Migrena – patofiziologija boli

Migraine is a primary episodic headache disorder characterized by a cascade of events that involve various combinations of neurologic, gastrointestinal and autonomic changes. Headache is probably caused by activation of meningeal and blood vessel nociceptors combined with an alteration in central pain modulation. Headache and its associated neuro-vascular changes are subserved by the trigeminal system. A link also exists between the migraine aura and headache. Cortical spreading depression (CSD) activates trigeminovascular afferents, causing a long-lasting increase in middle meningeal arterial blood flow and polypeptide release within the dura mater. The neuropeptides interact with the blood vessel wall, producing dilatation, plasma protein extravasation, and platelet activation. Neurogenic inflammation sensitizes nerve fibers (peripheral sensitization) that now respond to previously innocuous st imuli, such as blood vessel pulsations, causing, in part, the pain of migraine.Migrena je primarna glavobolja epizodnog karaktera karakterizirana nizom događaja koji uključuju kombinacije neuroloških, gastrointestinalnih i autonomnih promjena. Glavobolja je vjerojatno uzrokovana aktivacijom nociceptora u meningama i u stjenci krvnih žila, u kombinaciji s poremećajem u centralnoj modulaciji boli. Glavobolja i pridružene neurovaskularne promjene povezane su s trigeminalnim sustavom. Postoji također veza između migrenske aure i glavobolje. Kortikalna šireća depresija aktivira trigeminovaskularna aferentna vlakna, uslijed čega dolazi do dugotrajnog porasta protoka u srednjoj meningealnoj arteriji kao i u otpuštanju polipeptida unutar dure. Uslijed interakcije neuropeptida i stijenke krvne žile dolazi do dilatacije, ekstravazacije proteina plazme te aktivacije trombocita. Upala senzitizira živčana vlakna (periferna senzitizacija) te oni sad reagiraju na prethodno bezazlen podražaj, npr. pulzacije krvne žile, uzrokujući, barem djelomično, migrensku bol

Procjena indeksa zadržavanja daha tijekom ortostaze

The aim of the study was to assess differences in cerebrovascular reactivity in healthy subjects during orthostasis. Twenty healthy volunteers (11 men and 9 women) with no atherosclerotic risk factors were evaluated by use of transcranial Doppler. The breath holding index (BHI) was obtained in supine and upright posture using standardized procedure. Student\u27s t-test was used on comparison of the mean blood flow velocities (MBFV) and BHI between supine and upright posture and between the left and right side of the body. The middle cerebral artery MBFV in supine posture was 66.6 cm/s on the right side and 68.5 cm/s on the left side and in upright posture 60.6 cm/s on the right side and 62.3 cm/s on the left side. There was no significant MBFV difference either between supine and upright posture or between male and female subjects. The mean BHI in supine posture was 1.59 on the right side, 1.65 on the left side, and in upright posture 1.63 on the right side and 1.7 on the left side, without significant sex difference. There was no statistically significant differences in BHI between supine and upright posture (P=0.81 and P=0.68 for the right and left side, respectively) or between the two sides of the body in supine (P=0.71) and upright posture (P=0.8). in conclusion, evaluation of cerebrovascular reactivity yielded no significant difference in BHI values during orthostatic stress.Cilj ovoga istraživanja bio je ispitati postojanje razlike cerebrovaskularne reaktivnosti u zdravih ispitanika tijekom ortostaze. Metodom transkranijskog doplera pregledano je 20 zdravih ispitanika (11 muškaraca i 9 žena) bez prisutnih čimbenika rizika za razvoj aterosklerotske bolesti. Vrijednosti indeksa zadržavanja daha (IZD) određene su u ležećem i stojećem stavu na standardiziran način. Studentov t-test primijenjen je za usporedbu srednjih brzina strujanja krvi i IZD između ležećeg i stojećeg stava te u odnosu strana. Srednja brzina strujanja krvi u srednjoj cerebralnoj arteriji u ležećem stavu ispitanika bila je 66,6 cm/s desno i 68,5 cm/s lijevo, a u stojećem stavu 60,6 cm/s desno i 62,3 cm/s lijevo. Nije bilo značajne razlike u vrijednosti brzine strujanja krvi između ležećeg i stojećeg stava ispitanika kao niti između spolova. Prosječna vrijednost IZD u ležećem stavu bila je 1,59 desno, 1,65 lijevo, a u stojećem stavu 1,63 desno te 1,7 lijevo, podjednaka za oba spola. Statističkom obradom nije nađena razlika u vrijednosti IZD uspoređujući ležeći i stojeći stav (P=0,81 za desnu stranu, P=0,68 za lijevu stranu), a niti uspoređujući dvije strane u ležećem (P=0,71) i stojećem stavu (P=0,8). Nisu zabilježene značajne razlike IZD u procjeni cerebrovaskularne reaktivnosti tijekom ortostatskog stresa

