Ischaemic cerebrovascular events in HIV infection: a cohort study

Several case reports and series described ischaemic cerebrovascular events in HIV infection. However, the exact prevalence and the clinical features of these events are unknown. We performed a cohort study on 772 consecutive HIV infected patients and evaluated the rate of transient ischaemic attacks (TIA) and of completed stroke. A total prevalence of 1.9% for TIA (0.8%) and stroke (1.2%) was calculated resulting in an annual incidence rate of 216 per 100000. The prevalence was highest in the later stages of the infection. Stroke patients had a poorer immunological state than the TIA and the cohort patients. Probable (n = 3) and possible (n = 2) vasculitis and cardiogenic embolism (n = 2) could be detected as aetiology, the remaining patients had a cryptogenic event. Our data suggest that ischaemic cerebrovascular events are more common in HIV infected patients than in the general population and that a part of these events might be caused by HIV associated vasculitis or vasculopathy.     

Cervical intramedullar schistosomiasis as a rare cause of acute tetraparesis

INTRODUCTION: The trematode infection schistosomiasis affects at least 200 million people in endemic areas. Granulomas cause the typical manifestations of urogenital, intestinal and hepatolienal schistosomiasis. Involvement of other organs especially the central nervous system (CNS) is uncommon. CASE REPORT: We describe a 40-year old male with a history of repeated contact with schistosome contaminated water. After having suffered from flu-like symptoms with fever and arthralgias, he first presented with a polyradiculopathy of unknown origin. Then 4 weeks later an acute tetraparesis occurred. Spinal magnetic resonance imaging (MRI) revealed a spinal stenosis and query medullary hyperintensities at C6-C8 without contrast-enhancement. Serologic testing was positive for schistosomiasis. The intraoperative appearance at decompressive laminectomy revealed a myelitic form of schistosomiasis. Under therapy with praziquantel, initially high dose cortisone and intensive physiotherapy, symptoms slowly improved over months. On follow-up 1 year later, the patient presented with a spastic distally marked tetraparesis and sensory impairment from C6 downwards. CONCLUSION: Cervical intramedullar schistosomiasis is a rare cause of acute tetra- or para-paresis in patients, who have had contact with schistosomes. Early diagnosis is essential because of the excellent prognosis with specific therapy.     

Percutaneous removal of residual intrahepatic stones

In the Orient there is a high frequency of residual intrahepatic stones after biliary tract surgery. Percutaneous removal of residual intrahepatic stones was attempted in a group of 74 patients. Stones were exclusively intrahepatic in 57 patients, whereas 17 patients also had stones in the common bile duct. Biliary strictures were present in 60 cases (81%). A combination of techniques was used, including preshaped angulated catheters, irrigation-suction, balloon dilation of strictures, and crushing of large stones. In 36 cases all stones were removed and in 14 cases most stones were removed, for a success rate of 67.6%. Biliary stricture was the factor most often responsible for failure.     

Prostaglandin analog mechanisms are not effective in refractory chronic cluster headache

Prostaglandin E analogs have been shown to be effective in the treatment of refractory trigeminal neuralgia in patients with multiple sclerosis. Prostaglandin E inhibits the functions of T lymphocytes which are involved in the pathophysiology of cluster headache. Therefore, a double-blind, placebo-controlled, crossover study on the efficacy of misoprostol in chronic refractory cluster headache was performed. Eight patients were treated with 600 micrograms misoprostol and with placebo for a 2-week period. No differences in attack frequency, intensity, global impression, and side effects could be detected, suggesting that prostaglandin E analogs are not effective in the treatment of chronic cluster headache.     

Headache associated with sexual activity: prognosis and treatment options

The aim of this study was to provide data on the prognosis and treatment options of headache associated with sexual activity (HSA). Sixty patients diagnosed with HSA between 1996 and 2004 were followed up between 2003 and 2006 at least 12 months after the first interview. The further course of the disease and their contentedness with therapy were requested. On average, the second interview was performed 35.9 months after the first examination. Of the 45 patients who had suffered from single attacks or bouts prior to baseline examination, 37 had no further attacks. Seven patients suffered from at least one further bout with an average duration of 2.1 months. One patient developed a chronic course of the disease after an episodic start. Of the 15 patients with chronic disease at the first examination, seven were in remission and five had ongoing attacks at follow-up. Ten patients received indomethacin for preemptive therapy, with good results in nine patients. Eighteen patients received beta-blockers for prophylaxis, with good results in 15 patients. Episodic HSA occurs in approximately three-quarters and chronic HSA in approximately one-quarter of patients. Even in chronic HAS, the prognosis is favourable, with remission rates of 69% during an observation period of 3 years. For patients with longer-lasting bouts or with chronic HSA, prophylactic treatment with beta-blockers or preemptive therapy with indomethacin are often successful.     

