Relationship of Opening CSF Pressure and Visual Field Defect in Idiopathic Intracranial Hypertension

Background: Idiopathic intracranial hypertension (IIH) is an increased intracranial pressure with normal cerebrospinal fluid (CSF) characteristic in the absence of identifiable causes. The most important complication of this disorder is visual impairment. So far, no comprehensive study has been done on the relationship between the opening CSF pressure and visual field defect in IIH.Methods: In this study, 35 patients with increased intracranial pressure who fulfilled modified Dandy’s criteria underwent ophthalmologic examination and lumbar puncture. The opening CSF pressure was categorized into mild (25-30), moderate (30-40) and severe (>40). The degree of visual field defect was reported both quantitatively and qualitatively. Eventually, the statistical relationship was established among these variables.Results: The mean opening CSF pressure was 33.71 CmH2o. Twelve patients had minor CSF pressure, whereas in 14 and 9 patients the CSF pressure was respectively moderate and severe. There was not statistically significant relationship between the visual field defect and CSF pressure. The most common patterns of visual field involvement were enlarged blind spot and peripheral restriction.Conclusion: The most important morbidity in IIH is visual impairment. According to the findings, the visual field impairment is not pertinent to CSF pressure. In other words, neither high CSF pressure predicts intense visual defect, nor low CSF pressure indicates minimal visual impairment

Measuring Serum Level of Ionized Magnesium in Patients with Migraine

How to Cite This Article: Assarzadegan F, Asadollahi M, Derakhshanfar H, Kashefizadeh A, Aryani O, Khorshidi M. Measuring Serum Level of Ionized Magnesium in Patients with Migraine. Iran J Child Neurol. Summer 2015;9(3):13-16.AbstractObjectiveMigraine is known as one of the most disabling types of headache. Among the variety of theories to explain mechanism of migraine, role of serum magnesium is of great importance. Serum magnesium, as a pathogenesis factor, was considerably lower in patients with migraine. We established this study to see if serum ionized magnesium, not its total serum level, was different in migraineurs from normal individuals.Materials & MethodsIn this case control study, all participants were recruited from Neurology Clinic of Imam Hossein Hospital, Tehran, Iran. Ninety-six people were entered in the study, 48 for each of case and control groups. The two groups were matched by age and sex. Migrainous patients were selected according to the criteria of International Headache Society. Various characteristics of headache were recorded based on patients’ report. Controls had no history of migraine or any significant chronic headaches. Serum ionized magnesium level was measured in both of the case and control groups and the results were compared to each other. P value of <0.05 was considered as significant.ResultsCase group consisted of 13 males, 35 females, and control group included 14 males, as well as 34 females. Mean age was 33.47± 10.32 yr for case and 30.45 ±7.12 yr for control group. Twenty-eight patients described the intensity of their headaches as moderate; 15 patients had severe and the 5 remainders had only mild headaches. Mean serum level of ionized Mg was 1.16± 0.08 in case group and 1.13± 0.11 in control group of no significant difference (P >0.05).ConclusionSerum ionized magnesium, which is the active form of this ion, was not significantly different in migraineurs and those without migraine. This may propose a revision regarding pathogenesis of migraine and question the role of magnesium in this type of headache

The buffering effect of family functioning on the psychological consequences of headache

The current study aimed to examine whether high family functioning mitigates the association between headache intensity and distress. The sample consisted of 124 patients with chronic or recurrent headache. Patients completed validated questionnaires about headache intensity, family functioning, and distress. Hierarchical regression analyses were performed to examine the interaction between headache intensity and family functioning on distress. Headache intensity was positively associated with distress (r = .28, p = .002). As hypothesized, family functioning moderated this association (B = −.01, p = .023). More specifically, the positive association between headache intensity and distress was significant only among patients with lower family functioning (B = .01, p < .001) and not among patients with higher levels of family functioning (B = .006, p = .075). Functional families appear to buffer the distress level in patients; they showed relatively low levels of distress regardless of the severity of their headache. In contrast, patients with dysfunctional families who experienced more pain reported more distress, presumably because they did not receive adequate help and support from these families. This study underlines the importance of a broader perspective on family dynamics in coping with pain

The Role of Antiepileptic Treatment in the Recurrence Rate of Seizures After First Attack: A Randomized Clinical Trial

How to Cite This Article: Assarzadegan F, Tabesh H, Hesami O, Derakhshanfar H, Beladi Moghadam N, Shoghli A, Beale A.D, Hosseini-Zijoud S.M. The Role of Antiepileptic Treatment in the Recurrence Rate of Seizures After First Attack: A Randomized Clinical Trial. Iran JChild Neurol. Spring 2015; 9(2):46-52.AbstractObjectiveEpilepsy is a serious, potentially life-shortening brain disorder that occurs in patients of all ages and races. A total of 2–4% of people have experienced seizures at least once in their lifetime. Although treatment usually begins after a seizure, it is an important question whether the first cases of seizure do need to be treated by antiepileptic drugs. In this manner, we compare the recurrence rates of epilepsy in first seizure patients treated with sodium valproic acid as an antiepileptic drug versus a placebo.Material &amp; MethodsIn a randomized clinical trial study, 101 first seizure patients were randomly divided into two groups: one group was treated with antiepileptic drugs (sodium valproate 200mg, three times a day) and the other group was given a placebo.The recurrence rate of seizures was evaluated and compared between the groups after 6 months of follow up.ResultsEight recurrence cases were detected. All recurrence cases came from the placebo group, with four patients suffering an additional seizure after four months and between 4-6 month follow up. A comparison of recurrence rate detected a statistically significant difference between the drug group and placebo group.ConclusionOur data shows that the recurrences occurred only in the placebo group with the difference between the recurrence rates in the placebo versus drug-treated was significant. Our results suggest that drug therapy for people after their first seizure attack might reduce the probability of seizure recurrence

