Effectiveness of dry needling for headache: A systematic review

INTRODUCTION

Non-pharmacological treatment of patients with headache, such as dry needling (DN), is associated with less morbidity and mortality and lower costs than pharmacological treatment. Some of these techniques are useful in clinical practice. The aim of this study was to review the level of evidence for DN in patients with headache.

METHODS

We performed a systematic review of randomised clinical trials on headache and DN on the PubMed, Web of Science, Scopus, and PEDro databases. Methodological quality was evaluated with the Spanish version of the PEDro scale by 2 independent reviewers.

RESULTS

Of a total of 136 studies, we selected 8 randomised clinical trials published between 1994 and 2019, including a total of 577 patients. Two studies evaluated patients with cervicogenic headache, 2 evaluated patients with tension-type headache, one study assessed patients with migraine, and the remaining 3 evaluated patients with mixed-type headache (tension-type headache/migraine). Quality ratings ranged from low (3/10) to high (7/10). The effectiveness of DN was similar to that of the other interventions. DN was associated with significant improvements in functional and sensory outcomes.

CONCLUSIONS

Dry needling should be considered for the treatment of headache, and may be applied either alone or in combination with pharmacological treatments.

Mitochondrial m.13513G>A Point Mutation in ND5 in a 16-Year-Old Man with Leber Hereditary Optic Neuropathy Detected by Next-Generation Sequencing

This article reports a Leber hereditary optic neuropathy (LHON) case associated for the first time with mitochondrial m.13513G>A mutation. We present a 16-year-old man who complained of subacute, painless, visual loss. Ocular examination showed optic nerve atrophy, papillary pseudoedema, and optic disc pallor. Extraocular manifestations included hypertrophic myocardiopathy and myopathy. Initial genetic analysis excluded the three most common LHON mutations. Sanger sequencing of the whole mitochondrial deoxyribonucleic acid showed no mutation. Next-generation sequencing (NGS) revealed m.13513G>A mutation in the NADH dehydrogenase (ND5) subunit gene ( MT-ND5 ). The m.13513G>A mutation has never been associated with LHON phenotype without Leigh/mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes features. NGS techniques should be considered when this diagnosis is strongly suspected.

Clinical impact of microbleeds in patients with Alzheimer's disease

Introduction

Cerebral microbleeds (CMBs) are more frequent in patients with Alzheimer’s disease (AD) than in the general population. However, their clinical significance remains poorly understood. We carried out a multimodal approach to evaluate the impact of CMBs at a clinical, neuropsychological, and survival level, as well as on core AD biomarkers in the cerebrospinal fluid (CSF) in AD patients.

Methods

We prospectively recruited 98 patients with mild-moderate AD. At baseline, they underwent brain MRI, and AD CSF biomarkers and APOE genotypes were analysed. An extensive neuropsychological battery was performed at baseline and after 1 year of follow-up. We analysed the stroke incidence and mortality with survival analyses.

Results

Forty-eight (48.5%) patients had at least one CMBs. Eight (8.2%) patients had strictly nonlobar CMBs, 39 (40.2%) had any lobar CMB locations. The incidence of stroke was higher in AD patients with lobar CMBs than in those without CMBs (p < 0.05). Mortality did not differ among groups (p > 0.05). At the cognitive level, CMBs patients deteriorated more rapidly at 12 months according to MMSE scores, with no differences observed at 24 months. We did not observe differences in the other tests, except for an increase in caregiver burden in the CMBs group. The presence of cerebral amyloidosis and APOE ε4 were associated with a greater presence of CMBs.

Conclusion

CMBs are associated with an increased risk of ischemic stroke in AD patients without differences in mortality. Patients with CMBs did not seem to have different consequences associated with cognitive decline except for an increase in caregiver overload.

