1
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Maresca L, Fragale M, Petrella G, Boeris D. Management of post blood patch severe rebound intracranial hypertension by the usage of an external ventricular drain. BMJ Case Rep 2024; 17:e257743. [PMID: 38490699 PMCID: PMC10946380 DOI: 10.1136/bcr-2023-257743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2024] Open
Abstract
Spontaneous intracranial hypotension (SIH) is a condition characterised by postural headaches due to low cerebrospinal fluid (CSF) pressure, often stemming from CSF leakage. Diagnosis poses a significant challenge, and the therapeutic approach encompasses both conservative measures and operative interventions, such as the epidural blood patch (EBP). However, EBP carries the potential risk of inducing rebound intracranial hypertension (RIH), subsequently leading to high-pressure headaches. We present a case wherein RIH following EBP was effectively managed through the implementation of an external ventricular drain (EVD) aimed at reducing CSF pressure. The patient improved significantly, underscoring the potential utility, if not necessity, of EVD in carefully selected cases, highlighting the imperative for further research to enhance the management of SIH and optimise EBP-related complications.
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Affiliation(s)
- Leonardo Maresca
- Neurosurgery, ASST Grande Ospedale Metropolitano Niguarda, Milano, Lombardia, Italy
| | - Maria Fragale
- Neurosurgery, ASST Grande Ospedale Metropolitano Niguarda, Milano, Lombardia, Italy
- Neurosurgery, University of Rome La Sapienza, Rome, Lazio, Italy
| | - Giacomo Petrella
- Neurosurgery, ASST Grande Ospedale Metropolitano Niguarda, Milano, Lombardia, Italy
| | - Davide Boeris
- Neurosurgery, ASST Grande Ospedale Metropolitano Niguarda, Milano, Lombardia, Italy
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2
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Rampuria A, Mathew T, Honnali Ravindranath A. Triad of cluster-like headaches, hypertension and hypercoagulability a pointer to pheochromocytoma. BMJ Case Rep 2024; 17:e257899. [PMID: 38320821 PMCID: PMC10859995 DOI: 10.1136/bcr-2023-257899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024] Open
Abstract
We report the case of a middle-aged hypertensive woman presenting to the neurology department with short-lasting episodic headaches for 4 years. She was initially diagnosed and treated with cluster headaches for one year. Following this, she presented with right lower limb arterial claudication. Arterial Doppler of lower limbs showed thrombosis of the bilateral common femoral arteries. Further computed tomography (CT) angiogram of the lower limbs confirmed extensive arterial thrombosis in bilateral lower limbs. The CT angiogram incidentally detected a left adrenal lesion. She had elevated urinary vanillylmandelic Acid and 24-hour metanephrines suggesting the presence of a pheochromocytoma. She was initially medically managed and later underwent left open adrenalectomy. Histopathology examination of the sections proved pheochromocytoma. Postsurgery, the patient's symptoms improved remarkably. This case highlights the importance of diagnosing pheochromocytoma when you encounter a patient with refractory short-lasting headaches, hypertension and hypercoagulability.