Procjena indeksa zadržavanja daha tijekom ortostaze

The aim of the study was to assess differences in cerebrovascular reactivity in healthy subjects during orthostasis. Twenty healthy volunteers (11 men and 9 women) with no atherosclerotic risk factors were evaluated by use of transcranial Doppler. The breath holding index (BHI) was obtained in supine and upright posture using standardized procedure. Student\u27s t-test was used on comparison of the mean blood flow velocities (MBFV) and BHI between supine and upright posture and between the left and right side of the body. The middle cerebral artery MBFV in supine posture was 66.6 cm/s on the right side and 68.5 cm/s on the left side and in upright posture 60.6 cm/s on the right side and 62.3 cm/s on the left side. There was no significant MBFV difference either between supine and upright posture or between male and female subjects. The mean BHI in supine posture was 1.59 on the right side, 1.65 on the left side, and in upright posture 1.63 on the right side and 1.7 on the left side, without significant sex difference. There was no statistically significant differences in BHI between supine and upright posture (P=0.81 and P=0.68 for the right and left side, respectively) or between the two sides of the body in supine (P=0.71) and upright posture (P=0.8). in conclusion, evaluation of cerebrovascular reactivity yielded no significant difference in BHI values during orthostatic stress.Cilj ovoga istraživanja bio je ispitati postojanje razlike cerebrovaskularne reaktivnosti u zdravih ispitanika tijekom ortostaze. Metodom transkranijskog doplera pregledano je 20 zdravih ispitanika (11 muškaraca i 9 žena) bez prisutnih čimbenika rizika za razvoj aterosklerotske bolesti. Vrijednosti indeksa zadržavanja daha (IZD) određene su u ležećem i stojećem stavu na standardiziran način. Studentov t-test primijenjen je za usporedbu srednjih brzina strujanja krvi i IZD između ležećeg i stojećeg stava te u odnosu strana. Srednja brzina strujanja krvi u srednjoj cerebralnoj arteriji u ležećem stavu ispitanika bila je 66,6 cm/s desno i 68,5 cm/s lijevo, a u stojećem stavu 60,6 cm/s desno i 62,3 cm/s lijevo. Nije bilo značajne razlike u vrijednosti brzine strujanja krvi između ležećeg i stojećeg stava ispitanika kao niti između spolova. Prosječna vrijednost IZD u ležećem stavu bila je 1,59 desno, 1,65 lijevo, a u stojećem stavu 1,63 desno te 1,7 lijevo, podjednaka za oba spola. Statističkom obradom nije nađena razlika u vrijednosti IZD uspoređujući ležeći i stojeći stav (P=0,81 za desnu stranu, P=0,68 za lijevu stranu), a niti uspoređujući dvije strane u ležećem (P=0,71) i stojećem stavu (P=0,8). Nisu zabilježene značajne razlike IZD u procjeni cerebrovaskularne reaktivnosti tijekom ortostatskog stresa