Influence of Hospital Type on Outcomes of Patients With Acute Spontaneous Intracerebral Hemorrhage: A Population-Based Study

BACKGROUND AND OBJECTIVES

Whether the outcome of patients with spontaneous intracerebral hemorrhage (ICH) differs depending on the type of hospital where they are admitted is uncertain. The objective of this study was to determine influence of hospital type at admission (telestroke center [TSC], primary stroke center [PSC], or comprehensive stroke center [CSC]) on outcome for patients with ICH. We hypothesized that outcomes may be better for patients admitted to a CSC.

METHODS

This is a multicenter prospective observational and population-based study of a cohort of consecutively recruited patients with ICH (March 2020-March 2022). We included all patients with spontaneous ICH in Catalonia (Spain) who had a pre-ICH modified Rankin scale (mRS) score of 0-3 and who were admitted to the hospital within 24 hours of onset. We compared patients admitted to a TSC/PSC (n = 641) or a CSC (n = 1,320) and also analyzed the subgroup of patients transferred (n = 331) or not transferred (n = 310) from a TSC/PSC to a CSC. The main outcome was the 3-month mRS score obtained by blinded investigators. Outcomes were compared using adjusted ordinal logistic regression to estimate the common odds ratio (OR) and 95% CI for a shift in mRS scores. A propensity score matching (PSM) analysis was performed for the subgroup of transferred patients.

RESULTS

Relevant data were obtained from 1961 of a total of 2,230 patients, with the mean (SD) age of 70 (14.1) years, and 713 (38%) patients were women. After adjusting for confounders (age, NIH Stroke Scale score, intraventricular hemorrhage, hematoma volume, and pre-ICH mRS score), type of hospital of initial admission (CSC vs TSC/PSC) was not associated with outcome (adjusted common OR 1.13, 95% CI 0.93-1.38). A PSM analysis indicated that transfer to a CSC was not associated with more favorable outcomes (OR 0.77, 95% CI 0.55-1.10; p = 0.16).

DISCUSSION

In this population-based study, we found that, after adjusting for confounders, hospital types were not associated with functional outcomes. In addition, for patients who were transferred from a TSC/PSC to a CSC, PSM indicated that outcomes were similar to nontransferred patients. Our findings suggest that patient characteristics are more important than hospital characteristics in determining outcome after ICH.

TRIAL REGISTRATION INFORMATION

ClinicalTrials.gov Identifier: NCT03956485.

The influence of organisational management on door-to-needle times for fibrinolytic treatment

INTRODUCTION

Door-to-needle time (DNT) has been established as the main indicator in code stroke protocols. According to the 2018 guidelines of the American Heart Association/American Stroke Association, DNT should be less than 45minuts; therefore, effective and revised pre-admission and in-hospital protocols are required.

METHOD

We analysed organisational changes made between 2011 and 2019 and their influence on DNT and the clinical progression of patients treated with fibrinolysis. We collected data from our centre, stored and monitored under the Master Plan for Cerebrovascular Disease of the regional government of Catalonia. Among other measures, we analysed the differences between years and differences derived from the implementation of the Helsinki model.

RESULTS

The study included 447 patients, and we observed significant differences in DNT between different years. Pre-hospital code stroke activation, recorded in 315 cases (70.5%), reduced DNT by a median of 14minutes. However, the linear regression model only showed an inversely proportional relationship between the adoption of the Helsinki code stroke model and DNT (beta coefficient, -0.42; P<.001). The removal of vascular neurologists after the adoption of the Helsinki model increased DNT and the 90-day mortality rate.

CONCLUSION

DNT is influenced by the organisational model. In our sample, the application of the Helsinki model, the role of the lead vascular neurologist, and notification of code stroke by pre-hospital emergency services are key factors for the reduction of DNT and the clinical improvement of the patient.

WEBINO syndrome (wall-eyed bilateral internuclear ophthalmoplegia) secondary to ischemic stroke, about a case

WEBINO (wall-eyed bilateral internuclear ophthalmoplegia) syndrome is characterized by bilateral adduction impairment, nystagmus of the abducting eye, and primary gaze exotropia. We present the case of a 68 year-old man who was initially attended in emergency department with sudden onset diplopia. Neurological exploration revealed WEBINO and gait ataxia. Relevant medical history included liver transplantation and subsequent tacrolimus prescription. Complementary exams revealed ischemic lesion in mesencephalic tegmentum, involving medial longitudinal fasciculus and pretectal area. WEBINO syndrome is unfrequent. Among its etiologies, ischemic and demyelinating are the most frequent. In our case, iatrogenic etiology was also considered. Clinical recognition of this syndrome is required to perform adequate exams in order to reach diagnosis.

