Plasma and cerebrospinal fluid beta-endorphin in chronic tension-type headache.

Previous studies have provided evidence of an increased sensitivity to pain, a decreased hypothalamic opioid tone, and decreased cerebrospinal fluid (CSF) beta-endorphin (beta-EP) concentration in patients with primary chronic headache. We applied separate specific radioimmunoassays for beta-EP in CSF and plasma on samples from age-matched controls and a group of 50 patients with chronic tension-type headache (CTH) fulfilling the diagnostic criteria set by the International Headache Society. Median CSF beta-EP concentrations (95% confidence limits) were 12.8 pmol/l (11.0-14.5) in CTH patients and 11.9 pmol/l (10.9-14.2) in the control group, which is not significantly different (P = 0.28). Plasma beta-EP concentrations did not differ either, being 3.1 pmol/l (2.4-3.7) and 3.3 pmol/l (1.8-4.0) in the patients with CTH and in controls, respectively (P = 0.88). Plasma and CSF beta-EP concentrations did not correlate. Reversed-phase high performance liquid chromatography (HPLC) of CSF pools from the headache patients and controls revealed similar profiles of beta-EP-immunoreactivity both when C-terminally and N-terminally directed antisera were used, suggesting a normal post-translational processing of the pro-opiomelanocortin gene in patients with CTH. beta-EP is not involved in the pathogenesis of CTH, or such a role is not reflected in CSF or plasma concentrations of the neuropeptide.     

Substance P mechanism in cluster headache: Evaluation in plasma and cerebrospinal fluid

Substance P (SP), present in sensory afferent neurons, seems to process nociceptive information in the trigeminal system. SP, released from peripheral trigeminal endings, causes typical cluster headache (CH) signs, e.g. vasodilatation, conjunctival and nasal edema and miosis. Opiates and somatostatin (SRIF), both active in relieving CH attack, inhibit SP release from the central and peripheral trigeminal system. In the present study, plasma and cerebrospinal fluid (CSF), SP-like immunoreactivity (SPLI) and enkephalinase activity (EKA), and plasma SRIF-like immunoreactivity (SRIFLI) have been evaluated during spontaneous and histamine induced attacks in the cluster phase. During the histamine provoked attacks, CSF SPLI and plasma SRIFLI and EKA were unchanged, while plasma SPLI decreased significantly. During spontaneously occurring attacks, plasma SRIFLI was found to be unmodified and a significant lowering of SPLI was detected when compared with controls. Moreover, both during and between attacks in the cluster phase, plasma EKA was increased in comparison with the values in controls. It remains to be seen whether variations of plasma SPLI and EKA levels play a role in the CH mechanism.     

Glutamate and nitric oxide pathway in chronic daily headache: evidence from cerebrospinal fluid

A central sensitization has been advocated to explain chronic daily headache (CDH) due to sustained peripheral sensitization of allogenic structures responsible for sustained trigeminovascular system activation. Several mechanisms have been suggested to underlie central sensitization, but have been poorly investigated in CDH. They involve N-methyl-D-aspartate (NMDA) receptor activation and nitric oxide (NO) production and supersensitivity and increased and maintained production of sensory neuropeptides. The present study supports the above pathogenic mechanisms demonstrating a significant increase in glutamate and nitrite levels in the CSF of CDH patients, without a significant difference between patients without and those with analgesic overuse headache (P < 0.0001 and P < 0.002). The increase in CSF nitrites was accompanied by a significant rise in the CSF values of cyclic guanosine monophosphate (cGMP) in patients in comparison with controls (P < 0.0001). A statistically significant correlation emerged between visual analogic scale (VAS) values and glutamate, nitrites and cGMP. Although substance P (SP) and calcitonin gene-related peptide (CGRP), and to a lesser extent neurokinin A, were significantly increased in CSF compared with control subjects, their values did not correlate with glutamate, nitrites and cGMP levels in CSF in the patient group. The present study confirms the involvement of glutamate-NO-cGMP-mediated events underlying chronic head pain that could be the target of a new therapeutic approach which should be investigated.     

