Brain imaging in pregnant women with acute headache

Background

Brain imaging is one of the most important diagnostic methods for evaluating headache during pregnancy. In this study, we aimed to identify anamnestic and clinical predictors for pathological brain imaging findings in pregnant women suffering from acute headache.

Methods

We conducted a retrospective chart review of 151 pregnant women with acute headache between 2010 and 2016. We screened the medical records of these patients and analyzed radiological variables, including brain imaging frequency and modality, delay to imaging and imaging findings. In patients with brain imaging, we compared several anamnestic and clinical features between those with and without symptomatic pathological findings.

Results

Half of the patients (50.3%) underwent brain imaging, mainly magnetic resonance imaging (MRI) including venography (53.9%) or MRI including both venography and arteriography (31.6%). Symptomatic pathological results could be observed in 27.6% of the patients with a brain scan. Patients in the first trimester with acute headache had a statistically higher risk for a symptomatic pathological imaging finding (p?=?0.024). Strong pain intensity, a reduced level of consciousness and seizures were significantly associated with a symptomatic pathological imaging outcome across all stages of pregnancy.

Conclusion

Brain imaging may reveal a secondary headache etiology in more than 25% of pregnant women presenting with acute headache. In particular, when the acute headache is of severe intensity, and the headache is accompanied by seizures or a change in consciousness, brain imaging is required.

     

Interaction of the cholinergic system and the hypothalamic-pituitary-adrenal axis as a risk factor for depression: evidence from a genetic association study

Chronic stress and related disruption of hypothalamic-pituitary-adrenal axis reactivity is a known risk factor for depression. Besides its effects on glucocorticoids, stress also impacts the cholinergic system. Therefore, the interaction of two polymorphisms, one on the cholinergic CHRNA4 receptor gene and one on the glucocorticoid receptor gene (NR3C1), on depression was investigated. In a sample of 800 healthy participants, we genotyped for the BCL1 rs41423247 and the CHRNA4 rs1044396 single-nucleotide polymorphisms and assessed depressiveness by means of the Beck Depression Inventory. We identified a significant epistasis effect BCL1 by CHRNA4 showing that carriers of the CC genotype at the BCL1 locus who were also homozygous for the T allele at the CHRNA4 locus had the highest depression scores. This is the first evidence from molecular genetics to show that the hypothalamic-pituitary-adrenal axis and the cholinergic system--both involved in stress reactivity--represent a combined risk factor for depression.     

Multiple cerebral infarctions in a patient with Churg-Strauss syndrome

Neurological manifestation of Churg-Strauss syndrome (CSS) is common and usually consists of peripheral neuropathy due to small-vessel vasculitis, while cerebral manifestation is less frequent. We report the case of a 77-year-old woman with multiple cerebral infarctions and hypereosinophilia. The presence of hypereosinophilia, asthma, sinusitis and vasculitis led to the diagnosis of CSS. As cerebral infarctions occurred monophasically and an elevation of heart enzymes was present, we assumed cardiac involvement and multiple cerebral infarctions due to cardiac embolism. Treatment with high-dose IV methylprednisone and cyclophosphamide pulses led to significant improvement. This case illustrates multiple cerebral infarctions in CSS. CSS should always be considered in patients with hypereosinophilia and stroke.     

Near-death experiences are associated with rapid eye movement (REM) sleep intrusions in migraine patients,independent of migraine aura

Background and purpose

Migraine aura, near-death experiences (NDEs), and rapid eye movement (REM) sleep intrusions might share common mechanisms. Here, we investigated the prevalence of NDEs and REM sleep intrusions in people with migraine. We hypothesized that NDEs and REM sleep intrusions are more prevalent in migraine patients with aura than in those without.

Methods

We conducted a prospective cross-sectional cohort study at a tertiary headache center, based on a prespecified sample size (n = 808). Migraine patients completed a series of questionnaires, including questions about demographic and headache characteristics, the 16-item Greyson NDE scale, four questions about REM sleep intrusions, and the Depression, Anxiety, and Stress Scale 21 (DASS-21).

Results

Of 808 migraine patients (mean age 44.4 ± 13.3 years, 87.0% women), 353 (43.7%) had a current or previous history of migraine aura. Prevalence of NDE was 2.7% and not different in patients with and without aura (2.8% vs. 2.6%; p > 0.999). REM sleep intrusions were reported by 5.4% of participants and in a similar proportion of patients with and without aura (6.3% vs. 4.9%; p = 0.43). However, participants with REM sleep intrusions had had an NDE more often than participants without REM sleep intrusions (n = 5/44, 11.4% vs. n = 17/754, 2.2%; p = 0.005). Higher DASS-21 scores were associated with REM sleep intrusions (p < 0.001).