Prikaz medijanog živca ultrazvukom visoke rezolucije u zdravih ispitanika

Although electroneuro- and electromyography are still the leading diagnostic methods for investigation of peripheral nerve function, they do not provide information on their morphology. This study was conducted to evaluate the suitability of ultrasonography in visualization of median nerve in healthy volunteers. Twenty five asymptomatic volunteers (17 women and 8 men), age range 21- 47 years, participated in the study. Body height was measured and handedness ascertained, as well as average time spent daily working on a computer. The device used was Aloka Prosound Alpha 10 Premier with a 13-MHz probe, using custom preset for musculoskeletal sonography. The following dimensions of median nerve at the pisiform bone level were measured bilaterally: cross-sectional area (CSA), circumference, and longer and shorter diameter. Using the latter values, the flattening ratio (FR) was calculated. Median nerve and the surrounding soft tissue structures were easily depicted in all study subjects. The mean median nerve CSA was 9.70 mm2 (range 5-15 mm2,SD2.25 mm2), mean FR (longer/shorter diameter) 4.04 (range2.16-6.08), and median height 172.72 cm. Only one subject was left-handed. The mean time spent daily working on a computer (overall mean of 3.2 h/day) did not correlate with either CSA or FR for the dominant hand. In four subjects, an aberrant artery accompanying median nerve was visualized. High-resolution sonographic imaging is a fast and noninvasive method for assessment of various morphological properties of median nerve and can be used to enhance diagnostic efficiency.Iako su elektroneuro- i elektromiografija još uvijek vodeće dijagnostičke metode u ispitivanju funkcije perifernih živaca, one ne pružaju informacije o njihovoj morfologiji. Cilj studije bio je procijeniti prikladnost visokorezolucijske ultrasonografije u slikovnom prikazivanju medijanog živca u asimptomatskih dobrovoljaca. U studiji je sudjelovalo 25 asimptomatskih dobrovoljaca u dobi od 21 do 47 godina. Na uređaju Aloka Prosound Alpha 10 Premier (sonda 13 MHz) izmjerene su obostrano slijedeće dimenzije medijanog živca (razina os pisiforme): površina presjeka (CSA, cross-sectional area), opseg, duži i kraci promjer, te je izračunat omjer stješnjenja (FR flattening ratio). Izmjerena je visina ispitanika, utvrđena dominantnost ruke, kao i prosječno vrijeme koje ispitanici provedu na dan radeći za računalom (moguć čimbenik za kompresiju živca u dominantnoj ruci). Prosječna CSA medijanog živca bila je 9.70 mm2 (raspon 5-15 mm2, standardna devijacija od 2.25 mm2). Srednji omjer stješnjenja (duži promjer/kraći promjer) bio je 4.04, raspona od 2.16 do 6.08. Srednja visina ispitanika bila je 172.72 cm i samo je jedan ispitanik bio ljevak, dok je ostalima (96%) desna ruka bila dominantna. Prosječno vrijeme rada za računalom na dan (ukupni prosjek 3,2 h/dan) nije koreliralo s CSA ili FR dominantne ruke. Nadalje, u jednog je ispitanika nađen podvojeni medijani živac (n. medianus bifidus), dok se u dvoje ispitanika prikazala anomalna arterija koja prati medijani živac (a. mediana). Sonografski prikaz visoke rezolucije omogućuje utvrđivanje različitih morfoloških karakteristika medijanog živca, uključujući njegove različite dimenzije i eho arhitekturu. Uz to, ultrazvučni prikaz je izrazito prikladan (dostupan, brz, relativno jeftin i neinvazivan) kao metoda procjene morfologije perifernog živčevlja i može se stoga rabiti u svrhu povećanja dijagnostičke sigurnosti

Bolest kontralateralne karotide u bolesnika s okluzijom unutarnje karotidne arterije