颅底肿瘤切除术后脑脊液漏的诊断与治疗

目的 探讨颅底肿瘤切除术后脑脊液漏的诊断和处理措施。方法对25例颅底肿瘤切除术后脑脊液漏患者的临床资料进行回顾性分析。结果大部分术后脑脊液漏患者经漏液糖含量测定即可定性，利用CT脑池造影或MRI检查确定漏口位置；约72％的患者经保守治疗和腰池引流于3-32d内治愈，6例(24％)并发颅内感染，1例死亡。结论术后早期积极腰椎穿刺引流脑脊液，是预防和处理术后脑脊液漏行之有效的方法；仅少数保守治疗无效者需行手术修补。     

Involvement of corticotrophin-releasing factor and orexin-A in chronic migraine and medication-overuse headache: findings from cerebrospinal fluid

The study set out to investigate the role of corticotrophin-releasing factor (CRF) and orexin-A in chronic migraine (CM) and medication-overuse headache (MOH). Twenty-seven patients affected by CM and 30 with MOH were enrolled. Control CSF specimens were obtained from 20 age-matched subjects who underwent lumbar puncture for diagnostic purposes, and in all of them CSF and blood tests excluded central nervous system or systemic diseases. Orexin-A and CRF were determined by radioimmunoassay methods. Significantly higher levels of orexin-A and CRF were found in the CSF of MOH and to a lesser extent in patients with CM compared with control subjects (orexin-A: P  < 0.001 and P  < 0.02; CRF: P  < 0.002 and P  < 0.0003). A significant positive correlation was also found between CSF orexin-A values and those of CRF ( R  = 0.71; P  < 0.0008), monthly drug intake group ( R  = 0.39; P  < 0.03) and scores of a self-completion 10-item instrument to measure dependence upon a variety of substances, the Leeds Dependence Questionnaire (LDQ) in the MOH group ( R  = 0.68; P  < 0.0003). The significantly higher orexin-A levels found in CM and MOH can be interpreted as a compensatory response to chronic head pain or, alternatively, as an expression of hypothalamic response to stress due to chronic pain. A potential role for orexin-A in driving drug seeking in MOH patients through activation of stress pathways in the brain can also be hypothesized.     

The significance of age, sex, and cerebrospinal fluid pressure in post-lumbar-puncture headache

In this study of 300 neurological inpatients aged between 18 and 60 years the incidence of post-lumbar-puncture headache (PPH) was 37.3%. The more severe the headache, the more frequently it was associated with dizziness, nausea, vomiting, and tinnitus. If PPH occurred during the first day after lumbar puncture (LP), it was more severe, and lasted longer than PPH, which started later. The incidence of PPH and associated symptoms decreased with increasing age, and was much higher in females than males. The sex difference was nearly exclusively explained by a marked preponderance of PPH in females below 40 years of age, i.e. women in the fertile age. Furthermore, there was a decreased incidence of PPH and associated symptoms in patients with an initial higher than average cerebrospinal fluid (CSF) pressure (162 mm H2O). All these differences were statistically significant. Particularly high frequencies of PPH were found in young women with an initial CSF pressure lower than mean.     

脑脊液细胞学检测对以头痛起病的脑膜癌病诊断的意义

目的 探讨脑膜癌病的临床特点和诊断方法.方法 回顾性分析以头痛为首发症状的患者41例,经脑脊液细胞学确诊为脑膜癌病28例,结合文献进行分析.结果 经脑脊液细胞学检查发现异形细胞的患者共28例,余13例分别诊断为偏瘫性偏头痛1例,普通偏头痛2例,眼肌麻痹性偏头痛2例,特发性颅内压增高症3例,肌紧张性头痛3例,静脉窦血栓2例.结论 脑膜癌病临床表现无特异性,临床上常以头痛起病,反复CSF细胞学检查是确诊的重要手段.     

Moral agency in nursing: seeing value in the work and believing that I make a difference

The subject of this article is moral agency in nursing, studied by the use of an applied philosophical method. It draws upon nurses' accounts of how they see intrinsic value in their work and believe that they make a difference to patients in terms that leave their patients feeling better. The analysis is based on the philosophy of Iris Murdoch to reveal how nurses' accounts demonstrated that they hold a view of themselves and their professional practice that is intrinsically linked to, and dependent upon, their capacity to see good in the work they do.     

