Mehanizmi neuroplastičnosti u patofiziologiji kronične boli

Chronic pain is a widespread healthcare problem with great impact on mental health, professional and family life of the patient. It can be a consequence of many disorders; however, its pathogenesis has not yet been fully understood. Neuroplasticity is the ability of the nervous system to adapt to different changes and it is present throughout life, not only in prenatal period, infancy and childhood. However, in the pathophysiology of chronic pain, neuroplasticity shows its “dark side”. Due to the central sensitization process, noxious stimuli can produce chronic pain or misinterpretation of non-noxious stimuli (secondary hyperalgesia and allodynia). These changes occur at the level of brain cortex as well at peripheral nerves and receptors. This review summarizes a significant portion of literature dealing with neuroplasticity processes in well known chronic pain conditions such as migraine, chronic posttraumatic headache, low back pain, fibromyalgia, and others. The relevance of this topic lies in providing a new insight in the pathophysiology of chronic pain, while also offering a possibility of new therapeutic approaches including not only pharmacological agents.Kronična bol je rašireni zdravstveni problem s velikim utjecajem na mentalno zdravlje, profesionalni i obiteljski život bolesnika. Ona može biti posljedica mnogih bolesti, ali njezina patogeneza još nije u potpunosti razjašnjena. Neuroplastičnost je sposobnost živčanog sustava da se prilagodi različitim promjenama i prisutna je tijekom cijeloga života, a ne samo u prenatalnom i dojenačkom razdoblju i djetinjstvu. Međutim, u patofiziologiji kronične boli neuroplastičnost pokazuje svoju „tamnu stranu“. Uslijed procesa središnje senzitizacije štetni podražaji uzrokuju kroničnu bol, a neštetni podražaji se tumače kao bolni (sekundarna hiperalgezija i alodinija). Ove promjene mogu se događati na razini moždane kore, ali i na razini perifernih živaca i receptora. Ovaj pregledni članak obuhvaća značajan dio literature u kojoj su prikazana istraživanja koja su se bavila procesima neuroplastičnosti u čestim kroničnim bolnim stanjima poput migrene, kronične posttraumatske glavobolje, križobolje, fibromijalgije i drugima. Značenje ove tematike je u novom pristupu patofiziologiji kronične boli, odnosno u mogućnosti pronalaženja novih terapijskih opcija u liječenju kronične boli koje ne moraju sadržavati samo farmakološka sredstva

Special Conditions in Migraine Treatment (Status Migrainosus, Menstrual Migraine, Migraine During Pregnancy and Breastfeeding)

Migrenski status je stanje perzistirajućega migrenskog napadaja trajanja dužeg od 72 sata. Liječenje se temelji na parenteralnoj primjeni analgetika, antimigrenika, antiemetika i nadoknadi tekućine. Kortikosteroidi smanjuju rizik od povrata glavobolje. Veća prevalencija migrena u žena objašnjava se povezanošću estrogena i patofizioloških mehanizama migrene. Prava menstrualna migrena javlja se isključivo u danima oko početka ciklusa i nije česta. Migrena povezana s menstruacijom javlja se na početku ciklusa, ali i u drugim danima ciklusa i znatno je češće pojavnosti. U liječenju akutnog napadaja koristi se standardna abortivna terapija. Profilaksa menstrualne migrene i migrene povezane s menstruacijom može biti kratkotrajna (mini-profilaksa) i počinje 2 dana prije i traje obično do 3. ili 4. dana ciklusa, a u tu se svrhu koriste nesteroidni antireumatici (naproksen), triptani ili hormonska terapija. Ako mini-profilaksa nije učinkovita, potrebno je započeti kontinuiranu profilaksu koja može biti klasična ili hormonska. Tijekom trudnoće i dojenja terapijske su mogućnosti ograničene zbog mogućega štetnog utjecaja lijeka na trudnoću i dijete. U akutnoj terapiji sigurni u svim stanjima su paracetamol, sumatriptan te metoklopramid. Profilaksa migrene tijekom trudnoće većinom nije potrebna jer obično nakon prvog tromjesečja dolazi do redukcije broja migrena zbog stabilno visokih razina estrogena, a ako je indicirana, sigurnom se smatra primjena propranolola. Tijekom dojenja moguća je akutna terapija gotovo svim uobičajenim lijekovima za migrenu osim opijatima i ergotaminskim preparatima, a veći je i spektar lijekova koji se mogu primijeniti radi profilakse migrene. Blokatori CGRP-a ili njegovog receptora nisu indicirani za profilaktičku terapiju tijekom trudnoće i dojenja.Status migrainosus is a condition of prolonged and continuous migraine attack lasting longer than 72 hours. Treatment is based on parenteral use of analgesics, antimigraine agents, antiemetics and intravenous rehydration. Corticosteroids reduce the risk of headache recovery. The higher prevalence of migraines in women is a result of estrogen influence on migraine pathophysiology. A pure menstrual migraine is rare, and it occurs exclusively in the days around the beginning of the menstrual cycle. A menstrually-related migraine occurs at the beginning of the cycle, but also on other days of the cycle and is significantly more common. Standard abortive therapy is used for the treatment of acute attacks. A prophylaxis of menstrual migraine and menstrually-related migraine can be short-term, and mini-prophylaxis and NSAID (naproxen), triptans or hormone therapy from two days before and until the third or fourth day of menstruation are used for this purpose. If mini-prophylaxis is not effective, continuous prophylaxis is needed using standard prophylactic medications or hormonal therapy. During pregnancy and lactation, therapeutic options are limited due to safety concerns of the effect of the medication on pregnancy and the child. In acute therapy, paracetamol, sumatriptan and metoclopramide are safe in all conditions. Migraine prophylaxis during pregnancy is rarely indicated and then the use of propranolol is considered safe. During breastfeeding, the majority of medications for acute therapy are safe for the child, except opiates and ergotamine-based medications. Greater range of preventive drugs are compatible with breastfeeding. CGRP antagonists are not indicated for migraine prophylaxis during pregnancy and breastfeeding