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Affiliation(s)
- Archana Rampuria
- Dept of Medicine, St John's National Academy of Health Sciences, Bangalore, Karnataka, India
| | - Thomas Mathew
- Dept of Neurology, St John's National Academy of Health Sciences, Bangalore, Karnataka, India
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3
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Ortega A, Damodaran O, Tan IYL, Silsby M. Bilateral trigeminal neuralgia due to bilaterally duplicated superior cerebellar arteries. BMJ Case Rep 2024; 17:e258818. [PMID: 38238165 PMCID: PMC10806915 DOI: 10.1136/bcr-2023-258818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024] Open
Affiliation(s)
- Alexandra Ortega
- Westmead Clinical School, The University of Sydney Faculty of Medicine and Health, Camperdown, New South Wales, Australia
| | - Omprakash Damodaran
- Neurosurgery Department, Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Irene Yew Lan Tan
- Radiology Department, Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Matthew Silsby
- Westmead Clinical School, The University of Sydney Faculty of Medicine and Health, Camperdown, New South Wales, Australia
- Neurology Department, Westmead Hospital, Westmead, New South Wales, Australia
- Neurology Department, Concord Repatriation General Hospital, Concord, New South Wales, Australia
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4
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Prakash S, Patel H, Shah CS. Medication-overuse headache overlapping with serotonin syndrome. BMJ Case Rep 2024; 17:e256464. [PMID: 38176752 PMCID: PMC10773342 DOI: 10.1136/bcr-2023-256464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024] Open
Abstract
Serotonin syndrome (SS) is an iatrogenic, drug-induced clinical syndrome caused by an increase in the intrasynaptic concentration of serotonin. Serotonin plays a significant role in the pathophysiology of migraines. Upregulation of 5-HT2A receptors is found in medication-overuse headache (MOH). Several migraine medications, both preventative and abortive drugs, act on serotonin receptors. We report two patients with chronic migraine who developed MOH. Besides headache, patients had frequent attacks of dizziness, restlessness, irritability, insomnia, excessive sweating, abdominal discomforts and tremors. These symptoms were suggestive of withdrawal headache. However, on physical examinations, we elicited hyperreflexia, hypertonia, clonus, tachycardia, hypertension, mydriasis and hyperactive bowel sound. Both patients also met the criteria for SS. Cyproheptadine was started. All features, including headaches, got better after cyproheptadine administration within 24 hours. In 7 days, there was practically total improvement. Both patients continued to take cyproheptadine as a preventative medicine, and migraine frequency was under control.
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Affiliation(s)
- Sanjay Prakash
- Neurolgy, SBKS Medical Institute and Research Centre, Sumandeep Vidyapeeth, Vadodara, Gujarat, India
| | - Harsh Patel
- Neurolgy, SBKS Medical Institute and Research Centre, Sumandeep Vidyapeeth, Vadodara, Gujarat, India
| | - Chetsi Sudhir Shah
- Neurolgy, SBKS Medical Institute and Research Centre, Sumandeep Vidyapeeth, Vadodara, Gujarat, India
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5
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Elmståhl A, Buchwald F, Ilinca A. Varicella-zoster virus vasculopathy in a patient with multiple sclerosis receiving natalizumab. BMJ Case Rep 2023; 16:e254114. [PMID: 38081745 PMCID: PMC10729061 DOI: 10.1136/bcr-2022-254114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2023] [Indexed: 12/18/2023] Open
Abstract
We present a case of a woman in her 30s with relapsing-remitting multiple sclerosis, treated with natalizumab, who developed ophthalmic varicella zoster virus (VZV) infection, with subsequent vasculopathy causing cerebral ischaemic lesions. She was treated with acyclovir, prednisolone and acetylsalicylic acid and fully recovered. VZV vasculopathy is associated with stroke and immunomodulating treatments may increase the risks of these adverse events. To date, nine VZV-related vasculopathy cases in patients treated with natalizumab have been reported in English literature and are summarised in this paper. Although rare, VZV intracerebral vasculopathy is an important differential diagnosis in patients with unexplained new-onset neurological symptoms after a herpes zoster infection. Treatment guidelines for VZV vasculopathy and for continuing treatment of multiple sclerosis after such an event are currently not established.
