Lower extremity arterial insufficiency after long-term methysergide maleate therapy. Its evaluation with Doppler ultrasonic velocity detector.

Iatrogenic ergotism is the primary source of ergot intoxication. The patient whose case is reviewed had migraine headaches and received methysergide maleate for 13 years. She had, in July 1977, severe claudication of the lower extremities. Measurements of the peripheral arterial circulation were made using the Doppler ultrasonic velocity detector. The extent of disease and subsequent reversal were documented using arteriographic examination. Initial measurements showed the patient was able to walk for one minute and 34 seconds on a treadmill (2 mph, 10% grade) before stopping because of claudication. Symptoms cleared after drug withdrawal and repeated testing produced no claudication. The calculated index (posterior tibial/arm pressure) increased from a mean of 0.22 to 0.74 during the eight-month period following discontinuance of methysergide therapy with no recurrence of migraine headaches. A review of the literature is also presented.     

Laparoscopic Roux-en-Y gastric bypass in a patient with intestinal malrotation

A morbidly obese female with a body mass index of 50.7 kg/m2 and comorbidities of back pain and migraine headaches was taken to the operating room for a laparoscopic Roux-en-Y gastric bypass. She was incidentally found to have intestinal malrotation. The Roux-en-Y gastric bypass was completed laparoscopically, followed by laparoscopic division of Ladd's bands, and appendectomy.     

Topiramate induces type 3 renal tubular acidosis by inhibiting renal carbonic anhydrase.

Sir, We report a case of mixed (type 3) renal tubular acidosis (RTA)associated with the anti-convulsant drug topiramate used formigraine prophylaxis. A 47-year-old woman treated with topiramate(150 mg/day) since 12 months for invalidating migraine was referredfor a metabolic acidosis evidenced in a routine blood sampling.She complained of muscle weakness     

Coronary artery vasospasm with iron sucrose.

Sir, A 45-year-old lady with chronic renal failure (stage 4) andanaemia of chronic disease was administered intravenous ironsucrose. There was no history of cardiovascular disease, gastrointestinalblood loss, migraine, Raynaud's phenomenon or allergy. She didnot smoke or consume illicit drugs. Her haemoglobin was 8.6 gm/dl     

Allodynia as a complication of migraine: Background and management

Opinion statement  Allodynia is a normal part of the untreated migraine attack in most people with episodic migraine and is prevalent in chronic migraine. The extent to which allodynia contributes to the pain and disability of migraine attacks is unclear, as is its clinical importance. The presence of allodynia correlates with the severity and other features of migraine, including aura, migraine-associated symptoms, and motor symptoms. The development of allodynia is associated with resistance to triptan treatment. It is uncertain whether this treatment resistance is due to the accompanying increase in headache severity or whether the development of allodynia is the fundamental biologic event causing the new treatment-refractory state. Animal models support the relationship to allodynia. Intravenous ketorolac may be effective at treating migraine with allodynia several hours after the development of the throbbing pain, but prior treatment with opioid analgesics may confer treatment resistance. Occipital nerve blocks rapidly treat migraine pain and allodynia. Uncontrolled studies have successfully used dihydroergotamine to treat episodic and chronic migraine with allodynia.     

Tumor cerebral no conocido que se presenta con compresión del tronco cerebral tras punción dural accidental

A 36-year old primigravid of 41 weeks gestation was admitted to the labour ward. Her past medical history included hyperemesis gravidarum and migraine. An accidental dural puncture occurred during labour epidural analgesia. In the postpartum period she presented with continuous headache, and was treated with oral analgesics, oral caffeine, fluid therapy, and tetracosactide. She refused an epidural blood patch. On the seventh day postpartum, the patient was re-admitted to the Emergency Department with decreased level of consciousness and signs of brainstem compression. Cranial computed tomography and magnetic resonance imaging showed a posterior fossa tumour. An emergency craniotomy was performed with complete neurological recovery.This case emphasises the need to consider the differential diagnoses of post-dural puncture headache and to highlight the warning signs in patients who do not respond despite treatment with conventional therapy.     

Epidural hematoma after an epidural block in a patient with no coagulopathy

We report a case of epidural hematoma after a single epidural block. The patient was a 67-year-old woman with sciatica and osteoarthritis of the spine. She had no coagulopathy. She underwent a single epidural block without difficulty 3 times in 5 days. She had a lumbar MRI for an examination of the spine 4 days after the final epidural block. Subacute epidural hematoma of 0.8 x 1.5 x 3.0 cm was revealed on MRI at L 3-4. She had no new neurological symptoms. MRI 1 month later revealed a resolution of the hematoma. Epidural hematoma after an epidural block might occur in an outpatient with no bleeding tendency.     

