Responsiveness of short-lasting unilateral neuralgiform headache with conjunctival injection and tearing to hypothalamic deep brain stimulation

Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) is a severe primary headache disorder that is often refractory to medical therapy. Although the pathogenesis of this and other trigeminal autonomic cephalalgias is not completely understood, ipsilateral activation of the posterior and inferior hypothalamus has been identified on functional imaging studies during attacks. The authors report on a case of SUNCT syndrome successfully treated with hypothalamic deep brain stimulation and discuss the current literature.     

Neurosurgical treatment of short-lasting, unilateral, neuralgiform hemicrania with conjunctival injection and tearing

Trigeminal neuralgia solely involving the upper trigeminal nerve branch is rare. The SUNCT syndrome (short-lasting, unilateral, neuralgiform hemicrania with conjunctival injection and tearing) in which the periorbital pain lasts for 60-120 s, and is accompanied by conjunctival injection and tearing is even less common. Unlike trigeminal neuralgia, SUNCT is usually not relieved by medication. Three patients with SUNCT were treated with retrogasserian glycerol rhizolysis, two of them twice. All five treatments provided complete pain relief and the duration of the effects was 2 to more than 4 years. One of these three patients also had a third treatment with compression of retroganglionic fibres with a Fogarthy balloon, according to Mullan, of the upper trigeminal nerve with excellent results.     

Trigeminal autonomic cephalalgias. Part 1: cluster headache.

Cluster headache is characterized by severe, strictly unilateral pain attacks lasting 15 to 180 minutes localized to orbital, temporal, and midface areas accompanied by ipsilateral autonomic features. It represents 1 of 3 primary headaches classified as trigeminal autonomic cephalalgias. While its prevalence is small, it is not uncommon for cluster headache patients to present at dental offices seeking relief for their pain. It is important for oral health care providers to recognize cluster headache and render an accurate diagnosis. This will avoid the pitfall of implementing unnecessary and inappropriate traditional dental treatments in hopes of alleviating this neurovascular pain. The following article is part 1 of a review on trigeminal autonomic cephalalgias and focuses on cluster headache. Aspects of cluster headache including its prevalence and incidence, genetics, pathophysiology, clinical presentation, classification and variants, diagnosis, medical management, and dental considerations are discussed.     

Short-lasting, unilateral neuralgiform headache attacks with conjunctival injection and tearing syndrome treated successfully with transsphenoidal resection of a growth hormone-secreting pituitary adenoma

Short-lasting, unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) syndrome was first described in 1978 as one of the trigeminal autonomic cephalgias. In this paper the authors present a patient with a growth hormone-secreting pituitary adenoma who experienced resolution of SUNCT syndrome after transsphenoidal tumor resection.     

Trigeminal autonomic cephalalgias. Part 2: Paroxysmal hemicrania.

Paroxysmal hemicrania (PH) is characterized by severe, strictly unilateral pain attacks lasting 2 to 30 minutes localized to orbital, supraorbital, and temporal areas accompanied by ipsilateral autonomic features. It represents 1 of 3 primary headaches classified as trigeminal autonomic cephalalgias. Although PH is rare, patients may present to dental offices seeking relief for their pain. It is important for oral health care providers to recognize PH and render an accurate diagnosis. This will avoid the pitfall of implementing unnecessary and inappropriate traditional dental treatments in hopes of alleviating this neurovascular pain. This is part 2 of a review on trigeminal autonomic cephalalgias and focuses on PH. Aspects of PH including epidemiology, genetics, pathophysiology, clinical presentation, classification and variants, diagnosis, medical management, and dental considerations are discussed.     

Treatment of obstetric post-dural puncture headache. Part 1: conservative and pharmacological management

The 2009–12 MBRRACE-UK report highlighted the deaths of two women in whom dural puncture had occurred during insertion of a labour epidural catheter. One woman received an epidural blood patch, the other did not, but both suffered with chronic headaches following discharge from hospital. Neither woman was adequately followed-up. Death resulted from a cerebral vein thrombosis in one case and a subdural haematoma in the other. Surveys of clinical practice in the UK have revealed significant variation in anaesthetic practice in the management of obstetric post-dural puncture headache. To help provide guidance on treatment, the Obstetric Anaesthetists’ Association set up a working group to review the literature and produce evidence-based guidelines for management of obstetric post-dural puncture headache. These guidelines have been condensed into two review articles, the first of which covers conservative and pharmacological treatment.     