The one-year incidence of carotid occlusion is 6/100 000 inhabitants in general population. Stroke incidence and mortality rate in these patients vary. Patients that underwent carotid endarterectomy (CES) are at a higher risk of progression of contralateral carotid stenosis. The aim of the study was to investigate the management and natural history of the contralateral internal carotid artery disease in patients with internal carotid artery occlusion (ICAO). During one year, 297 patients with ICAO were investigated. Follow up examinations were retrospectively analyzed and patients were divided into groups according to contralateral carotid disease. Out of 297 patients, only one investigation was performed in 90 patients with carotid occlusion. Thirty three patients were followed up due to postoperative ICAO. In 14 patients, ICAO developed during ultrasonographic follow up. In this group of patients, 9 had unchanged contralateral findings, whereas in 5 patients disease progression was observed. Out of 44 patients with ICAO and contralateral subtotal stenosis at initial investigation, 42 underwent carotid surgery. Postoperatively, 32 patients had normal findings, 6 developed mild carotid stenosis, 2 developed moderate carotid stenosis, and 2 had postoperative carotid occlusion. Two patients were followed-up without intervention. Nine patients with bilateral ICAO were followed-up for years. Follow up was continued in 106 patients with ICAO and contralateral mild to moderate changes. The finding was unchanged in 68 patients. In 21 (30%) patients the disease progressed to subtotal stenosis and 18 patients underwent carotid surgery. Accordingly, contralateral carotid disease progression was observed in one third of patients with carotid occlusion. Additional studies on the issue are needed.Godišnja incidencija okluzije unutarnje karotidne arterije (ACI) u općoj populaciji je 6/100.000 stanovnika. Godišnja razina moždanih udara i smrti vezanih uz okluziju ACI varira. U bolesnika u kojih je učinjena karotidna endarterektomija postoji povećani rizik progresije kontralateralne karotidne stenoze. Cilj ove studije bio je prikazati stanje kontralateralne karotidne bolesti u bolesnika s karotidnom okluzijom. U jednogodišnjem razdoblju u Cerebrovaskularnom laboratoriju Klinike za neurologiju pregledano je 8.000 bolesnika obojenim doplerom karotidnih arterija prema protokolu. Zabilježeno je 297 bolesnika s okluzijom ACI. Retrospektivno su analizirani nalazi doplera te su bolesnici prema nalazu na kontralateralnoj karotidnoj arteriji svrstani u 6 skupina. Okluzija ACI otkrivena je na prvom pregledu u 90 od 297 bolesnika. Poslijeoperacijski se okluzija razvila u 33 bolesnika. U 14 bolesnika okluzija je nastala tijekom praćenja. Kontralateralno je 9 bolesnika iz ove skupine imalo nepromijenjen nalaz, dok je u 5 zabilježena progresija bolesti. Operirana su 42 od 44 bolesnika s okluzijom ACI i subtotalnom stenozom kontralateralno na prvom pregledu. Poslijeoperacijski je 32 bolesnika imalo uredan nalaz, 6 je razvilo početnu stenozu, 2 umjerenu stenozu, a 2 poslijeoperacijsku okluziju ACI. Dvoje bolesnika je dalje praćeno bez intervencije. Devetoro bolesnika s obostranom okluzijom ACI praćeno je 4,9 godina. Praćenje je nastavljeno i u 106 bolesnika s okluzijom ACI te kontralateralno početnim do umjerenim promjenama. Nalaz je bio nepromijenjen u 68 bolesnika. U 21 (30%) bolesnika stenoza je napredovala do subtotalne, a 18 bolesnika je operirano. Dakle, progresija kontralateralne karotidne bolesti nastupila je u trećine bolesnika s okluzijom ACI

Razvoj poslijeoperacijske okluzije karotidne arterije zbog prisutnosti rizičnih čimbenika