Presentation of hemiplegic migraine--hemiplegia and hemi-sensory loss following general anaesthesia

We report a case of a 15-year-old male who developed severe left-sided hemiplegia and hemi-sensory loss 20 minutes after arrival in post anaesthetic care unit following an uneventful general anaesthesia for removal of a cannulated screw of left hip. Initial CT and MRI/MRA with diffusion-weighted imaging were unremarkable. The patient was transferred to The Royal Children's Hospital Melbourne and was commenced on heparin infusion pending investigation results. Complete recovery occurred within 36 hours. Eventually, hemiplegic migraine was diagnosed on the basis of negative investigations and a retrospective history of the patient's migraine. This case demonstrates that the management of peri-operative neurological deficits must be approached in a systematic fashion. Hemiplegic migraine is a well-defined clinical syndrome. It is not merely a diagnosis of exclusion.     

Acute epidural hematoma caused by contrecoup head injury--case report

A 50-year-old woman presented with a rare case of contrecoup epidural hematoma (EDH) associated with coup EDH. She was hit by a car while riding a bicycle, and struck the left parietal region of her head on the ground. She was dazed for a few minutes. On admission, she complained of nausea but exhibited no neurological deficits. Skull radiography revealed a linear fracture of the left temporal bone. Computed tomography (CT) demonstrated acute EDH in the right frontal region due to contrecoup injury, and thin EDH in the left temporal region due to coup injury. She vomited repeatedly after admission. She became lethargic and exhibited right hemiparesis. CT, taken 2 hours later, revealed enlargement of the left coup EDH, but no enlargement of the right contrecoup EDH. An emergent evacuation of the enlarged coup EDH was performed. Immediately after the operation, she became alert and the right hemiparesis subsided. The contrecoup EDH was conservatively treated, in the absence of enlargement. She was discharged 12 days after the injury without neurological deficits.     

Anesthesia for a patient with Kartagener''s syndrome undergoing ambulatory bilateral breast cancer surgery

Kartagener's syndrome is an inherited disease characterized by a triad of symptoms, bronchiectasis, situs inversus and sinusitus. We report a case of a 53-year-old woman with the syndrome who received bilateral simple mastectomies and axillary lymph node dissections on ambulatory basis. She received antibiotic treatment until the day of surgery. She was admitted to our day surgery unit with productive cough and rales on both lungs on the day of surgery. General anesthesia was induced and maintained with propofol, fentanyl and vecuronium. Laryngeal mask airway (LMA) was placed. She received rectal diclofenac and bupivacaine infiltration into surgical field for pain relief. During pressure controlled ventilation, EtCO2, blood pressure and heart rate increased and SpO2 decreased gradually. These symptoms were resolved after resumption of spontaneous ventilation. She coughed out phlegm in LMA during surgery. The sputa were sucked out using bronchofiberscope. She made an uneventful recovery although she had productive cough preoperatively. She was discharged from the hospital without respiratory complication after overnight observation.     

Migraine with atypical aura in the recovery room: a sometimes complicated diagnosis!

Migraine is a frequent neurological pathology. However, the diagnosis can be difficult to establish, especially when it is accompanied with an atypical aura that can be confounded with a stroke. We describe a case of 38-yr-old patient who presented just after general anesthesia with a perioperative acute migraine with atypical aura which was wrongly treated as a serious cerebral stroke. The patient had not mentioned migraine in her history before the surgery. This lack of information led to unnecessary therapy.     

Case of spinal anesthesia for pyrolomyotomy in a former preterm infant with chronic lung disease

A former premature infant (1,795 g) with chronic lung disease underwent pyrolomyotomy under spinal anesthesia. She had been managed with artificial ventilation for 2 months after birth and had developed chronic lung disease. She showed frequent apnea with desaturation several times per day and 21 x min(-1) of oxygen had been administered. She began projectile vomiting 1 month after extubation and then was diagnosed as hypertrophic pyrolic stenosis by ultrasonography. She was transferred to our hospital to have pyrolomyotomy. After admission to pediatric intensive care, she was managed with nasal-DPAP to prevent apnea. Surgery was completed on the second day after admission under spinal anesthesia using 1.0 mg x kg(-1) of hyperbaric bupivacaine. Spinal puncture was accomplished with 19 mm of 27 G needle after removal of lidocaine patch which had been applied 1 hour before. After the outflow of clear CSF was confirmed, the anesthetics was administered. After we confirmed the anesthesia level up to T5, surgery was commenced. She was managed with mask CPAP to prevent deasaturation under spontaneous respiration during surgery. She required nasal-CPAP to prevent apnea after surgery and she was transferred back to the referred hospital on the 3rd postoperative day without any sequela.     

