Cases reported "Headache"

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1/55. Headache in Chiari malformation: a distinct clinical entity?

    A relatively common group of developmental anomalies of the posterior fossa and its contents make up the Chiari malformations. The most common of these anomalies are the Chiari malformations type I and type II. Many patients with these defects are asymptomatic, but many of them suffer from headaches. Although the prevalence of common primary headache disorders in patients with Chiari malformations is similar to that of the general population, a particular type of occipital headaches occurs more frequently in patients with a Chiari malformation. In the two patients described in the illustrative case presentations, the major complaint was headache. Both had Chiari malformation type I diagnosed. Chiari malformation should be considered in the differential diagnosis of patients who complain of exertional headache. Exertional headaches or worsening of pain during Valsalva's maneuver should prompt clinical suspicion of an underlying intracranial lesion and warrants further evaluation by appropriate neuroimaging studies.
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2/55. Is sphenoid sinus opacity significant in patients with optic neuritis?

    PURPOSE: optic neuritis secondary to sinus disease is an infrequent but well-documented association. When a patient presents with signs of optic nerve dysfunction and orbital inflammation the significance of widespread sinus disease on radiology is clear and the management is straightforward. We present a group of patients with isolated optic neuritis and radiological evidence of spheno-ethmoiditis and discuss the clinical relevance of this finding. methods: We reviewed the notes of 11 patients with optic neuritis who, because of atypical headache, underwent neuroimaging revealing sphenoid sinus opacity. Six patients had endoscopic drainage of the sphenoid sinus; 4 were treated medically. RESULTS: Sinus contents included fungal infection (2), mucopurulent material (5), polyps (1) and necrotic tumour (1). Narrowing of the optic canal due to chronic osteomyelitis was found in 1 patient with irreversible optic atrophy. Visual loss was reversible in 6 patients. Four patients had normal radiological findings after treatment. Two patients had recurrent optic neuritis with sphenoid sinusitis on MRI scan, resolving on treatment, during the 4 year follow-up period. CONCLUSIONS: Possible mechanisms of nerve damage in this situation include direct spread of infection, occlusive vasculitis and bony deficiency in the wall of the sinus. patients presenting with isolated optic neuritis and atypical headache should be scanned; an opaque sphenoid sinus in the context of visual loss should not be dismissed as coincidental but assumed to be pathological and the patient referred for drainage. sphenoid sinusitis is an uncommon but treatable cause of optic neuritis.
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3/55. Once a shunt, always a shunt?

    Over a period of 15 years, during which some 1000 operations were performed, CSF-drainage systems were able to be removed in 40 of a total of 444 children with communicating hydrocephalus or hydrocephalus associated with myelomeningocele. Shunts were removed from 26 children in the former group, of whom 17 continued to be compensated; in the latter group there were 14 removals, all of whom remained compensated. It is stressed that true compensation can be proven only by continuous measurement of ventricular fluid pressure over periods of several hours or at intervals of days or weeks, and four cases are discussed in which decompensation occurred, in two cases with fatal results.
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4/55. Traumatic intracerebral venous thrombosis associated with an abnormal golf swing.

    OBJECTIVES: To describe the occurrence of cerebral venous thrombosis in a 40-year-old man whose cerebral event was induced by a poor golf swing, to review the literature on possible mechanisms producing venous thrombosis, and to compare this case with the literature. BACKGROUND: Headache is the most frequent symptom in patients with cerebral venous thrombosis. However, patients presenting with a headache due to cerebral venous thrombosis are uncommon. The known risk factors for thrombosis include both acquired and genetic factors. When the interaction of these two groups occurs, the magnitude of this interaction is thought to produce a dynamic state that can favor thrombosis. Our case report illustrates that moderate levels of anticardiolipin antibodies together with the mild trauma of a golf swing can induce a cerebral venous thrombosis. This case also suggests that although headache is rarely due to cerebral venous thrombosis, it should be excluded by good medical acumen and testing. RESULTS: Minor trauma induced by a poor golf swing was chronologically related to the development of a progressive cerebral venous thrombosis. The patient had none of the risk factors associated with a predisposition to venous thrombosis: hypercoagulable state, concurrent infection, pregnancy/puerperium, collagen vascular disorder, malignancy, migraine, false-positive VDRL, previous deep vein thrombosis, renal disease, factor v Leiden, or a hematological disorder. There was no anatomical abnormality that would predispose the patient to a cerebral venous thrombosis. The only laboratory abnormality was a moderate anticardiolipin antibody level (25 GPL). The patient was placed on warfarin sodium therapy and is currently without clinical sequela from the venous thrombotic event. CONCLUSIONS: Under certain circumstances, minor trauma can induce cerebral venous thrombosis. A review of the literature indicates that cerebral venous thrombosis in the presence of anticardiolipin antibodies and in the absence of systemic lupus erythematosus is a rare event. Previously, only major traumatic events have been reported to be associated with cerebral venous thromboses. The chronological development of cerebral venous thrombosis after a faulty golf swing strongly indicates that given a background of moderate levels of anticardiolipin antibodies, even minor trauma can induce a venous thrombotic event.
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5/55. case reports: headache caused by a spinal cord stimulator in the upper cervical spine.

    We report persistent headaches developing in a patient subsequent to the placement of a spinal cord stimulator in the upper cervical spine. These persistent headaches responded to dihydroergotamine and sumatriptan. Headaches ceased upon repositioning of the stimulator lower in the cervical spine. We postulate an effect of the device on the trigeminovascular system via the nucleus caudalis trigeminalis and/or spinal trigeminal tract.
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6/55. Parietal sinus pericranii: case report and technical note.

