracy, being single or widowed and presence of urinary incontinence were significant predictors of being dead at the end of 1 year. In the survivors factors independently affecting dependence at the end of one year were age, presence of coma on admission and urinary incontinence. Our results suggest that not only stroke severity but also socioeconomic variables are important in determining the prognosis of stroke patients.

Validity and Reliability of the Turkish Migraine Disability Assessment (MIDAS) Questionnaire

OBJECTIVES

The aim of this study is to assess the comprehensibility, internal consistency, patient-physician reliability, test-retest reliability, and validity of Turkish version of Migraine Disability Assessment (MIDAS) questionnaire in patients with headache.

BACKGROUND

MIDAS questionnaire has been developed by Stewart et al and shown to be reliable and valid to determine the degree of disability caused by migraine.

DESIGN AND METHODS

This study was designed as a national multicenter study to demonstrate the reliability and validity of Turkish version of MIDAS questionnaire. Patients applying to 17 Neurology Clinics in Turkey were evaluated at the baseline (visit 1), week 4 (visit 2), and week 12 (visit 3) visits in terms of disease severity and comprehensibility, internal consistency, test-retest reliability, and validity of MIDAS. Since the severity of the disease has been found to change significantly at visit 2 compared to visit 1, test-retest reliability was assessed using the MIDAS scores of a subgroup of patients whose disease severity remained unchanged (up to +/-3 days difference in the number of days with headache between visits 1 and 2).

RESULTS

A total of 306 patients (86.2% female, mean age: 35.0 +/- 9.8 years) were enrolled into the study. A total of 65.7%, 77.5%, 82.0% of patients reported that "they had fully understood the MIDAS questionnaire" in visits 1, 2, and 3, respectively. A highly positive correlation was found between physician and patient and the applied total MIDAS scores in all three visits (Spearman correlation coefficients were R= 0.87, 0.83, and 0.90, respectively, P <.001). Internal consistency of MIDAS was assessed using Cronbach's alpha and was found at acceptable (>0.7) or excellent (>0.8) levels in both patient and physician applied MIDAS scores, respectively. Total MIDAS score showed good test-retest reliability (R= 0.68). Both the number of days with headache and the total MIDAS scores were positively correlated at all visits with correlation coefficients between 0.47 and 0.63. There was also a moderate degree of correlation (R= 0.54) between the total MIDAS score at week 12 and the number of days with headache at visit 2 + visit 3, which quantify headache-related disability over a 3-month period similar to MIDAS questionnaire.

CONCLUSION

These findings demonstrated that the Turkish translation is equivalent to the English version of MIDAS in terms of internal consistency, test-retest reliability, and validity. Physicians can reliably use the Turkish translation of the MIDAS questionnaire in defining the severity of illness and its treatment strategy when applied as a self-administered report by migraine patients themselves.

Prolonged hyperglycemia in the early subacute period after cerebral infarction: effects on short term prognosis

Although the adverse effect of admission hyperglycemia in cerebral infarction on prognosis is well known, studies generally have not questioned the effect of hyperglycemia in the early subacute period on prognosis after a stroke. Forty-six patients with acute ischemic stroke were seperated into 3 groups: Group 1) Known diabetes or admission blood glucose (ABG) > or = 140 mg/dl and HbA1c > or = 8,0%); Group 2) ABG > or = 140 mg/dl and HbA1c < 8,0%; and Group 3) ABG < 140 mg/dl and HbA1c < 8,0%. Blood glucose was followed-up 4 times a day for 10 days after the stroke and the mean of these measurements was calculated as the mean of glycemic regulation (MGR). Neurological evaluation was done at presentation and on day 10 and 30 with the National Institute of Health (NIH) scale. Oedema, lesion size and presence of hemorrhagic transformation were evaluated using CT. The MGR was significantly higher in group 1 compared to the other two groups (p < 0,001 and p < 0,01) and in group 2 compared to group 3 (p < 0,001). Patients with clinical worsening had a significantly higher MGR (p < 0,05). Patients with marked cerebral edema had a significantly higher MGR (p < 0,01) compared to patients with lesser edema. No correlation was found between MGR and lesion size or hemorrhagic transformation. Our results show that hyperglycemia in the early subacute period after cerebral infarction is associated with more pronounced cerebral edema and has an adverse effect on short term prognosis. We suggest that studies investigating the effect of insulin infusion on stroke prognosis should also consider infusions for a longer period than 24 hours.