Septorhinoplasty as a treatment modality in refractory migraine headaches

Migraine headaches are fairly common among people throughout the world with many treatment modalities. The cornerstone of treatment has been traditionally medical treatment which is mostly symptomatic and needs to be repeated. A few surgical procedures have been proposed which eliminate the inciting factor, and septorhinoplasty is one of them. Between October 2001 and August 2004, 24 patients suffering from migraine headaches, underwent septorhinoplasty at 15th Khordad Hospital, Tehran, Iran. Our inclusion criteria were refractory migraine, contact points demonstrated by computed tomography scan, and significant headache improvement after topical anesthesia to the contact area. Reduced severity and frequency of migraine headaches were documented which is statistically significant (p < 0.05). Septorhinoplasty in selected patients with contact points could reduce frequency, severity, and duration of migraine attacks.     

Report of a case with a delayed hemolytic transfusion reaction after open heart surgery

A case of delayed hemolytic transfusion reaction (DHTR) caused by blood transfusions after open heart surgery was reported in a 61-year-old woman. She had undergone mitral annuloplasty 8 years before. She underwent the 2nd mitral and tricuspid annuloplasty for recurrent mitral and tricuspid regurgitation in 1988. After the reoperation, she developed severe hemolytic anemia with fever. The anti-Jka antibody was detected in her serum by the blood antibody screening test. She was diagnosed to have a DHTR. She was treated conservatively and recovered.     

Immediate post-transplant nephrosis in a patient with congenital nephrotic syndrome

A 19-month-old girl with congenital nephrotic syndrome of the Finnish type underwent a living-related renal transplant; 24 h after transplantation she became massively nephrotic. She did not respond to steroids, plasmapheresis, and high-dose cyclosporine. A month later, a renal biopsy showed only glomerular foot process effacement. She was treated with high-dose methylprednisolone pulses and oral cyclophosphamide. She rapidly went into complete remission with no further relapses. Graft function has been stable 2 years after transplantation. Received: 24 June 1999 / Revised: 21 February 2001 / Accepted: 23 February 2001     

Interactions between migraine and stroke

Opinion statement When a patient with migraine has a stroke, all other causes of stroke should be ruled out before the stroke is attributed to migraine. Migraine mimics that present with headaches and stroke, including arteriovenous malformation and cervical carotid artery dissection, should be considered. Patent foramen ovale is a risk factor for both migraine and stroke and should be ruled out with transesophageal echocardiography. A patient with migraine with aura with persistent focal neurologic deficits in the distribution of the typical aura can be diagnosed with migrainous stroke. Patients with migraine with aura with persistent focal neurologic deficits can be treated pharmacologically with intravenous verapamil or magnesium sulfate to relieve the symptoms in familial hemiplegic migraine and sporadic hemiplegic migraine. Prophylactic treatment should be administered to patients with frequent attacks of migraine with aura to prevent recurrence. Oral verapamil is recommended for patients with familial hemiplegic migraine and may be effective in patients with sporadic hemiplegic migraine. Endovascular closure of patent foramen ovale has been reported to prevent recurrence of migraine with aura. The role of patent foramen ovale closure remains controversial pending completion of controlled randomized trials.     

Apnoeic spells following general anaesthesia in a patient with familial hemiplegic migraine

Hemiplegic migraine is an unusual variant of migraine, characterised by a temporary hemiparesis or hemiplegia associated with headache. We report a patient with hemiplegic migraine who developed atypical migraine with apnoeic spells, aphasia and hemiparesis following general anaesthesia. We review the clinical features of hemiplegic migraine and the considerations for its anaesthetic management.     

Late onset anastomotic pseudoaneurysm of renal allograft artery: case report, diagnosis, and treatment

A large, late onset, extrarenal pseudoaneurysm at the anastomotic site of the renal allograft artery is reported herein. The patient was a 25-year-old woman who presented 2 months after a normal vaginal delivery. She had received a renal allograft 6 years before admission without any renal compliants after transplantation. She presented with lower abdominal pain and an elevated creatinine level. Digital subtraction angiography revealed a pseudoaneurysm at the anastomotic site; surgical treatment was performed via a venous patch angioplasty. She has been followed postoperatively for 18 months with normal kidney function and without any other renal or vascular problems.     

Gastrotracheal fistula: a late complication after transhiatal esophagectomy

A 51-year-old woman underwent a transhiatal esophagectomy for a failed antireflux procedure. She did well for 15 months, when she developed evidence of hemoptysis followed by tracheogastric fistula. She underwent operative repair with the use of a pericardial patch to replace the membranous trachea and interposition of a latissimus dorsi flap to isolate the stomach from the tracheal suture line. She has done well after this operation.