    BACKGROUND: sinus pericranii is a rare vascular anomaly that is defined as a group of abnormal communications between the extracranial and intracranial venous systems, usually involving the superior sagittal sinus. Different surgical techniques have been used to manage this anomaly. Surgical technique and radiologic findings are discussed. CLINICAL PRESENTATION: A case of parietal sinus pericranii is presented that was developed spontaneously. This 33-year-old woman presented with a soft fluctuant mass in the right parietal region adjacent to the midline. She complained of headache and dizziness. The preoperative radiologic findings of simple skull X-ray, computed tomography, bone scan, and direct venogram are presented.The lesion was removed completely and then multiple small vascular channels through the underlying skull were obliterated by air-powered diamond drilling. The presence of vascular endothelium in the pathologic specimen suggested a congenital origin. CONCLUSION: We think this method is very easy and useful for managing the multiple small fenestrations of the sinus pericranii without recurrence.
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7/55. Psychosomatic disorders in pediatrics.

    Psychosomatic symptoms are by definition clinical symptoms with no underlying organic pathology. Common symptoms seen in pediatric age group include abdominal pain, headaches, chest pain, fatigue, limb pain, back pain, worry about health and difficulty breathing. These, more frequently seen symptoms should be differentiated from somatoform or neurotic disorders seen mainly in adults. The prevalence of psychosomatic complaints in children and adolescents has been reported to be between 10 and 25%. These symptoms are theorized to be a response to stress. Potential sources of stress in children and adolescents include schoolwork, family problems, peer pressure, chronic disease or disability in parents, family moves, psychiatric disorder in parents and poor coping abilities. Characteristics that favour psychosomatic basis for symptoms include vagueness of symptoms, varying intensity, inconsistent nature and pattern of symptoms, presence of multiple symptoms at the same time, chronic course with apparent good health, delay in seeking medical care, and lack of concern on the part of the patient. A thorough medical and psychosocial history and physical examination are the most valuable aspects of diagnostic evaluation. Organic etiology for the symptoms must be ruled out. Appropriate mental health consultation should be considered for further evaluation and treatment.
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8/55. The outcome of treating patients with suspected rebound headache.

    OBJECTIVE: To prospectively document the outcome of patients suspected of having rebound headache. BACKGROUND: Previous publications on rebound headache have, for the most part, implied that the patients improve, but have failed to specify the percent who improved, the pattern of improvement, or the end point that is achieved. methods: This was a prospective study of 50 consecutive patients presenting with chronic daily headache of over 2 months' duration who were suspected of having rebound headache from the medications that they were using for pain relief, and who were eligible to follow our usual treatment protocol, ie, abrupt termination of the offending medications and use of subcutaneous injections of dihydroergotamine for excruciating headache. RESULTS: One year after the initial patient was enrolled and 8 months after the last patient was enrolled, 29 patients (58%) achieved the goal of 6 or more consecutive headache-free days; the mean time to achieve this goal was 84 days. Another 9 patients showed varying degrees of improvement; 1 continued to improve and achieved 5 consecutive headache-free days after having omitted her medications for 10 months. Eleven patients failed to stop their medications or stopped their medications for only a brief interval. One patient continued to have daily headaches after having essentially omitted all pain relief medications for 12 months and was the only true treatment failure in the group. CONCLUSIONS: Most patients suspected of having rebound headache comply with the instructions to omit the offending agents and can be helped. This information might help other physicians who are treating patients suspected of having rebound headache.
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9/55. The clinical and MRI correlate of ischaemia in the ventromedial midbrain: Claude's syndrome.

    The eponymous syndrome of Claude is caused by a lesion of the red nucleus and adjacent third nerve nucleus, resulting in the combination of an ipsilateral oculomotor palsy and contralateral ataxia. The MRI correlate of this syndrome has only occasionally been described. We present three cases with MRI findings which confirm the association of this clinical syndrome with infarction of the ventromedial midbrain. The coexistence of hypertension and small vessel ischaemia in two cases suggests this type of infarct may arise as a result of small vessel disease.
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10/55. Communicating the right therapy for the right patient at the right time: acute therapy.

    OBJECTIVE: review of problems arising from communication difficulties in headache practice. methods: literature review and assessment of practice experience. BACKGROUND: Advances in understanding of the pathophysiology of migraine and the availability of specific acute therapies have given migraine sufferers access to effective treatment and physicians a wide array of therapeutic alternatives. There remains uncertainty about the best drug group for any given patient and about which triptan to use when and in which formulation; about patient preference and satisfaction; about interpretations of pivotal trials and meta-analyses; and about the relevance of large group efficacy and safety data to the individual patient. The clinician may be daunted by the array of triptans with choices of dosage and multiple formulations and will likely learn how to use two or three of them at most, as in depression and hypertension. In the context of the wide array of choices and the complexities of assessing responses and patient preferences, this paper attempts to provide a framework for incorporating the evidence with clinical experience and for communicating these concepts effectively. Benefits, HARMS AND COSTS: None. RESULTS AND CONCLUSION: Even when an appropriate recommendation is determined, therapy may fail unless the doctor patient relationship permits open communication, time for questions and answers and time for instruction on how to use a given medication, and its probable effects. translating evidence into patient-friendly language is a skill as necessary as that of making the clinical decision itself. Tools are available that can support this effort and aid in creating an environment of "partnership".
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