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Affiliation(s)
- Anna Elmståhl
- Department of Neurology, Skåne University Hospital, Malmö, Sweden
| | - Fredrik Buchwald
- Department of Neurology, Skåne University Hospital, Division of Neurology, Department for Clinical Sciences, Lund University, Malmö, Sweden
| | - Andreea Ilinca
- Department of Neurology, Skåne University Hospital, Division of Neurology, Department for Clinical Sciences, Lund University, Malmö, Sweden
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6
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Lin SZZ, Lizwan M, Tan MB, Sonu SK. Case of infiltrative optic neuropathy with hypertrophic pachymeningitis as a manifestation of en plaque meningioma. BMJ Case Rep 2023; 16:e257046. [PMID: 38081732 PMCID: PMC10728933 DOI: 10.1136/bcr-2023-257046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023] Open
Abstract
We describe a case of infiltrative optic neuropathy with hypertrophic pachymeningitis noted on MRI of the brain, presenting a diagnostic dilemma with a wide variety of differential diagnoses to consider. Our patient is a middle-aged woman with a 20-year history of migranous-sounding headaches who was incidentally found to have worsening vision in her left eye during a routine driving test visual acuity check. Neurological examination revealed a left grade III relative afferent pupillary defect and a central scotoma with red desaturation. Subsequent MRI of her brain and anterior visual pathway revealed features suggestive of an infiltrative left optic neuropathy with hypertrophic pachymeningitis. An extended workup including diagnostic lumbar puncture and blood tests for possible autoimmune, infective and neoplastic causes proved unyielding. Eventually, an endoscopic transsphenoidal biopsy helped to clinch the diagnosis of a (meningothelial subtype) WHO grade 1 meningioma as the cause of her clinical and radiological presentation.
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Affiliation(s)
- Shawn Zhi Zheng Lin
- Neurology, National Neuroscience Institute - Singapore General Hospital Campus, Singapore
| | | | - Mark Bangwei Tan
- Department of Diagnostic Radiology, Singapore General Hospital, Singapore
| | - Sumit Kumar Sonu
- Neurology, National Neuroscience Institute - Singapore General Hospital Campus, Singapore
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7
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Moreno-Cortez KM, Chujfi-Zamora M, Reyes-Vaca JG, Rodriguez-Leyva I. Facial pain associated with vein of Trolard thrombosis Case report Neurology. BMJ Case Rep 2023; 16:e256545. [PMID: 37973537 PMCID: PMC10661060 DOI: 10.1136/bcr-2023-256545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023] Open
Abstract
Cerebral venous thrombosis is a rare condition, with identified and described risk factors mainly associated with prothrombotic states, with a wide variety of symptomatology based on the site affected, the most common being intracranial hypertensive syndrome, focal or encephalopathy. Cortical veins of the superficial system are among the least frequently affected veins. The following describes a case of painful facial symptoms progressing to a focal syndrome associated with a history of chronic oral contraceptive use, with thrombosis of vein of Trolard detected and successfully treated with oral anticoagulants.
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Affiliation(s)
- Katia Mabiael Moreno-Cortez
- Neurology, Hospital Central Dr Ignacio Morones Prieto, San Luis Potosi, Mexico
- Neurology Service, Facultad de Medicina, Universidad Autonoma de San Luis Potosi, San Luis Potosi, Mexico
| | - Manir Chujfi-Zamora
- Neurology, Hospital Central Dr Ignacio Morones Prieto, San Luis Potosi, Mexico
- Neurology Service, Facultad de Medicina, Universidad Autonoma de San Luis Potosi, San Luis Potosi, Mexico
| | - Jorge Guillermo Reyes-Vaca
- Neurology Service, Facultad de Medicina, Universidad Autonoma de San Luis Potosi, San Luis Potosi, Mexico
- Radiology and Image, Hospital Central Dr Ignacio Morones Prieto, San Luis Potosi, Mexico
| | - Ildefonso Rodriguez-Leyva
- Neurology, Hospital Central Dr Ignacio Morones Prieto, San Luis Potosi, Mexico
- Neurology Service, Facultad de Medicina, Universidad Autonoma de San Luis Potosi, San Luis Potosi, Mexico
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8
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Singh DK, Kumar Sharma P, Singh N, Chand V. Intraventricular migration of fourth ventricular neurocysticercosis: an unusual complication during endoscopic surgery. BMJ Case Rep 2023; 16:e255813. [PMID: 37399344 DOI: 10.1136/bcr-2023-255813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2023] Open
Abstract
A boy in his middle childhood presented with intermittent episodes of headache with vomiting for 6 months. Plain CT of the head and MRI of the brain revealed fourth ventricular cysticercal cyst with acute obstructive hydrocephalus. Endoscopic excision of the cyst was done along with endoscopic third ventriculostomy and septostomy with external ventricular drain placement. Although we were able to decompress the cysticercal cyst, unfortunately, the cyst got slipped from the grasper leaving the grasped cyst wall in the tooth of the grasper. Through this case report, we want to highlight that such a complication could also happen during neuroendoscopic cysticercal cyst removal and how we dealt with it. Our patient was discharged neurologically intact and was symptom free on follow-up.