Complete unilateral ureteral obstruction in the fetal lamb. Part I: long-term outcomes of renal hemodynamics and anatomy

PURPOSE: We evaluated the long-term consequences of complete fetal UUO on renal hemodynamics and anatomy. MATERIALS AND METHODS: A total of 26 fetal lambs underwent surgical UUO at 90 days of gestation and 14 twin matched animals served as controls. Synchronous bilateral ARBF was measured using mean transit time technology. Standard anatomical analysis, including evaluation of RPV, was performed in the kidneys. Measurements were done 10, 20 and 40 days following UUO in groups 1 to 3, respectively and in 1-month-old lambs in group 4. RESULTS: All obstructed kidneys underwent typical hydronephrotic transformations with a progressive decrease in parenchymal volume compared to that of contralateral and control kidneys. ARBF in obstructed kidneys was significantly decreased compared to their contralateral counterparts in all groups (p <0.01). Comparing ARBF to RPV showed that the decrease in ARBF was proportional to the loss of parenchymal volume in fetal obstructed kidneys but it remained significant in lambs (p <0.05). CONCLUSIONS: Complete UUO alters ARBF, while vascularization of the remaining renal parenchyma is maintained in fetuses. Profound impairment of the renal arterial supply observed in lambs may be due to physiological changes linked to birth.     

High resolution computed tomography: Part 3. The larynx and hypopharynx

High resolution computed tomography (CT) is a highly desirable addition to clinical examination of the larynx and hypopharynx. The anatomy and pathology of the larynx and hypopharynx is discussed and illustrated by CT.     

Nimodipine and chronic vasospasm in monkeys: Part 3. Cardiopulmonary effects

A subarachnoid hemorrhage was induced in 30 cynomolgus monkeys by the placement of a 6- to 7-ml blood clot through a frontotemporal craniectomy (Day 0). The monkeys underwent a 1-week-long, randomized, blind trial comparing various doses of nimodipine to placebo, sham, and no treatment. The treatment groups were: nimodipine, 3 mg/kg every 8 hours (n = 6), 6 mg/kg every 8 hours (n = 6), and 12 mg/kg every 8 hours (n = 6); placebo (polyethylene glycol 400), 0.33 ml/kg every 8 hours (n = 6); and no treatment (n = 6). An additional sham group underwent craniectomy without clot placement (n = 6) so that 36 animals in total were operated upon. Differences in cardiopulmonary indices between Day 0 and Day 7 were compared within and between groups. No significant differences were obtained in the sham and no treatment groups. The nimodipine 6- and 12-mg/kg groups showed significant decreases in blood pressure (P less than 0.04 and P less than 0.015). Systemic vascular resistance was increased in the placebo and 3-mg/kg groups (P less than 0.02) and decreased in the 12-mg/kg group (P less than 0.015). Stroke index was increased in the 12-mg/kg group (P less than 0.05). Cardiac index and stroke index correlated positively with nimodipine dosage (r = 0.99, P less than 0.05). There were no pronounced changes in pulmonary artery wedge pressure, central venous pressure, alveolar-arterial oxygen pressure difference, arteriovenous oxygen content difference, and percentage of shunting.     

Direct administration of methotrexate into the central nervous system of primates. Part 2: Distribution of 3H methotrexate after intrathecal lumbar injection.

The kinetics of distribution of 3H methotrexate (3HMTX) in the central nervous system, plasma, and urine after intraventricular, lumbar percutaneous puncture, and spinal catheter injections were compared. Levels of 3HMTX in whole brain after lumbar percutaneous injection were 40 times less than after intraventricular injection. Injection of 3HMTX via a spinal catheter increased the level of 3HMTX in whole brain but this was still tenfold less than after direct intraventricular instillation. Also, it was found that a disproportionately high amount of 3HMTX was in the brain-stem-cerebellum region which would further reduce the concentration of methotrexate in the cerebral hemispheres. Both intraventricular and lumbar spinal catheter administration of 3HMTX produced 3HMTX levels greater than 10(-6)M (moles/kg wet weight) in spinal cord tissue as measured by 3H specific activity between 2 to 8 hours after injection. Administration by lumbar percutaneous puncture, however, rarely resulted in this suggested therapeutic level of 10(-6)M. Initial 3HMTX levels in plasma after lumbar percutaneous instillation was 24 times greater than after intraventricular or lumbar spinal catheter injections. This indicated significant and unavoidable extradural leakage after lumbar percutaneous puncture, which may account for the substantially lower levels of 3HMTX in the brain and spinal cord tissue. It is concluded that intraventricular instillation of methotrexate is the best route of administering the drug to achieve therapeutic levels of methotrexate in both whole brain and throughout the spinal cord.     