Postoperative internal carotid artery (ICA) occlusion is a rare condition with few data on the risk factors. The aim of the study was to analyze risk factors and ischemic symptomatology in patients with postoperative ICA occlusion. During one year period, 33 patients with postoperative ICA occlusion were examined at Cerebrovascular Laboratory. Medical history, clinical findings and atherosclerosis risk factors were compared with data on 33patients with satisfactory postoperative finding. Student\u27s t-test was used on data comparison (P<0.05). In 31 of 33 patients, ICA occlusion was recorded on the first postoperative examination, 3 months after carotid endarterectomy (18 right and 15 left). In 8 patients, combined occlusion of the common carotid artery and ICA was found (4 right, 4 left). One patient ICA developed occlusion during the first and third postoperative year each. Clinically, three patients presented with ischemic symptoms (one stroke and two transitory ischemic attacks (TIA)). The following risk factors were present in the group with postoperative ICA occlusion: hypertension in 18, smoking in 10, hyperlipidemia in 8, diabetes mellitus in 9, history of stroke in 13, TIA in 3, heart attack in 4 and coronary disease in 3 patients; the respective figures in the control group were as follows: 25, 11, 16, 7, 7, 3, 4 and 3. There was no significant between-group difference in the presence of risk factors. Study results suggested that postoperative ICA occlusion was not caused by atherosclerosis risk factors but by perioperative complications.Poslijeoperacijska okluzija unutarnje karotidne arterije je rijetka komplikacija s nedovoljno poznatim rizičnim čimbenicima. Cilj ove studije bio je analizirati čimbenike rizika ateroskleroze i simptome ishemije kod bolesnika s okluzijom karotidne arterije nakon karotidne endarterektomije. Tijekom godine dana je u Cerebrovaskularnom laboratoriju pregledano 33 bolesnika s poslijeoperacijskom okluzijom unutarnje karotidne arterije. Uzeti su anamnestički podaci, analizirana je klinička slika, te čimbenici rizika ateroskleroze. Podaci su uspoređeni s podacima 33 bolesnika sa zadovoljavajućim poslijeoperacijskim nalazom. Podaci su uspoređeni Studentovim t-testom. U 31 od 33 bolesnika okluzija je ustanovljena tijekom prvog pregleda 3 mjeseca nakon karotidne endarterektomije, u troje bolesnika uz pojavu ishemijske simptomatologije. U 8 bolesnika zabilježena je poslijeoperacijska okluzija cijelog karotidnog stabla. U jednog je bolesnika okluzija nastala tijekom prve godine praćenja. dok je u jednog nastupila nakon tri godine. Čimbenici rizika ateroskleroze u skupini s poslijeoperacijskom okluzijom su bili: hipertenzija u 18, pušenje u 10, hiperlipidemija u 8, dijabetes melitus u 9, preboljeli moždani udar u 13, preboljela TIA u 3, infarkt miokarda u 4, angina pektoris u 3 bolesnika, dok su u skupini sa zadovoljavajućim poslijeoperacijskim nalazom to bili: hipertenzija u 25, pušenje u 11, hiperlipidemija u 16, dijabetes melitus u 7, preboljeli moždani udar u 7, preboljela TIA u 3, infarkt miokarda u 4, angina pektoris u 3 bolesnika. Nije bilo značajne razlike u prisutnim čimbenicima rizika. Dakle, rana poslijeoperacijska okluzija karotidne arterije najvjerojatnije nije uzrokovana uobičajenim čimbenicima rizika ateroskleroze, nego periproceduralnim komplikacijama

Pinealne ciste - pregledni osvrt

Pineal cysts occur in all ages, predominantly in adults in the fourth decade of life. In series of magnetic resonance imaging (MRI) studies, the prevalence of pineal cysts ranged between 1.3% and 4.3% of patients examined for various neurologic reasons and up to 10.8% of asymptomatic healthy volunteers. The diagnosis of pineal cyst is usually established by MRI with defined radiological criteria to distinguish benign pineal cyst from tumors of this area. A recent study demonstrated the findings obtained by transcranial sonography to correspond to those obtained by MRI in the detection of both pineal gland cyst and pineal gland itself, and could be used in the future mainly as follow up examination. Pineal cysts usually have no clinical implications and remain asymptomatic for years. The most common symptoms include headache, vertigo, visual and oculomotor disturbances, and obstructive hydrocephalus. Less frequently, patients present with ataxia, motor and sensory impairment, mental and emotional disturbances, epilepsy, circadian rhythm disturbances, hypothalamic dysfunction of precocious puberty, and recently described occurrence of secondary parkinsonism. Symptomatic cysts vary in size from 7 mm to 45 mm, whereas asymptomatic cysts are usually less than 10 mm in diameter, although a relationship between the cyst size and the onset of symptoms has been proved to be irrelevant in many cases. There is agree-ment that surgical intervention should be undertaken in patients presenting with hydrocephalus, progression of neurologic symptoms, or cyst enlargement. Tissue sample of the pineal lesion can be obtained by open surgery, stereotaxy and neuroendoscopy.Pinealne ciste se pojavljuju u svim dobnim skupinama, a najviše kod odraslih u 4. desetljeću života. U nalazima magnetske rezonance (MR) mozga pojavljuju se kod 1,3% do 4,3% bolesnika s različitim neurološkim simptomima te kod 10,8% asimptomatskih zdravih dobrovoljaca. Dijagnoza ciste pinealne žlijezde se postavlja pomoću MR mozga s utvrđenim radiološkim kriterijima koji razlikuju benignu pinealnu cistu od ostalih tumora ove regije. Nedavne studije pomoću transkranijske sonografije (TCS) mozga su pokazale da TCS može prikazati pinealnu žlijezdu i cistu, a nalazi odgovaraju nalazima na MR mozga. TCS se u budućnosti može upotrebljavati u praćenju veličine ciste pinealne žlijezde. Pinealne ciste najčešće nemaju kliničkog značenja te ostaju asimptomatske godinama. Najznačajniji simptomi su glavobolja, vrtoglavica, vidni i okulomotorni simptomi te opstruktivni hidrocefalus. Rjeđe se opisuju ataksija, osjetna i motorička oštećenja. mentalne i emocionalne tegobe, epilepsija, poremećaj cirkadijanog ritma, hipotalamične disfunkcije te sekundarni parkinsonizam. Simptomatske ciste mogu biti promjera od 7 mm do 45 mm, dok su asimptomatske ciste promjera do 10 mm, iako dosadašnje studije pokazuju kako veličima ciste i pojava simptoma ne moraju biti povezane. Postoji suglasnost da se operacijski zahvat provodi kod bolesnika s hidrocefalusom, progresijom neuroloških simptoma ili kod povećanja ciste pinealne žlijezde. Uzorak tkiva može se dobiti otvorenom operacijom, stereotaksijom ili neuroendoskopijom