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Affiliation(s)
- Deepak Kumar Singh
- Neurosurgery, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Prevesh Kumar Sharma
- Neurosurgery, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Neha Singh
- Radiodiagnosis and Imaging, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Vipin Chand
- Neurosurgery, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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9
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Yoshimura Y, Kanda-Kikuchi J, Hara T, Sugimoto I. Idiopathic hypertrophic pachymeningitis in a patient with a history of diffuse large B cell lymphoma. BMJ Case Rep 2023; 16:e254847. [PMID: 37316284 DOI: 10.1136/bcr-2023-254847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023] Open
Abstract
A man in his early 70s with a 4-year history of diffuse large B cell lymphoma (DLBCL) was admitted to our hospital with diplopia and achromatopsia. Neurological examination revealed visual impairment, ocular motility disorder and diplopia on looking to the left. Blood and cerebrospinal fluid investigations showed no significant findings. MRI revealed diffusely thickened dura mater and contrast-enhanced structures in the left apical orbit, consistent with hypertrophic pachymeningitis (HP). We performed an open dural biopsy to distinguish the diagnosis from lymphoma. The pathological diagnosis was idiopathic HP, and DLBCL recurrence was ruled out. Following methylprednisolone pulse and oral prednisolone therapy, his neurological abnormalities gradually receded. Open dural biopsy played an important role not only in diagnosing idiopathic HP but also in relieving the pressure on the optic nerve.
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Affiliation(s)
- Yusuke Yoshimura
- Department of Neurology, Toranomon Hospital Kajigaya, Kawasaki, Kanagawa, Japan
| | - Junko Kanda-Kikuchi
- Department of Neurology, Toranomon Hospital Kajigaya, Kawasaki, Kanagawa, Japan
| | - Takayuki Hara
- Department of Neurosurgery, Toranomon Hospital, Minato-ku, Tokyo, Japan
| | - Izumi Sugimoto
- Department of Neurology, Toranomon Hospital Kajigaya, Kawasaki, Kanagawa, Japan
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10
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Huang S, Williams C, Thomas J, Khalil N, Wenderoth J, Parsons M. 'Diagnostic anchoring' and a delayed diagnosis of reversible cerebral vasoconstriction syndrome. BMJ Case Rep 2023; 16:16/5/e252540. [PMID: 37188490 DOI: 10.1136/bcr-2022-252540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
We present a case of a woman in her 60s with acute left hemispheric ischaemic stroke syndrome due to tandem occlusions of the proximal left internal carotid artery and left middle cerebral artery. This was treated with emergent carotid artery stenting and endovascular clot retrieval. The patient made a complete recovery and was discharged home only to represent a few days later with focal neurological symptoms, profound headache and labile blood pressure. The diagnostic and management challenges of reversible cerebral vasoconstriction syndrome, including imaging assessment and the importance of avoiding 'diagnostic anchoring' are discussed.
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Affiliation(s)
- Shiwei Huang
- Department of Interventional Radiology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Cameron Williams
- Department of Interventional Radiology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - James Thomas
- Department of Neurology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Najwa Khalil
- Department of Neurology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Jason Wenderoth
- Department of Interventional Radiology, Liverpool Hospital, Liverpool, New South Wales, Australia
- Institute of Neurological Sciences, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Mark Parsons
- Department of Neurology, Liverpool Hospital, Liverpool, New South Wales, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
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11
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Sarkis Y, Worden A, Schreiber T, Lapitz A. High index of suspicion: diagnosing a carotid-cavernous fistula. BMJ Case Rep 2023; 16:16/3/e253473. [PMID: 36863755 PMCID: PMC9990649 DOI: 10.1136/bcr-2022-253473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023] Open
Abstract
A woman in her 70s presented with acute bilateral retro-orbital headache, diplopia, chemosis and eye swelling. Ophthalmology and neurology were consulted after detailed physical examination and diagnostic workup including laboratory analysis, imaging and lumbar puncture. The patient was diagnosed with non-specific orbital inflammation and was started on methylprednisolone and dorzolamide-timolol for intraocular hypertension. The patient's condition improved slightly, but a week later, she developed subconjunctival haemorrhage in the right eye, which prompted investigation for a low-flow carotid-cavernous fistula. Digital subtraction angiography showed bilateral indirect carotid-cavernous fistula (Barrow type D). The patient underwent bilateral carotid-cavernous fistula embolisation. Her swelling improved considerably on day 1 after the procedure and her diplopia improved over the following weeks.