Factors related to in-hospital mortality in patients with refractory Status Epilepticus

BACKGROUND

Status Epilepticus (SE) is a neurological emergency characterized by prolonged or recurrent seizures without recovery between episodes. SE is associated with high morbidity and mortality, especially when it becomes refractory. SE is refractory (RSE) when it persists despite first-line and second-line antiseizure treatment. The factors related to mortality remain poorly understood.

OBJECTIVE

Our objective was to analyze the factors related to in-hospital mortality in patients with RSE at our center.

METHODS

We retrospectively reviewed patients with RSE who required hospitalization between 2019 and 2024. Patients with post-anoxic SE were excluded. Demographics, semiology, etiology and management data were obtained. We analyzed the relationship between different variables and in-hospital mortality. Variables related to mortality in the bivariate analysis were included in logistic regression analysis.

RESULTS

Ninety-four patients with suspected RSE were hospitalized. Five were excluded due to post-anoxic SE and nine were not refractory SE. Finally, 80 patients were included. The mean age was 60 (range 20-90). Forty-three (53.8%) were female. Thirty-two (40.0%) patients had previous diagnosis of epilepsy. Twenty-nine (36.3%) patients died during hospitalization. In the bivariate analysis, factors related to mortality were older age, a history of cancer and chronic kidney disease, hemodynamic instability, renal failure, electrolyte disturbances, seizure recurrence, a history of previous epilepsy, acute symptomatic etiology and Status Epilepticus Severity Score (STESS) (all p < 0.05). In multivariate analysis, age [OR 7.763 (CI 1.11-54.40)], hemodynamic instability [OR 23.41 (3.91-140.20)] and seizure recurrence [OR 20.97 (2.25-195.68)] were associated with in-hospital mortality. A past history of epilepsy was inversely related to mortality [OR 0.014 CI 95 % (0.005-0.550)]. A simple scoring system incorporating these variables predicted mortality better than STESS.

CONCLUSION

Complications during hospitalization, such as hemodynamic instability and seizure recurrence, appear to be important variables related to in-hospital mortality in patients with RSE. A previous history of epilepsy appears to be inversely related to mortality.

The influence of organisational management on door-to-needle times for fibrinolytic treatment

INTRODUCTION

Door-to-needle time (DNT) has been established as the main indicator in code stroke protocols. According to the 2018 guidelines of the American Heart Association/American Stroke Association, DNT should be less than 45minutes; therefore, effective and revised pre-admission and in-hospital protocols are required.

METHOD

We analysed organisational changes made between 2011 and 2019 and their influence on DNT and the clinical progression of patients treated with fibrinolysis. We collected data from our centre, stored and monitored under the Master Plan for Cerebrovascular Disease of the regional government of Catalonia. Among other measures, we analysed the differences between years and differences derived from the implementation of the Helsinki model.

RESULTS

The study included 447 patients, and we observed significant differences in DNT between different years. Pre-hospital code stroke activation, recorded in 315 cases (70.5%), reduced DNT by a median of 14minutes. However, the linear regression model only showed an inversely proportional relationship between the adoption of the Helsinki code stroke model and DNT (beta coefficient, -0.42; P<.001). The removal of vascular neurologists after the adoption of the Helsinki model increased DNT and the 90-day mortality rate.

CONCLUSION

DNT is influenced by the organisational model. In our sample, the application of the Helsinki model, the role of the lead vascular neurologist, and notification of code stroke by pre-hospital emergency services are key factors for the reduction of DNT and the clinical improvement of the patient.

