Airplane headache – an underestimated problem?

The airplane headache is an incident of severe, clinically stereotypical pain during ascent or descent of an airplane. The entity is considered rare; however, growing numer of passengers in air transport results in better recognition of the problem. The airplane headache typically lasts less than 30 minutes and is unilateral, most often in fronto-orbital region and is connected with take-off or (more often) landing of the aircraft. The most important causative factor is sinus barotrauma attributed to changes in air pressure in passenger airliners during different phases of flight. So far there are only single cases or case series described in the literature. However, the problem can affect even a few percent of airline passengers. The condition is rare among children. The most effective treatment are triptans, but naproxen, paracetamol and nasal decongestants may play an important role either. There is an urgent need to conduct more researches on epidemology, pathogenesis and treatment of the headache attributed to airplane travel

Optimization of pain management in cervical dystonia

Cervical dystonia (CD) is the third most common movement disorder characterized by sustained or intermittent muscle contractions causing abnormal movements, postures, or both. Pain in the course of CD is a frequent symptom reported by the 54.6% - 88.9% of patients, which strongly affects the disability and quality of life, and is the most common reason patients are looking for treatment. Despite the main effect of botulinum toxin (BoNT) is muscle relaxation through the inhibition of the acetylcholine release at the neuromuscular junction, the analgesic effect of BoNT is probably attributed to the acting on central nervous system. Up to 20% of patients discontinue therapy due to treatment failure or adverse effects. Most poor responses are related to suboptimal treatment and a minority to immunoresistance which currently concerns only 0-2,5% of CD cases. In case of confirmed immunoresistance to BoNT-A standard therapy, the use of BoNT-B or alternative BoNT-A is recommended. The currently available management of improving the analgesic efficacy of first-line treatment in patients without immunoresistance includes: the eradication of BoNT adverse events, the determination of individual BoNT dosage, reviewing injections technique with electromyography or ultrasound guidance, the implementation of a rehabilitation program and the applying of the invasive or non-invasive brain stimulation methods. However, due to the lack of evidences from the large, randomized, controlled, clinical trials, an issuance of unambiguous recommendations remains difficult. Further studies on a poor response to BoNT injections and analgesic effects of above methods in the treatment of the CD-related pain are needed

Oligoclonal bands as predictors of multiple sclerosis in clinically isolated syndrome

Clinically Isolated Syndrome (CIS) is the first episode of inflammatory and demyelinating symptoms. According to the classification criteria of multiple sclerosis (MS) from 2013, CIS is defined as the first clinical manifestation of the disease. McDonald's 2010 criteria, considered the gold standard in the diagnosis of MS, are based on the clinical symptoms and the characteristic changes in magnetic resonance imaging (MRI). Unfortunately, up to 60-70% of patients with CIS do not meet the criteria for diagnosing MS at an early stage. At the same time, approximately 85% of patients with CIS will develop clinically defined MS (CDMS) in the future. When looking for other diagnostic tools, attention was paid to the role of oligoclonal bands (OBs) as predictors of MS development. Oligoclonal bands are immunoglobulins produced intrathecally by B-lymphocytes and plasma cells. Their level is examined in cerebrospinal fluid (CSF) collected by lumbar puncture. Studies carried out on a group of patients with CIS showed that people with positive test results for oligoclonal bands are twice as likely to develop MS than people with negative OBs. These conclusions are reflected in the revised McDonald's criteria in 2017, where OBs are used in the diagnosis of CIS patients with absence of new symptoms of the disease and changes in MRI. Early diagnosis makes possible to implement modifying disease drugs in the initial stage and, consequently, to achieve better therapeutic effects. The emphasis is also put on the development of other predictors in body fluids, which are effective in the diagnosis of people with CIS and negative oligoclonal bands. Many factors, including Epstein-Barr virus, chitinase-3 like 1, chitinase-3 like 2, chitotriosidase, multi-specific response to measles, rubella and varicella known as "MRZ reaction" or T-cell gene mutation are studied as a potential risk factors for MS development. Their use in diagnostics would improve the detection of MS in earlier stages, and thus the treatment of larger population of patients

Symptomatic cavernous hemangioma of fronto-parietal region of the brain in a young female patient – a case report

Introduction: Cavernous hemangioma is a bening blood vessel malformation that can be located in the central nervous system. Although most patients who are found to have a CNS hemangioma are asymptomatic, the entity can cause a wide spectrum of symptoms including severe ones like epileptic seizures, stroke, diplopia, dysfasia or cognitive functions’ disorders. Case report: A 21-year-old female patient was admitted to the Department Of Neurology due to transient vision impairment, dysfasia, headache and tinnitus. Physical examination revealed no focal neurological signs. A brain MRI was performed. A cavernous hemangioma of 7-8 mm in size was found. The patient was examined by neurosurgeon as well, who did not qualify her for an immediate surgery. Discussion: Although cavernous hemangiomas are often asymptomatic, sometimes they can be a causative factor of different neurological symptoms. One should always take into account a possibility of cerebral hemangioma presence in young patients that suffer from headaches, tinnitis or have impaired vision