Brain death and donor management in the intensive care unit: experiences over the last 3 years

We sought to examine the frequency of brain death in the ICU, the donation rate, and the problems encountered during donor management between the years of January 2000, the date we began treating patients with neurologic pathologies and traumatic brain injury, and March 2003. Between January 2000 and March 2003, 134 patients diagnosed with brain death in our ICU were studied prospectively for the reason of brain death, the time between admission to ICU, and the diagnosis of brain death, the frequency of diabetes insipidus, the inotrope requirement, hypothermia, electrolyte imbalance, arrhythmia, and cardiac arrest. Among the approximately 2600 patients admitted to the general 24-bed ICU, 940 had cerebral injuries. In this group, the mortality rate was 33.5% (315 out of 940 patients) including brain-dead patients. Donor care was performed in 94 patients with organs suitable for transplantation out of 134 brain-dead patients. Fifty (53.2%) out of 94 patients became organ donors. The donor ratio was 12 per million-population per year as a mean value of the study period, which was approximately 10 times higher than the average ratio in Turkey. Although we observed many life-threatening problems during donor management, none of these patients died or had acute organ dysfunction.

Effect of donepezil on EEG spectral analysis in Alzheimer's disease

EEG spectral analysis allows a quantitative analysis of changes in the frequency bands during disease progression in Alzheimer's disease (AD) and could be used to monitor treatment and disease progression. Eighteen patients with probable AD were evaluated by Folstein Mini Mental State Examination (MMSE) and EEG spectral analysis before donepezil treatment, 2 months after 5 mg/day and 4 months after the dose was raised to 10 mg/day. EEG evaluations were done in 4 derivations (T3-T5, T4-T6, C3-P3, C4-P4). Six months after treatment there was a significant reduction in the temporal delta amplitudes and an increase in the amplitudes of all the other frequency ranges including theta amplitudes both in the temporal and centroparietal derivations. MMSE scores increased during treatment but the change was not significant. These findings show that donepezil exerts a positive effect on EEG in AD by decreasing delta activity and increasing alpha and beta activity. The increase in theta activity after treatment may reflect a therapeutic shift of delta activity to theta activity.

Normalization of high interictal cerebrovascular reactivity in migraine without aura by treatment with flunarizine

BACKGROUND

Modification of migraine-associated cerebrovascular reactivity may provide insight into the mechanism of action of a given therapeutic intervention.

METHODS

With transcranial Doppler and a breath-holding index, cerebrovascular reactivity to hypercapnia was evaluated in 20 patients with migraine without aura interictally and in 11 healthy controls. Patients were started on prophylactic treatment with flunarizine 10 mg per day, and measurements were repeated at the end of every month for 3 months. Headache status was evaluated clinically via a headache index. Headache index; breath-holding index; systolic, diastolic, and mean blood flow velocities; and pulsatility index measurements were recorded at every session.

RESULTS

The baseline breath-holding index was significantly higher in the migraine group compared to the control group (P =.002). No difference in other parameters was found between the groups. The change in the headache index was significant (P<.001), indicating a beneficial effect from flunarizine. The breath-holding index improved significantly after treatment (P<.001), and the baseline difference in the breath-holding index between the pretreatment migraine group and the control group was no longer evident at 3 months. There was no significant change with treatment in the other transcranial Doppler parameters.

CONCLUSIONS

Our finding of unchanged blood flow velocities but normalized cerebrovascular reactivity after treatment suggests that the mechanism of action of flunarizine in migraine does not involve a vasodilatory effect on cerebral vessels. It may be instead that flunarizine modifies cerebrovascular reactivity through its action on centrally located structures that subserve autonomic vascular control.

Exaggerated interictal cerebrovascular reactivity but normal blood flow velocities in migraine without aura

Interictal cerebrovascular reactivity and blood flow velocities were tested in 23 patients with migraine without aura and 10 age- and sex-matched healthy controls by using the breath holding index (BHI). The mean systolic, diastolic and mean velocities and pulsatility indices were not different in the controls and patients. The BHI was found to be significantly greater (P=0011) in the patients (1.64 +/- 0.33) compared with the controls (1.26 +/- 0.37), showing an exaggerated reactivity to hypercapnia in migraineurs. Reactivity to pCO2 theoretically depends on pre-existing arteriolar tone and thereby on baseline velocity. Our finding of similar blood flow velocities in controls and patients suggests that the underlying cause for this high reactivity may not be an increased vasotonus but an increased sensitivity to changes in blood CO2 levels.

