Cardiac safety in cluster headache patients using the very high dose of verapamil (≥720?mg/day)

Use of high doses of verapamil in preventive treatment of cluster headache (CH) is limited by cardiac toxicity. We systematically assess the cardiac safety of the very high dose of verapamil (verapamil VHD) in CH patients. Our work was a study performed in two French headache centers (Marseilles-Nice) from 12/2005 to 12/2008. CH patients treated with verapamil VHD (≥720 mg) were considered with a systematic electrocardiogram (EKG) monitoring. Among 200 CH patients, 29 (14.8%) used verapamil VHD (877±227 mg/day). Incidence of EKG changes was 38% (11/29). Seven (24%) patients presented bradycardia considered as nonserious adverse event (NSAE) and four (14%) patients presented arrhythmia (heart block) considered as serious adverse event (SAE). Patients with EKG changes (1,003±295 mg/day) were taking higher doses than those without EKG changes (800±143 mg/day), but doses were similar in patients with SAE (990±316 mg/day) and those with NSAE (1,011±309 mg/day). Around three-quarters (8/11) of patients presented a delayed-onset cardiac adverse event (delay ≥2 years). Our work confirms the need for systematic EKG monitoring in CH patients treated with verapamil. Such cardiac safety assessment must be continued even for patients using VHD without any adverse event for a long time.     

Evaluation of an IGM‐specific ELISA for early detection of bluetongue virus infections in domestic ruminants sera

Competitive‐ELISA (c‐ELISA) is the most widely used serological test for the detection of Bluetongue virus (BTV) viral protein 7 (VP7) antibodies (Ab). However, these BTV c‐ELISAs cannot to distinguish between IgG and IgM. IgM Ab are generated shortly after the primary immune response against an infectious agent, indicating a recent infection or exposure to antigens, such as after vaccination. Because the BTV genome or anti‐VP7 Ab can be detected in ruminant blood months after infection, BTV diagnostic tools cannot discriminate between recent and old infections. In this study, we evaluated an IgM‐capture ELISA prototype to detect ruminant anti‐BTV VP7 IgM on 1,650 serum samples from cattle, sheep, or goats. Animals were BTV‐naive, infected, or/and vaccinated with BTV‐1, ‐2, ‐4, ‐8, ‐9, ‐16, or ‐27, and we also included 30 sera from cattle infected with the Epizootic haemorrhagic disease virus (EHDV) serotype 6. Results demonstrated that this ELISA kit is specific and can detect the presence of IgM with satisfactory diagnostic specificity and sensitivity from 1 to 5 weeks after BTV infection in domestic ruminants (for goats and cattle; for sheep, at least up to 24 days). The peak of anti‐VP7 IgM was reached when the level of infectious viruses and BTV RNA in blood were the highest. The possibility of detecting BTV‐RNA in IgM‐positive sera allows the amplification and sequencing of the partial RNA segment 2 (encoding the serotype specific to VP2) to determine the causative BTV serotype/strain. Therefore, BTV IgM ELISA can detect the introduction of BTV (or EHDV) in an area with BTV‐seropositive domestic animals regardless of their serological BTV status. This approach may also be of particular interest for retrospective epidemiological studies on frozen serum samples.     

Transient global amnesia followed by vertebrobasilar ischemia in a case of dolichoectatic basilar artery

A 59-year-old hypertensive patient presented with transient global amnesia without neurological signs or symptoms. During the following 3 years, he experienced several attacks of vertebrobasilar insufficiency and a cerebellar infarction. CT scan and MRI found a partially thrombosed dolichoectatic basilar artery but no significant lesion within the limbic system. These data suggest transient global amnesia was due to a transient ischemia in the basilar artery distribution.     

Endoscopic treatment of a voluminous benign symptomatic cyst of the pineal region responsible for an obstructive hydrocephalus

Asymptomatic non neoplastic cysts of the pineal region are common incidental findings in adults. On the contrary, voluminous and symptomatic cysts of the pineal region are rare and their management are not well defined. We present the case of a 32-year-old woman suffering who suffered from mild intracranial hypertension, gait disturbance and vertigo for one year. The neuroradiological workup showed a voluminous cyst of the pineal region responsible for an obstructive hydrocephalus. An endoscopic etiological treatment was decided. The operation consisted in a marsupialization of the cyst in the third ventricle with a stereotactic guidance system. A frozen section of the cyst wall failed to show tumoral cells. Immediate postoperative course was uneventful. Intracranial hypertension symptoms resolved in 24 hours. Clinical examination and neuropsychological testing were normal at two years postoperatively. The two years follow-up cerebral MRI demonstrated a remnant cystic cavity without mass effect and the patency of the aqueduct of Sylvius. Endoscopic treatment of symptomatic pineal cysts constitutes an interesting therapeutic alternative in the management of this pathology.     

Prospective controlled trial of gamma knife surgery for essential trigeminal neuralgia

OBJECT: Stereotactic radiosurgery is an alternative to conventional surgery for the treatment of trigeminal neuralgia. The authors conducted a prospective evaluation of the safety and efficacy of this method in a large series of patients. METHODS: A total of 100 patients presenting with trigeminal neuralgia were treated and followed up for a minimum of 12 months. The mean age was 68.2 years; 54 patients were male, and 46 were female. Seven had a history of multiple sclerosis, and 42 had already received conventional surgical treatment for trigeminal neuralgia. The intervention consisted of gamma knife surgery to the retrogasserian cisternal portion of the fifth cranial nerve. The median dose used at the maximum was 85 Gy (range 70-90 Gy). The number and intensity of pain attacks were recorded by the patient from 3 months before radiosurgery to a minimum of 12 months after treatment. Before and a minimum of 12 months after treatment, the patient completed a quality-of-life questionnaire. Neurological examination and quantitative sensory testing to evaluate sensory perception were performed by an independent neurologist over this same time period. At the last visit 83 of 100 patients were reported to be pain free. Fifty-eight of these 83 patients had stopped taking medication during the study. All quality-of-life parameters were improved (p < 0.001). Six patients reported facial paresthesia, and four patients reported hypesthesia. These symptoms were classified as mild. None of the complications reported for other techniques were observed. CONCLUSIONS: Radiosurgery is a safe and effective alternative treatment for trigeminal neuralgia and is associated with a particularly low rate of hypesthesia.     

Parameters That Improve Cleaning Efficiency of Subgingival Air Polishing on Titanium Implant Surfaces: An In Vitro Study

Background: This study aims to reveal how air polishing behaves on a titanium surface by evaluating the size and shape of the cleaned area and the influence of different device settings, probing depths, and cleaning movements. Methods: Forty‐eight titanium sandblasted large‐grit acid‐etched surface film‐coated disks were treated with an air abrasive system using a subgingival plastic nozzle. Two subgingival models were used: open‐ended (step 1) and defined‐size (step 2). In step 1, the most effective parameters were investigated by 5‐second static applications under different settings. In step 2, the best settings were used for dynamic application to test influence of different movements (up–down, slowly up, rotation). For both steps, powder and water consumption and total cleaned area were calculated. Results: Air pressure was the main factor with the strongest effect on cleaning. Increasing air pressure extended cleaning area. Other factors, such as nozzle depth and excessive powder flow amount, had weak influence. Cleaning effect reached deeper than the nozzle physically reached. Step 2 showed that there was no significant difference between different nozzle movements; however, cleaning efficiency decreased significantly without movement. Conclusions: For the most effective clinical use of air polishing, it should be applied with high pressure, deep insertion of nozzle, and enough water flow. Additionally, the nozzle has to be moved to get the best cleaning effect.