Cervical dystonia: pain relieving effects of botulinum toxin treatment

Cervical dystonia (CD) is a third most common movement disorder characterized by sustained or intermittent muscle contractions causing abnormal movements and postures of head and neck. Physical, emotional, cognitive, and self-awareness aspects are also affected, so CD is currently considered to be a “network” disorder with the involvement of multiple brain regions and cellular mechanisms. Pain occurs in 54.6% to 88.9% of patients with CD and is the most disabling non-motor symptom which strongly attributes to the quality of life deterioration. The dystonia-related pain is also the main reason patients are looking for treatment. Despite the high prevalence only small number of studies develops this issue. Botulinum toxin (BoNT) is a safe, efficacious and first choice treatment for CD. Up to 90% of patients reports an improvement in pain and motor symptoms after BoNT injections, however above mentioned effects may be partially independent due to the earlier and longer pain relief compared to muscle relaxation. The results of current studies suggest analgesic effects of BoNT are related to not only the acting in the neuromuscular junction. The central processing of nociceptive stimuli is contributed to be the main effect of BoNT analgesic therapy. To date, evidence for the association between dystonia-related pain and BoNT treatment become more significant but is still lacking. Further research is needed to investigate above correlation and issue an unambiguous high-level recommendations of analgesic therapy in CD

Transient ischemic attack of the brain as the first link in a decompensatory event chain of cerebro- and cardiovascular incidents in a 68-year-old female patient with radiological features of Fahr’s syndrome – a case report

Introduction: Transient ischemic attack (TIA) is a reversible episode of neurologic deficit, that symptomatically can be similar to stroke, but lasts shorter than 24 hours and does not cause any radiological changes in brain images. TIA is a major risk factor for subsequent ischemic stroke. Fahr’s syndrom is a rare, genetically conditioned incidence of calcified deposits in basal ganglia and cerebral cortex. Case report: A 68-year-old female patient was admitted to the Department of Neurology due to an incident of left limbs weakness and left mouth angle drop. The symptoms lasted 5 minutes. The initial brain CT revealed no acute ischemic foci, although the radiologist found characteristic features of Fahr’s syndrome. Carotid ultrasound showed stenosis of right internal carotid artery. The patient experienced an ischemic stroke in 6th day from initial symptoms. 4 days later a myocardial infarction occurred as well. Discussion: TIA is a major prognostic factor for an ischemic stroke with the greatest risk of incidence in the first week after initial symptoms. Proper imaging diagnostics and prophylactic treatment with aspirin and statins should be administered. Patients after TIA incident should stay under watchful neurological supervision during the first 3 months after the attack

Internal carotid and vertebral artery dissections — a comparison of clinical, radiological and prognostic characteristics

Aim of study. To examine whether baseline characteristics, potential risk factors, clinical symptoms, radiological presentation, and long-term outcomes differ between internal carotid artery dissection (ICAD) and vertebral artery dissection (VAD).Clinical rationale for study. Cervical artery dissection (CeAD) is a major cause of cerebral ischaemia in young adults. Its clinical course is highly variable, resulting in challenges in making a proper diagnosis.Methods. We performed a retrospective analysis of 31 patients (mean age 42.2 years) with CeAD (18 with ICAD, 13 with VAD) treated in our neurology department from 2008 to 2018. Appropriate imaging confirmed the diagnosis of CeAD.Results. Patients with ICAD presented Horner syndrome significantly more often (44.4% vs 7.6%; p = 0.04). Patients with VAD more often had ischaemic events (ischaemic stroke, TIA or transient blindness) (84.6% vs 44.6%; p = 0.0032). Ischaemic stroke was more severe in patients with ICAD [(median NIHSS 6, interquartile range 4–12) vs VAD (median NIHSS 4, interquartile range 1.5–5.5), p = 0,03]. Occlusion occurred more often in patients with VAD (69.2% vs 22.2%; p = 0.013). Most patients had a favourable outcome (mRS 0–2).Conclusions and clinical implications. In a series of patients with CeAD, we observed significant differences between VAD and ICAD in terms of clinical symptoms and radiological features

Biomarkers in Multiple Sclerosis: a review of diagnostic and prognostic factors

Introduction. Multiple Sclerosis (MS) is a chronic, demyelinating disease of the central nervous system which affects mostly young people. Because it leads to disability and cognitive impairment, it is crucial to recognise MS at an early stage.State of the art. Magnetic resonance imaging is the golden standard in MS diagnosis. However, it is not an infallible diagnostic tool, especially at the stage of clinically isolated syndrome. The incorporation of oligoclonal bands in the diagnostic process of MS is a step towards the extension of diagnostic methods. Recently, a lot of research has been carried out on potential biomarkers in blood serum and cerebrospinal fluid that may be useful in the diagnosis of MS.Clinical implications. This article summarises current knowledge on the use of new prognostic factors such as neurofilament light chain, chitinase 3-like 1 and 2, heat shock proteins, and tubulins in MS.Future directions. Despite numerous studies on the use of biomarkers in the diagnosis of MS, more extensive research is needed to determine the clinical usefulness of these molecules and to develop diagnostic tests applicable in everyday practice. This in turn may result in earlier MS detection, faster implementation of treatment, and better therapeutic effects