Conclusions

In this tertiary center cohort study, the prevalence of NDE and REM sleep intrusions was not influenced by migraine aura status. However, we identified an association between NDE and REM sleep intrusions, which corroborates the notion that they might share pathophysiological mechanisms.     

Glyceroltrinitrate facilitates stimulated CGRP release but not gene expression of CGRP or its receptor components in rat trigeminal ganglia

Nitric oxide (NO) donors induce delayed headaches in migraineurs. In a corresponding rat model NO donors cause delayed ongoing activity in central trigeminal neurons which process intracranial afferent input. Cellular models indicate that NO may increase the release or production of calcitonin gene-related peptide (CGRP), a key mediator in primary headaches. CGRP release from intact isolated trigeminal ganglia of adult male Wistar rats was investigated in vitro. Exposure to high NO donor concentrations did not affect basal or stimulated CGRP release. After a two hour infusion of the NO donor glyceroltrinitrate (250 μg/kg/h), however, inflammatory mediators-induced CGRP release was 80% higher compared to control animals. Administration of the soluble guanylate cyclase inhibitor ODQ or the application of 8Br–cGMP revealed a cGMP-independent mechanism. In four groups of separate experiments total mRNA was extracted from rat trigeminal ganglia up to 6 h after glyceroltrinitrate or saline infusion. Gene expression of CGRP and the CGRP-receptor components, receptor activity-modifying protein 1, receptor component protein and calcitonin receptor-like receptor was measured by quantitative RT-PCR. Glyceroltrinitrate infusion did not change mRNA levels of these genes compared to infusion of saline. The present data suggest that prolonged increase in NO levels facilitates stimulated CGRP release from trigeminal ganglion neurons. The underlying mechanism appears to be independent of the cGMP pathway and not to interact with CGRP in the trigeminal ganglion. Delayed headaches induced by NO may change CGRP or CGRP-receptor expression.     

Intracisternal injection of inflammatory soup activates the trigeminal nerve system

The release of calcitonin gene-related peptide (CGRP) and sensitization of the trigeminal nerve system are important elements in migraine pathophysiology. Sensitization can be induced by topical meningeal administration of inflammatory soup (IS). CGRP release is a marker of trigeminal nerve activation. We examined the effect of intracisternal IS administration on CGRP release in rat jugular vein blood at baseline, 2 and 15 min after the beginning of IS infusion. IS administration caused a significant increase of CGRP levels after 2 and 15 min compared with baseline. Daily oral treatment with topiramate for 4 and 8 weeks led to a dose- and time-dependent reduction of IS-induced CGRP release. Sumatriptan also attenuated stimulated neuropeptide release. These results indicate that intracisternal IS administration leads to activation of the trigeminal system. The inhibition of CGRP release by topiramate offers a possible mechanism that may in part account for the preventative antimigraine activity of this drug.     

Follicle size by ultrasound versus cervical mucus quality: normal and abnormal patterns in spontaneous cycles

Ultrasound (US) has been demonstrated to be the method of choice for diagnosing luteinized unruptured follicle syndrome and to be a valuable adjuvant in the assessment of luteal phase defect. In this prospective study, the use of US with postcoital testing (PCT) is evaluated. Fifty control infertility patients were examined with serial US for follicle dynamics in conjunction with PCT. Standard curves for follicle dynamics versus cervical mucus quality (Insler score) were calculated. Eighteen patients referred for abnormal mucus underwent similar evaluation. Their follicle dynamics versus mucus quality were compared with those of the controls. The findings were: (1) there is a predictable relationship between follicle size and mucus quality, (2) the majority of patients with abnormal mucus have normal follicular dynamics, and (3) a minority of patients with abnormal mucus have either a narrow mucus window or abnormal follicular dynamics. In addition, US was found to be cost-effective in the overall fertility evaluation.     

Mucociliary activity of free transplanted respiratory epithelium]

The function of free grafted respiratory epithelium was investigated in inbred rats. In nine of ten animals it could be shown that the respiratory epithelium not only regenerated as an epithelial surface lining but also regained mucociliary activity. The grafted epithelium was able to secrete mucus, which was equal in protein fragmentation to the secretion of normal nasal mucosa. The grafted respiratory epithelium showed normal ciliary function which could be demonstrated by recording the ciliary beat pattern present and by subsequent histological examination. Morphologically, a regular structure of ciliae (9 + 2) was found on the upper pole of the regenerated ciliated cells.