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Affiliation(s)
- Yara Sarkis
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Astin Worden
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Torsten Schreiber
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Alvaro Lapitz
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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12
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Engel ER, Ham JA. Amelioration of trichotillomania with onabotulinumtoxinA for chronic migraine. BMJ Case Rep 2023; 16:16/2/e254006. [PMID: 36731940 PMCID: PMC9896224 DOI: 10.1136/bcr-2022-254006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
We report a case of a woman in her 30s who struggled with a life-long history of trichotillomania (TTM; hair-pulling disorder), which was unsuccessfully treated with behavioural therapy and selective serotonin reuptake inhibitors. In addition to TTM, our patient had a history of chronic migraine which brought her to our clinic, and treatment with onabotulinumtoxinA (OBTA) was initiated per the Phase III REsearch Evaluating Migraine Prophylaxis Therapy protocol. After experiencing improvement with migraine symptoms, she began off-label treatment with OBTA for her TTM with 45 units being injected, 5 units per site, in diffuse regions of her scalp, primarily on the affected areas of TTM-induced alopecia. The patient reported marked improvement in her TTM signs and symptoms, which resulted in hair regrowth as early as the first follow-up visit 12 weeks post-treatment initiation. Treatment effects were maintained, and additional hair regrowth was observed at the 1-year post-treatment visit, which equated to four cycles of treatment.
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Affiliation(s)
| | - Jeremy-Ann Ham
- Department of Medicine, Scripps Green Hospital, La Jolla, California, USA
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13
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Todd CM, Yu A, Lay C, Lagman-Bartolome AM. Effect of testosterone therapy on migraine frequency and disability in two transgender patients: a case report. BMJ Case Rep 2023; 16:16/1/e251895. [PMID: 36693705 PMCID: PMC9884870 DOI: 10.1136/bcr-2022-251895] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
With an increasing number of patients seeking gender-affirming hormone therapy (GAHT), the clinical impact of testosterone treatments on headache needs to be determined. Our case report looks at the potential effect of testosterone on migraine among transgender patients. We present two transmasculine patients who used masculinising hormone therapy with testosterone. Both patients described their headache as moderate-to-severe pain with features that fulfilled the criteria for chronic migraine without aura. Following GAHT, one patient improved in both frequency and intensity of headache symptoms while the other noted improvement in headache intensity alone. Our report postulates that testosterone therapy may have a positive impact on headaches in individuals participating in GAHT, highlighting the need for further research on the role of testosterone therapy on headache in transmasculine individuals.