Visual evoked potentials in Parkinson's disease-correlation with clinical involvement

A total of 18 patients with Parkinson's disease were evaluated clinically and by transient checker-board VEP study. There were significant differences between bradykinesia (P<0.01), rigidity (P<0.02), and tremor (P<0.05) subscores of the more and less severely affected sides. There were no asymmetry of VEP latency or amplitude between the more and less severely affected sides by stimulation of the corresponding eye. There were no significant correlations between the VEP latency or amplitude and any of the clinical features except the bradykinesia scores. The bradykinesia scores on the more severely involved side (r: 0.57; P=0.014) and less severely involved side (r: 0.82; P=0.00003) showed medium to high degree positive correlations with VEP amplitudes by stimulation of the corresponding eye. By studying monocular fullfield responses our data can only suggest that there is no prechiasmal asymmetry. The positive correlation between the VEP amplitude and bradykinesia score might indicate that D2 receptors dominate in the retina.

The 'dry-needle technique': intramuscular stimulation in tension-type headache

The 'dry-needle technique', an intramuscular stimulation technique carried out by using a fine solid, 1-inch long, 30-gauge needle, was investigated in the treatment of tension-type headache (TTH) in a randomized, placebo-controlled trial. Fifteen patients with TTH received intramuscular needle insertions into six designated trigger points, while 15 controls received subcutaneous insertions. Headache indices, muscle tenderness and neck ROMs were evaluated before and after treatment. Mean headache indices improved significantly after treatment, both in the treatment group and in the placebo group, but the difference between the two groups was insignificant. In the treatment group the tenderness score and the neck ROM limitation score were significantly improved after treatment, while there was no significant improvement in the placebo group. We conclude that more and larger controlled, comparative trials are needed to show whether the dry-needle technique is an effective non-pharmacological alternative for the treatment of TTH.

Efficacy of intravenous magnesium sulfate in the treatment of acute migraine attacks

OBJECTIVE

To study the efficacy and tolerability of 1 g of intravenous magnesium sulfate as acute treatment of moderate or severe migraine attacks.

BACKGROUND

Migraine is a common disorder in which not only the pain but also the accompanying symptoms such as nausea and vomiting reduce activity and productivity of sufferers. Many drugs used for the treatment of acute migraine attacks have many side effects, are not well tolerated, are ineffective in some patients, or cannot be used during pregnancy or in patients with ischemic heart disease. Magnesium deficiency has been proposed to play a role in the pathophysiology of migraine, and recently treatment of migraine with magnesium has gained considerable interest.

METHODS

This was a randomized, single-blind, placebo-controlled trial including 30 patients with moderate or severe migraine attacks. Fifteen patients received 1 g intravenous magnesium sulfate given over 15 minutes. The next 15 patients received 10 mL of 0.9% saline intravenously. Those in the placebo group with persisting complaints of pain or nausea and vomiting after 30 minutes also received 1 g magnesium sulfate intravenously over 15 minutes. The patients were assessed immediately after treatment, and then 30 minutes and 2 hours later. Intensity of pain, accompanying symptoms, and side effects were noted.

RESULTS

All patients in the treatment group responded to treatment with magnesium sulfate. The pain disappeared in 13 patients (86.6%); it was diminished in 2 patients (13.4%); and in all 15 patients (100%), accompanying symptoms disappeared. In the placebo group, a decrease in pain severity but persisting nausea, irritability, and photophobia were noted in 1 patient (6.6%). Accompanying symptoms disappeared in 3 patients (20%) 30 minutes after placebo administration. All patients initially receiving placebo were subsequently given magnesium sulfate. All of these patients responded to magnesium sulfate. In 14 patients (93.3%), the attack ended; in 1 patient (6.6%), pain intensity decreased; and in all 15 patients (100%), accompanying symptoms disappeared. Both the response rate (100% for magnesium sulfate and 7% for placebo) and the pain-free rate (87% for magnesium sulfate and 0% for placebo) showed that magnesium sulfate was superior to placebo. Twenty-six patients (86.6%) had mild side effects which did not necessitate discontinuing treatment during magnesium sulfate administration.

CONCLUSION

Our results show that 1 g intravenous magnesium sulfate is an efficient, safe, and well-tolerated drug in the treatment of migraine attacks. It is possible that magnesium sulfate could be used in a broader spectrum of patients than other drugs commonly used for attack treatment. In view of these results, the effect of magnesium sulfate in acute migraine should be examined in large-scale studies.