Etiología de la parálisis del nervio hipogloso. Revisión sistemática

Introducción y objetivo: La parálisis del nervio hipogloso es una entidad poco frecuente, caracterizada por alteración del habla y problemas para tragar. En este estudio realizamos una revisión de las etiologías de dicho déficit.Método: Realizamos una búsqueda en pubmed, seleccionando aquellos artículos en los cuales se mencione la etiología de la parálisis del nervio hipogloso. Resultados: Dos son los estudios con gran número de pacientes. En primero de ellos, publicado en 1996 con 100 pacientes, la etiología más frecuente es la tumoral, seguida de los traumatismos y las lesiones isquémicas. En el segundo de ellos, del 2016, con 245 pacientes incluidos, la etiología principal es la iatrogénica postoperatoria, seguida de la tumoral y la idiopática.Discusión: Son pocos los estudios que recogen un número importante de pacientes con parálisis del nervio hipogloso. Los primeros datan de la década de los 90, en los cuales la principal etiología era la tumoral. En el último estudio, publicado en 2016, la primera causa es la iatrogénica postquirúrgica, seguida de la neoplásica y la idiopática. Con 20 años de diferencia entre los dos principales estudios existe un cambio en la etiología. El aumento de los casos postquirúrgicos puede ser debido a un aumento en el número de intervenciones, siendo a su vez más largas y agresivas, resultando llamativo, y de difícil explicación, el creciente número de casos etiquetados como idiopáticos.Conclusiones: La etiología de la parálisis del nervio hipogloso ha cambiado a lo largo de las décadas. En el siglo XX la principal etiología era la tumoral. En el siglo XXI la etiología principal es la iatrogénica postquirúrgica, encontrándose en segundo lugar la tumoral y en tercero la idiopática. Con la inclusión de 345 pacientes de los dos grandes artículos en la revisión sistemática podemos concluir que la primera causa de parálisis es la tumoral, seguida de la iatrogénica y la idiopática.

Prehospital scale to differentiate intracerebral hemorrhage from large-vessel occlusion patients: a prospective cohort study

Evaluating scales to detect large vessel occlusion (LVO) could aid in considering early referrals to a thrombectomy-capable center in the prehospital stroke code setting. Nevertheless, they entail a significant number of false positives, corresponding to intracranial hemorrhages (ICH). Our study aims to identify easily collectible variables for the development of a scale to differentiate patients with ICH from LVO. We conducted a prospective cohort study of stroke code patients between May 2021 and January 2023. Patients were evaluated with CT/CT-Angiography at arrival. We compared clinical variables and vascular risk factors between ICH and LVO patients. Out of 989 stroke code patients, we included 190 (66.7%) LVO cases and 95 (33.3) ICH cases. In the multivariate analysis, headache (odds ratio [OR] 3.56; 1.50-8.43), GCS < 8 (OR 8.19; 3.17-21.13), SBP > 160mmHg (OR 6.43; 3.37-12.26) and male sex (OR 2.07; 1.13-3.80) were associated with ICH, while previous hypercholesterolemia (OR 0.35; 0.19-0.65) with LVO. The scale design was conducted, assigning a score to each significant variable based on its specific weight: +2 points for SBP > 160, + 1 points for headache, + 1 points for male sex, + 2 points for GCS < 8, and - 1 points for HCL. The area under the curve was 0.82 (0.77-0.87). A score ≥ 4 exhibited a sensitivity of 0.10, a specificity of 0.99, a positive predictive value of 0.21, and a negative predictive value of 0.98. We present the development of a prehospital scale to discriminate between ICH and LVO patients, utilizing easily detectable variables in the prehospital setting.

Effectiveness of dry needling for headache: A systematic review

INTRODUCTION

Non-pharmacological treatment of patients with headache, such as dry needling (DN), is associated with less morbidity and mortality and lower costs than pharmacological treatment. Some of these techniques are useful in clinical practice. The aim of this study was to review the level of evidence for DN in patients with headache.