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Affiliation(s)
- Candice Marie Todd
- Centre for Headache, Women's College Hospital, Toronto, Ontario, Canada .,Division of Neurology, Adult Neurology Fellowship Program, University of Toronto, Toronto, Ontario, Canada
| | - Amy Yu
- Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Christine Lay
- Centre for Headache, Women's College Hospital, Toronto, Ontario, Canada
| | - Ana Marissa Lagman-Bartolome
- Centre for Headache, Women's College Hospital, Toronto, Ontario, Canada.,Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
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14
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Maldar SB, Pinto CJ. Homozygous familial hypercholesterolaemia in a patient presenting with hypertensive encephalopathy. BMJ Case Rep 2022; 15:15/10/e250265. [PMID: 36316049 PMCID: PMC9628547 DOI: 10.1136/bcr-2022-250265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Homozygous familial hypercholesterolaemia (HoFH) is a disorder affecting low-density lipoprotein (LDL) receptor genes. Patients typically have a triad of elevated LDL-cholesterol (LDL-C), xanthomatosis and premature atherosclerotic cardiovascular disease. Our patient, a preteen boy, presented with signs of hypertensive encephalopathy. Physical examination showed arcus cornealis, planar xanthomas and tuberous xanthomas. After appropriate investigations, a direct aetiology of the hypertension could not be elucidated; however, our patient's hypertension resolved with the reduction in serum lipid levels. β-hydroxy β-methylglutaryl coenzyme A reductase and cholesterol absorption inhibitors were administered as first-line treatment. A significant proportion of patients with HoFH continue to have elevated LDL-C levels, thereby requiring second-line agents, such as proprotein convertase subtilisin/kexin type inhibitors (evolocumab), microsomal triglyceride transfer protein inhibitors (lomitapide) and angiopoietin-like protein inhibitors (evinacumab). This case report aimed to raise awareness among paediatricians to consider HoFH as a possible aetiology in a child presenting with hypertension and suggestive physical findings.
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Affiliation(s)
- Shadab B Maldar
- Department of Pediatric Medicine, Karnataka Institute of Medical Sciences, Hubballi, Karnataka, India
| | - Christopher Jude Pinto
- Department of Internal Medicine, Karnataka Institute of Medical Sciences, Hubballi, Karnataka, India
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15
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Masaad D, Youssef S, Safadi MF, Shehadeh Agha M. MRI-negative myelitis associated with cerebral venous thrombosis after COVID-19 infection. BMJ Case Rep 2022; 15:15/10/e250535. [PMID: 36307141 PMCID: PMC9621158 DOI: 10.1136/bcr-2022-250535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Transverse myelitis and cerebral venous thrombosis represent some of the described neurological complications of coronavirus disease. A woman in her early 30s presented with headache, left-sided sensory symptoms and voiding difficulty. The patient also reported dry cough, fever, nasal congestion, anosmia and ageusia 2 weeks before presentation. The clinical examination showed sensory disturbances on the left side of the body, starting from the lower abdomen and extending to the left leg, which was consistent with transverse myelitis. The laboratory assessment confirmed a previous infection with coronavirus disease and excluded autoimmune entities. Radiological investigations revealed left transverse sinus thrombosis with no spinal cord abnormalities. The treatment was started with therapeutic anticoagulation and intravenous high-dose steroids. The patient showed significant improvement, and the neurological deficits resolved after 3 months. This is the first documented case of imaging-negative myelitis associated with cerebral venous thrombosis after coronavirus disease.
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Affiliation(s)
- Dea Masaad
- Department of Neurology, Al-Mouwasat Hospital, Damascus, Syrian Arab Republic
| | | | - Mhd Firas Safadi
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Dresden, Sachsen, Germany
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16
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Rivas Ruvalcaba F, Moreno-Cortez KM, Badial-Ochoa S, Rodriguez-Leyva I. Optic ataxia in a patient with HaNDL syndrome. BMJ Case Rep 2022; 15:15/10/e252055. [PMID: 36192033 PMCID: PMC9535137 DOI: 10.1136/bcr-2022-252055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
We present a woman in her 40s who arrived at the emergency room with hypertension and optic ataxia. Her medical history is only relevant for obesity. Her lumbar puncture revealed high intracranial pressure and lymphocytic pleocytosis, and her neuroimaging tests, including angiography and venography, were normal. The patient improved after a cerebrospinal fluid drainage with a lumbar puncture, and her clinical manifestations resolved in parallel to the lymphocytic pleocytosis.The patient was diagnosed with a syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis and fully recovered 21 days after her discharge.