Transkranijska sonografija u procjeni oštećenja pinealne žlijezde

We have recently reported that transcranial sonography (TCS) is a method competitive to magnetic resonance neuroimaging (MRI) in the evaluation of pineal gland lesions. The aim of the present is study was to assess the usefulness of TCS in a larger patient sample during a two-year follow up. Twenty patients with incidental pineal gland cyst (PGC) detected by MRI scan of the brain and 40 healthy controls without any previous documented data on a disease related to pineal gland were evaluated by TCS and compared with MRI scans. There were no statistically significant differences in PGC size measured by TCS by two observers (p=0.475), PGC size measured by TCS and MRI (first observer, p=0.453; and second observer, p=0.425), size of the pineal gland measured by TCS and MRI in control group (first observer, p=0.497; and second observer, p=0.370), and pineal gland size measured by TCS by two observers in control group (p=0.473). Study results suggested TCS to be a suitable method in the evaluation of pineal gland lesions. Although its resolution cannot match the MRI resolution, its repeatability and accuracy might add to its practical value. We suggest that the repeat MRI scan of such lesions might be replaced by clinical and TCS follow up.Naša prethodna studija je pokazala da je transkranijska sonografija (TCS) moždanog parenhima kompetitivna metodi magnetske rezonancije (MRI) u procjeni pinealne žlijezde. Cilj ove studije bio je pokazati mogućnosti TCS u bilježenju signala pinealne žlijezde i njene cistične morfologije te pokazati korelaciju sa snimkama MRI na većem broju bolesnika kroz dvije godine praćenja. U studiju je bilo uključeno 20 bolesnika s novootkrivenom cistom pinealne žlijezde na MRI i 40 kontrolnih osoba. Snimanje TCS je provelo dvoje neovisnih istraživača na uređaju Aloka SSD-5500 i bez uvida u rezultate MRI. Pinealna cista je označena kao svaka hipoehogena struktura unutar hiperehogene zone žljezdanog tkiva ili hipoehogena lezija sa septumom ili bez njega, okružena tankom ehogenom linijom. širine žlijezde i lezije su izmjerene u latero-lateralnoj i antero-posteriornoj projekciji te uspoređene s rezultatima snimaka MRI. Podaci su obrađeni analizom ANOVA. Rezultati nisu pokazali statistički značajnu razliku između rezultata dvoje istraživača na TCS (p=0,475), veličine ciste mjerene pomoću TCS i MRI (prvi istraživač, p=0,453; drugi istraživač, p=0,425) i veličine pinealne žlijezde mjerene pomoću TCS u kontrolnoj skupini (p=0,473). Rezultati studije pokazuju mogućnosti TCS u otkrivanju pinealne regije uz dobru korelaciju s rezultatima MRI i značajnu podudarnost u rezultatima između dvoje neovisnih ispitivača. TCS se pokazala kao metoda kompetitivna metodi MRI u evaluaciji pinealnih cista, te ukazuje na mogućnost praćenja bolesnika kliničkim pregledom i pomoću TCS