METHODS

We performed a systematic review of randomised clinical trials on headache and DN on the PubMed, Web of Science, Scopus, and PEDro databases. Methodological quality was evaluated with the Spanish version of the PEDro scale by 2 independent reviewers.

RESULTS

Of a total of 136 studies, we selected 8 randomised clinical trials published between 1994 and 2019, including a total of 577 patients. Two studies evaluated patients with cervicogenic headache, 2 evaluated patients with tension-type headache, one study assessed patients with migraine, and the remaining 3 evaluated patients with mixed-type headache (tension-type headache/migraine). Quality ratings ranged from low (3/10) to high (7/10). The effectiveness of DN was similar to that of the other interventions. DN was associated with significant improvements in functional and sensory outcomes.

CONCLUSIONS

Dry needling should be considered for the treatment of headache, and may be applied either alone or in combination with pharmacological treatments.

Parálisis idiopática del nervio hipogloso. Descripción de un caso

Introducción: La parálisis del nervio hipogloso es una mononeuropatía poco fre-cuente. Las etiologías más habituales son la tumoral, la traumática, la isquémica cere-bral y la iatrogénica, Descripción: Presentamos el caso de un paciente con neuropa-tía idiopática del nervio hipogloso, en el que por edad, la presencia de factores de riesgo vascular, la microangiopaía cerebral y la evolución nos lleva a discutir acerca de la posibilidad de que se trate de una mononeuropatía isquémica o diabética como etiología del déficit. Discusión: En estudios publicados de parálisis idiopáticas del nervio hipogloso la edad de presentación se sitúa entre los 20 y 45 años y tienen una evolución y recuperación favorable, atribuyéndole un mecanismo fisiopatológico similar al de la paralisis de Bell. En nuestro caso la exploración física y las pruebas complementarias realizadas no mostraron etiología del déficit, encontrándonos ante un nuevo caso de parálisis idiopática del nervio hipogloso. Sin embargo por la edad del paciente, la presencia de múltiples factores de riesgo vascular, la microangiopía cerebral y la persistencia de la sintomatología nos hace plantear la existencia de un mecanismo local, isquémico o diabético, como causa de la mononeuropatía presen-tada y pensar que nos podemos encontrar ante un mecanismo fisiopatológico similar al producido en otras mononeuropatías, como la del III o VI par craneal. Conclusión: Presentamos una parálisis del nervio hipogloso idiopática, que por las característi-cas de nuestro paciente nos hace pensar y discuti una posible etiología isquémica o diabética del déficit.

Factors Related to Nonachievement of Intensive Blood Pressure-Lowering Target in Patients with Intracerebral Hemorrhage

BACKGROUND

Spontaneous intracerebral hemorrhage (ICH) is one of the most disabling forms of stroke. Intensive lowering of blood pressure (BP) has been postulated as one of the therapies that can improve functional outcomes. However, this intensive reduction is not always achieved. We aimed to study the differences between patients in whom intensive BP lowering was achieved during the first 24 h after admission and those in whom this BP lowering was not possible.

METHODS

We retrospectively reviewed medical charts to obtain information on BP management during the first 24 h. Our protocol establishes that intensive BP lowering below 140 mm Hg of systolic BP should be pursued.

RESULTS

In total, 210 patients were included. In 107 (51.0%), an intensive target BP was not achieved. This group of patients had higher initial National Institutes of Health Stroke Scale scores and poorer clinical evolution, with more early neurological deterioration, higher requirements for antihypertensive treatment, higher necessity for surgical evacuation, more withdrawal of life-sustaining therapies, and higher mortality at 3 months (all p < 0.05). In the multivariable analysis, high BP levels at admission remained related to the nonachievement of BP-lowering goals, despite a higher administration of antihypertensive medications.

CONCLUSIONS

In this study, the intensive BP-lowering goal was not achieved in about half of the patients with ICH, despite the high proportion of patients receiving antihypertensive medications. This group of patients had poorer outcomes and higher mortality rates at 3 months. High BP at presentation may be difficult to control in patients with high clinical severity of ICH despite aggressive management.