Endoscopic endonasal skull base surgery: Part 3--The clivus and posterior fossa.

OBJECT: As a minimally invasive surgical strategy, endonasal endoscopy has been implemented for the surgical treatment of clival and midline posterior fossa lesions which conventionally require radical and extensive surgical exposures. A cadaver study was performed and, subsequently, this technique was adopted into patient treatment. METHODS: Six cadaver head specimens were used in this study. Anterior sphenoidotomy was attained by either a paraseptal or middle turbinectomy approach. The ideal head positioning was measured. The clival bone was removed with a high-speed drill from sella to foramen magnum in the vertical dimension and from carotid artery to carotid artery in the transverse dimension. The width of the clival bony window between the carotid arteries was measured at the level of the sellar floor and the caudal end of the carotid artery. The surgical anatomy was studied. RESULTS: Although the middle turbinectomy approach provided a wider surgical corridor, exposure with the paraseptal approach was sufficiently ample. Ideal head positioning was at 15-degree flexion of the forehead-chin line. The average width between carotid arteries at the sellar floor level was 16 mm (range 12-22 mm) and at the lower end of the carotid arteries it was 19 mm (range 14-23 mm). When the dura mater was opened, the anterior view of the pons and medulla with corresponding cranial nerves and vasculature was encountered. Four illustrative patient cases are presented. CONCLUSIONS: This endonasal endoscopy provided excellent surgical exposure from the sella to the foramen magnum at the midline clivus and posterior fossa. Surgical techniques and illustrations of four patients are presented.     

Bicornuate and unicornuate uterus associated with unilateral renal aplasia and abnormal solitary kidneys: report of 3 cases

We present 3 cases of a genital abnormality associated with unilateral renal aplasia in which the single kidney was abnormal. Renal aplasia associated with unicornuate uterus or uterus didelphia is rare but it has been reported previously. However, except for vesicoureteral reflux the single kidney usually is normal. Modern methods of evaluating renal function and urodynamics will be helpful when abnormal kidneys are found and will avoid unnecessary surgery. It is mandatory to suspect abnormalities of the urinary tract when genital maldevelopment is encountered and vice versa.     

Experimental cerebral oligemia and ischemia produced by intracranial hypertension. Part 3: Brain energy metabolism.

The authors studied the effect on cortical metabolites of intracranial hypertension produced by the infusion of mock cerebrospinal fluid into the cisterna magna in rabbits subjected to 15 minutes of cerebral oligemia (20 torr) or 15 minutes of complete ischemia. In both groups high-energy metabolites were exhausted within the first 5 minutes of the 15-minute insult. Significant recovery of the high-energy intermediates occurred within 15 minutes of reperfusion, well before return of electroencephalogram (EEG) activity. Continued reperfusion, during which electrical activity and function were returning, brought only moderate improvement in energy metabolites. In contrast, severe lactic acidosis persisted at least 15 minutes after insult, but was reduced by the time EEG activity returned. At no time were there striking differences in metabolites between the oligemic and ischemic groups. These results indicate that recovery in general, and the significantly earlier recovery of oligemic as compared to ischemic animals, cannot be explained on the basis of energy supply. Whether the persistence of lactic acidosis is an important factor limiting return of function requires further study.     

Suprascapular entrapment neuropathy: a clinical, anatomical, and comparative study. Part 3: comparative study

The suprascapular ligament seems to serve no defined function in the human. A comparative study was undertaken to elucidate its function. The suprascapular region was dissected in species representing seven existing primate families and six subprimate families. A striking dichotomy of pattern was observed. In the New World primates, the suprascapular ligament appeared to be continuous with the coracoclavicular ligament; the former merely served to increase the area of bony attachment of the coracoclavicular ligament. In the Old World monkeys and subprimate mammals, the suprascapular ligament was entirely absent. The human anatomy was comparable to that found in the New World primates. This dichotomy of pattern seems to be related to the function of the upper extremity in the different classes of mammals.