Noninvasive imaging of craniocervical artery dissection

Craniocervical arterial dissections (CCAD) are being increasingly identified due to growing awareness of diverse clinical picture along with advances in imaging technologies. Although rare, CCADare frequent cause of stroke in young adults. Neurosonological tests serve as an excellent noninvasive screening and monitoring tool, but brainMR andMRA are necessary for confirmation of the diagnosis. Ultrasound examination may show direct or indirect signs. Direct signs are: echolucent intramural hematoma, string sign, double lumen, or stenosis and/or occlusion of an arterial segment usually not affected by atherosclerosis. Indirect signs are: increased or decreased pulsatility index upstream or downstream of the suspected lesion, more than 50% difference in blood flow velocity compared to the unaffected side, or detection of intracranial collateral flow. Since CCAD have been increasingly identified, a whole spectrum of clinical pictures are been recognizes. Neurosonology showed high sensitivity in CCAD detection

Umjetnost: neuroznanstveni pristup

Scientists have for centuries tried to localize and define artistic talent. Modern diagnostic techniques that enable visualization and measurement of brain morphology and function are positron emission tomography (PET), magnetic resonance imaging (MRI), functional transcranial Doppler (fTOD) and some biochemical methods. In the majority of people, the left hemisphere is dominant, but the right hemisphere is considered to be creative, visual, imaginative and intuitive. Right hemisphere is associated with musical skills and good three-dimensional orientation. It is also associated with good coordination and athletic skills. Creative people have less marked hemispheric dominance. Using the functional (fMRI) technique, the activation of visual cortex while watching different kinds of compositions was visible; the specific pattern of cortical activation was identified for looking at the landscapes, portraits, abstract compositions or different combination of colors. For music perception, the interplay of activity on both sides of the brain is necessary. In the right side, the centers for perceiving pitch, certain aspects of melody, harmony, timbre and rhythm are placed, and in the left side the processes of rapid changes in frequency and intensity, both in music and words are taking place. Adaptation of the brain, i.e. brain plasticity can arise upon listening or performing music. It is possible to use music, painting and dancing as an aid in the treatment of somatic, neurologic or psychiatric disorders.Stoljećima znanstvenici pokušavaju lokalizirati i definirati umjetnički talent. Pozitronska emisijska tomografja (PET), funkcionalna magnetska rezonanca (fMRI) i funkcionalna dopler sonografija (fTCD) su moderne dijagnostičke metode koje omogućavaju vizualizaciju moždane morfologije i funkcije. U većine osoba dominantna je lijeva hemisfera, dok se za desnu hemisferu smatra da je kreativna, vizualna, intuitivna i zadužena za maštu, dobru trodimenzionalnu orijentaciju, koordinaciju, sportske i glazbene vještine. U kreativnih osoba dominantnost hemisfera je manje izražena. fMRI omogućuje registriranje aktivacije vidne kore za vrijeme promatranja različitih kompozicija poput pejzaža. portreta, apstraktnih kompozicija i kombinacija boja. Za percepciju glazbe potrebna je suradnja obiju hemisfera. U desnoj hemisferi se registrira ton, melodija, ritam i harmonija, dok su centri za brzu promjenu frekvencija u lijevoj hemisferi. Glazba potiče procese neuroplastičnosti. Glazbu, slikarstvo i ples moguće je koristiti kao pomoćno sredstvo u liječenju somatskih, neuroloških i psihijatrijskih poremećaja