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Affiliation(s)
- Francisco Rivas Ruvalcaba
- Neurology Department, Hospital Central Dr Ignacio Morones Prieto, San Luis Potosi, Mexico.,Neurology Department of the Facultad de Medicina, Universidad Autonoma de San Luis Potosi, San Luis Potosi, Mexico
| | - Katia Mabiel Moreno-Cortez
- Neurology Department, Hospital Central Dr Ignacio Morones Prieto, San Luis Potosi, Mexico.,Neurology Department of the Facultad de Medicina, Universidad Autonoma de San Luis Potosi, San Luis Potosi, Mexico
| | - Sandra Badial-Ochoa
- Neurology Department, Hospital Central Dr Ignacio Morones Prieto, San Luis Potosi, Mexico.,Neurology Department of the Facultad de Medicina, Universidad Autonoma de San Luis Potosi, San Luis Potosi, Mexico
| | - Ildefonso Rodriguez-Leyva
- Neurology Department, Hospital Central Dr Ignacio Morones Prieto, San Luis Potosi, Mexico .,Neurology Department of the Facultad de Medicina, Universidad Autonoma de San Luis Potosi, San Luis Potosi, Mexico
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Siripurapu G, Pandit AK, Radhakrishnan DM, Srivastava AK. Case of spontaneous intracranial hypotension: clinical, neuroimaging and treatment approach. BMJ Case Rep 2022; 15:e245222. [PMID: 35537766 PMCID: PMC9092134 DOI: 10.1136/bcr-2021-245222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2022] [Indexed: 11/03/2022] Open
Abstract
A woman in her 40s presented with a 3-month history of intermittent bilateral daily headache of moderate intensity. She had severe headaches for almost 1 month prior to the presentation, which was aggravated by standing and relieved by lying down. She underwent a non-contrast CT of the head followed by MRI of the brain and spine. Neuroimaging of the brain showed features of intracranial hypotension and spine MRI myelography fast imaging employing steady state acquisition sequences confirmed the site of cerebrospinal fluid (CSF) leak. An epidural blood patch (EBP) was placed to close the CSF leakage site. She had significant improvement in her symptoms and repeat MRI at 4 weeks of follow-up showed resolution of imaging abnormalities. She became symptom-free without the requirement of additional EBP. Our report highlights the importance of suspecting and evaluating spontaneous intracranial hypotension in a patient presented with a typical orthostatic headache. Early intervention and keeping a low threshold for evaluation based on a few early clinical and imaging clues can lead to successful management of such cases.
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Cavasin N, Gava UA, Magrini S, Cagliari E. Treatment of a ruptured fetal-type posterior communicating aneurysm with a combined approach using the new contour neurovascular system. BMJ Case Rep 2022; 15:e248065. [PMID: 35440434 PMCID: PMC9020296 DOI: 10.1136/bcr-2021-248065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2022] [Indexed: 11/04/2022] Open
Abstract
Fetal-type posterior communicating artery (FPCom) aneurysms are associated with higher rates of recurrence after endovascular treatment than aneurysms at other locations. We report the case of a patient with a subarachnoid haemorrhage and ruptured right-sided FPCom aneurysm. The patient underwent acute endovascular treatment with application of a novel combined approach-partial coiling to protect the dome and occlusion of the neck with a new flow-disrupter, endosaccular device, Contour (Cerus Endovascular)-as a stable, single-step treatment to prevent rebleeding in the acute stage and long-term potential recurrences.
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Abstract
Angle closure is usually associated with older patients, as it typically manifests in middle to later life, being associated with an age-related increased lens volume. However, angle closure can occur in any age group if there is an anatomical predisposition that promotes pupillary block or an anterior pulling of the iris. During an acute angle closure, patients generally experience ocular pain, headache, nausea, vomiting and conjunctival hyperaemia. These attacks can be misinterpreted as migraine, particularly if subacute or chronic and the demographic characteristics of the patient do not suggest a primary angle closure event. Diagnosing a headache as ocular related is of paramount importance, since there is an effective treatment. We report a case of a child with intermittent headache which revealed a subacute angle closure in both eyes.
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Affiliation(s)
- Nuno Pinto Ferreira
- Department of Ophthalmology, Hospital de Santa Maria, Lisbon, Lisbon, Portugal
| | | | | | - Luis Abegão Pinto
- Visual Sciences Study Center, Faculty of Medicine of Lisbon University, Lisbon, Portugal
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