内镜下经鼻切除颅底肿瘤术中高流量脑脊液漏的处理*

目的探讨内镜下经鼻切除颅底肿瘤术中高流量脑脊液漏的处理方法及疗效。方法回顾性分析2013年5月-2016年1月使用内镜下扩大经鼻入路(EEEA)切除的48例术中出现高流量脑脊液漏的颅底肿瘤患者的临床资料。肿瘤切除后采用含带蒂鼻中隔黏膜瓣(HB瓣)的多层颅底重建技术,术后予以腰大池置管引流、抗感染等治疗。结果上述病例术中以鞍上池开放最为常见,第三脑室开放17例;颅底硬膜缺损位于蝶骨平台至鞍底42例,鞍底3例,斜坡3例,缺损面积均大于2 cm2。术后发生脑脊液漏4例(8.3%),并伴随颅内感染,1例予以延长脑脊液引流时间和加强抗感染后治愈,余3例再次内镜下修补,原因分别为带蒂鼻中隔瓣移位和部分坏死,其中成功2例,死亡1例。术后随访5个月~3年,颅底组织愈合良好,无脑脊液漏、颅内感染发生。结论采用含HB瓣的多层颅底重建技术是一种有效的处理内镜颅底外科手术中高流量脑脊液漏的方法。     

Documentation of cerebrospinal fluid opening pressure and other important aspects of lumbar puncture in acute headache

Background: Measuring cerebrospinal fluid (CSF) opening pressure by lumbar puncture (LP) is an essential tool in the investigation of patients with acute headache. Aim: To assess documentation of opening CSF pressure in those with acute headache undergoing LP. General documentation of the procedure and CSF investigations was also assessed. Methods: Retrospective review of medical records of patients admitted to a teaching hospital Acute Medical Admissions Unit over a three‐month period with a presenting complaint of headache. Results: A total of 106 patients presented with headache of whom 48 patients had at least one LP attempted. Only 41 patients (85%, 95% CI 72–94) had their LP documented. Of 47 patients that had a successful LP, 22 (47%) had a recorded opening pressure. Eighteen (32%) of all patients had their position recorded, with seven (15%) patients having had position and opening pressure documented. Twenty patients (43%) had the appropriate results documented. Twelve patients (31%) had paired serum glucose measured. Conclusions: Documentation of a LP for headache in the acute setting was generally poor. CSF opening pressure measurement was frequently omitted and no appropriate action taken if high. Paired serum glucose was rarely measured. Acute physicians may benefit from a proposed protocol and documentation sticker.     

Application of a three-dimensional printed model to localize a cranial cerebrospinal fluid leak: a case report

Localization of defect sites is a major challenge for surgical repair of cerebrospinal fluid (CSF) leaks. Here, we report a case in which we applied a 3-dimensional (3D) printed model to accurately identify the defect sites and facilitate the successful repair of a cranial CSF leak. A 37-year-old female patient diagnosed with recurrent nasopharyngeal carcinoma suffered CSF rhinorrhea and severe bacterial meningitis. Lumbar drainage and antibiotic administration failed to control the condition. In addition to high resolution computed tomography and magnetic resonance imaging, we applied a 3D printed model of the skull to improve the understanding of the osseous destruction at the skull base and aid in accurately localizing the defect sites of the right middle fossa. Accordingly, a right temporalis pedicled flap combined with an autogenous fascia lata flap was applied to cover the defect sites. The leak stopped postoperatively, and meningitis was relieved by enhanced antibacterial treatment. As a complement to high resolution computed tomography and magnetic resonance imaging, a 3D printed model may improve localization of complex defect sites and surgical planning by allowing preoperative visualization of the skull condition.     

The transient syndrome of headache with neurological deficits, cerebrospinal fluid pleocytosis and acute confusional state: a case report

The syndrome of transient Headache and Neurological Deficits with cerebrospinal fluid Lymphocytosis (HaNDL) now referred to in the IHS ICHD–II code 7.8, is only infrequently accompanied by a confusional state and severe agitation. We report the case of a 34–year–old man who suffered from three episodes of headache with transient focal neurological deficits that were consistent with HaNDL but that were accompanied by an intense, confusional agitated state that required admission, in the first episode, in a psychiatric unit.