Noninvasive imaging of craniocervical artery dissection

Craniocervical arterial dissections (CCAD) are being increasingly identified due to growing awareness of diverse clinical picture along with advances in imaging technologies. Although rare, CCADare frequent cause of stroke in young adults. Neurosonological tests serve as an excellent noninvasive screening and monitoring tool, but brainMR andMRA are necessary for confirmation of the diagnosis. Ultrasound examination may show direct or indirect signs. Direct signs are: echolucent intramural hematoma, string sign, double lumen, or stenosis and/or occlusion of an arterial segment usually not affected by atherosclerosis. Indirect signs are: increased or decreased pulsatility index upstream or downstream of the suspected lesion, more than 50% difference in blood flow velocity compared to the unaffected side, or detection of intracranial collateral flow. Since CCAD have been increasingly identified, a whole spectrum of clinical pictures are been recognizes. Neurosonology showed high sensitivity in CCAD detection

Embolijski moždani udar uzrokovan disekcijom unutarnje karotidne arterije: neinvazivno praćenje rekanalizacije pomoću obojenog doplera i transkranijskog Doplera

Craniocervical arterial dissection is an under-recognized and uncommon cause of stroke. We describe a 66-year-old hypertensive female patient who developed internal carotid artery dissection at an atypical location, with consequential ischemic stroke. Double lumen was visible by color doppler flow imaging, and high-intensity transient signals were detected. Transcranial doppler ultrasonography was used to monitor cessation of ipsilateral distal microembolization associated with clinical improvement on anticoagulant therapy. In embolic stroke due to embolization from a dissected internal carotid artery, neurosonologic investigations enabled noninvasive visualization and monitoring of the time course of vessel dissection and secondary embolism.Disekcija krvnih žila glave i vrata je rjeđi uzrok moždanog udara koji se često ne prepoznaje. Prikazujemo 66-godišnju bolesnicu s hipertenzijom u koje je nastupila disekcija unutarnje karotidne arterije na netipičnom mjestu i posljedični moždani udar. Dvostruki lumen je bio vidljiv uporabom obojenog doplera karotidnih arterija, a zabilježeni su prolazni signali visokog intenziteta. Transkranijskim doplerom praćen je prestanak distalne mikroembolizacije koja je bila povezana s kliničkim poboljšanjem uz primjenu antikoagulantne terapije. U embolijskom moždanom udaru uzrokovanom disekcijom unutarnje karotidne arterije neurosonološko ispitivanje je omogućilo neinvazivnu dijagnostiku i praćenje tijeka disekcije i sekundarne embolizacije

Embolijski moždani udar uzrokovan disekcijom unutarnje karotidne arterije: neinvazivno praćenje rekanalizacije pomoću obojenog doplera i transkranijskog Doplera

Craniocervical arterial dissection is an under-recognized and uncommon cause of stroke. We describe a 66-year-old hypertensive female patient who developed internal carotid artery dissection at an atypical location, with consequential ischemic stroke. Double lumen was visible by color doppler flow imaging, and high-intensity transient signals were detected. Transcranial doppler ultrasonography was used to monitor cessation of ipsilateral distal microembolization associated with clinical improvement on anticoagulant therapy. In embolic stroke due to embolization from a dissected internal carotid artery, neurosonologic investigations enabled noninvasive visualization and monitoring of the time course of vessel dissection and secondary embolism.Disekcija krvnih žila glave i vrata je rjeđi uzrok moždanog udara koji se često ne prepoznaje. Prikazujemo 66-godišnju bolesnicu s hipertenzijom u koje je nastupila disekcija unutarnje karotidne arterije na netipičnom mjestu i posljedični moždani udar. Dvostruki lumen je bio vidljiv uporabom obojenog doplera karotidnih arterija, a zabilježeni su prolazni signali visokog intenziteta. Transkranijskim doplerom praćen je prestanak distalne mikroembolizacije koja je bila povezana s kliničkim poboljšanjem uz primjenu antikoagulantne terapije. U embolijskom moždanom udaru uzrokovanom disekcijom unutarnje karotidne arterije neurosonološko ispitivanje je omogućilo neinvazivnu dijagnostiku i praćenje tijeka disekcije i sekundarne embolizacije