The influence of acetazolamide on cerebral low-flow regions in migraine--an interictal 99mTc-HMPAO SPECT study.

Acetazolamide, a carbonic anhydrase inhibitor, has proved to be useful in the assessment of "vasodilatory capacity" in cerebrovascular disease. To obtain further information on the nature of interictal low-flow regions in migraine, we reinvestigated 20 asymptomatic patients suffering from migraine with aura (n = 15) or without aura (n = 5) and who had either minor (n = 12) or marked (n = 8) regional hypoperfusion when examined in a previous 99mTc-HMPAO SPECT investigation. These patients received acetazolamide IV prior to tracer application. In 14/20 cases regional hypoperfusion resolved. Three patients with migraine with aura had less pronounced regional hypoperfusion compared to baseline. No change in baseline hypoperfusion was detectable in three older patients. No further decreases in flow were measured. In contrast to patients with cerebrovascular ischemia, in whom acetazolamide usually enhances low-flow regions, vasodilatory capacity appears intact in most migraine patients with interictal regional hypoperfusion. Thus, the "acetazolamide test" might be useful in the differential diagnosis of migraine with aura from transient cerebrovascular ischemia.     

Migraine and left-handedness are not associated. A new case-control study and meta-analysis

To investigate the possible association between migraine and left-handedness, we enrolled 100 patients with a diagnosis of migraine according to the International Headache Society diagnostic criteria and 100 age- and sex-matched control subjects into a case–control study. Handedness was determined by the Edinburgh Handedness Inventory. There was no significant difference in the frequency or grade of left-handedness between the two groups. Additionally, we pooled our data with those from five similar studies, which did not alter the result. Thus, neither our study nor the meta-analysis support Geschwind and Behan's hypothesis of an association between migraine and left-handedness.     

Anforderungen an eine interdisziplinäre Schmerzvorlesung

ZusammenfassungHintergrund Schmerztherapie ist auch nach der Neufassung der Approbationsordnung kein curricular verankerter Lehrgegenstand im Medizinstudium in Deutschland.Methodik Zur Erfassung der Wünsche von Studierenden an eine fakultative Lehrveranstaltung in Schmerztherapie ist während 2 Semestern an der Medizinischen Fakultät der Universität Münster eine Befragung unter Studierenden durchgeführt worden, die freiwillig eine solche Lehrveranstaltung besuchen wollten.Ergebnisse Die Hauptinteressen richten sich auf die Vermittlung konkreter Schmerzsyndrome (Rücken-, Kopf-, Tumorschmerz), der Pharmakotherapie und der Struktur der schmerztherapeutischen Versorgung. Weibliche Studierende äußerten ein signifikant stärkeres Interesse an der Schmerztherapie für bestimmte Zielgruppen (Frauen, Kinder, alte Menschen, Menschen mit HIV-Infektion). Als wichtigste Bestandteile von Lehrveranstaltungen wurden Fallbeispiele und Patientenvorstellungen gewünscht.Schlussfolgerung Die Analyse der gegenwärtig vorgeschlagenen Curricula für eine universitäre Lehrveranstaltungen in Schmerztherapie ergibt, dass die Curricula der IASP und der EFIC zu umfangreich bzw. zu theoretisch orientiert sind. Das Curriculum der DGSS deckt sich weitgehend mit den Wünschen von Studierenden. Fakultative Lehrveranstaltungen zur Schmerztherapie sollten die ermittelten Wünsche der Studierenden in der Themenauswahl und in den didaktischen Methoden berücksichtigen.     

TSE-sequences with spin-echo contrast.

The article presents a discussion of the basic signal behavior of contrast-modified RARE(TSE,FSE...)-sequences which have been modified such that the echo train used for image encoding is preceded by a long echo interval in order to introduce the T(2)-contrast of conventional spin-echo sequences while maintaining the high imaging speed of TSE. Sequences aimed at breathhold abdominal imaging as well as for the detection of hemorrhages in the CNS have been implemented and optimized. The significant difference in image contrast at identical echo times compared to unmodified TSE is demonstrated for different tissues.