Which Stroke Patients are Suitable for Endovascular Treatment in Emergency Department?

استروک بخش قابل توجهی از علل مراجعات به بخش اورژانس را شامل می شود. این عارضه در صورت تشخیص سریع و مداخله درمانی مناسب می تواند با پیامد مطلوبی همراه باشد، ولی در صورت تاخیر در درمان با هزینه های فراوانی برای فرد، خانواده وی و همچنین سیستم بهداشت جامعه همراه خواهد بود. بنابراین تشخیص به موقع قدم اول و اساسی در برخورد با این بیماران در بخش اورژانس محسوب می شود و بعد از آن انتخاب روش درمانی مناسب در الویت خواهد بود. امروزه روش های درمانی مختلفی در برخورد با این بیماران، از اقدامات حمایتی تا ترومبولیتیک تراپی و مداخلات اندوواسکولار، در دسترس می باشند و یکی از سوالات اصلی در درمان سکته مغزی حاد در بخش اورژانس این است که کدام بیمار برای دریافت کدام درمان مناسب است؟ مداخلات اندوواسکولار روش درمانی نسبتا جدیدی است که می تواند لخته را از داخل عروق مغزی بیرون آورده و در مطالعات مختلف نشان داده شده است که یکی از موثرترین مداخلات درمانی در برخورد با سکته مغزی می باشد. مطالعات مختلفی در حمایت از فواید آن در سالهای اخیر منتشر شده اند که باعث تغییر گایدلاین های درمانی بیماران دچار استروک در امریکا و اروپا شده و نقش مداخلات اندوواسکولار پررنگ تر گردیده است. البته این مداخله درمان، روشی تهاجمی به شمار می رود که می تواند با عوارضی نیز همراه باشد و بنابراین برای دستیابی به حداکثر موفقیت در درمان با این روش باید تلاش شود تا بیمارانی که با احتمال بیشتری از این مداخله سود می برند به این منظور انتخاب شوند. گفته می شود اگر دلیل سکته مغزی انسداد یک رگ بزرگ باشد بهترین کاندید برای اینترونشن و درمان آندوواسکولار می باشد. در این شرایط مهمترین وظیفه پزشک بخش اورژانس، شناسایی عروق مسدود شده است. مهمترین روش تشخیصی که گایدلاینهای موجود در این زمینه پیشنهاد می دهند انجام سی تی آنژیوگرافی می باشد که وضعیت عروق بزرگ را از ابتدای شریان آئورت تا کوچکترین عروق داخل مغز نشان می دهد. بعضی از مراکز درمانی این اقدام را فقط برای موارد با احتمال سکته های وسیع مغزی انجام می دهند ولی پیشنهاد می شود که هم سی تی اسکن مغزی و هم سی تی آنژیوگرافی برای همه موارد استروک حتی موارد خفیف نیز انجام گیرد؛ چرا که ممکن است این بیماران در معرض بروز یک سکته وسیع قریب الوقوع باشند. در بعضی از مراکز تکنیک CT Perfusion را به دوگانه سی تی اسکن مغزی و سی تی آنژیوگرافی (CTA) اضافه می کنند. متاسفانه این تکنیک تقریبا در اغلب مراکز کشور ایران در دسترس نیست. ولی در مراکز پیشرفته دنیا در همان مقطعی که سی تی اسکن مغزی انجام می شود قابل انجام بوده و می تواند وضعیت دقیقی از حجم درگیری بافت مغزی و حتی برگشت پذیری بافت درگیر در استروک را نشان دهد. عروق مناسب برای ترومبکتومی شامل شاخه شریان مغزی میانی (MCA) کاروتید اینتراکرانیال، خصوصا قسمت افقی آن (M1) و در بعضی موارد بعد از دو شاخه شدن کاروتید (M2) می باشد. همچنین با پیشرفت های صورت گرفته، ترومبکتومی کاروتید اکستراکرانیال نیز امروزه قابل انجام است. ولی تقریبا هیچگاه شریان های مغزی قدامی (ACA) و شریان مغزی خلفی (PCA) در شرایط فعلی کاندید اینترونشن نیستند. مطالعات گسترده ای شامل IMS-3، MR-CLEN، ESCAPE،  EXTEND-IA، SWIFTPRIME و PREVASCAT با هدف انتخاب عروق مناسب و کاندیداهای مداخله اندوواسکولار انجام گرفته اند که تقریبا هیچ یک امکان انجام ترومبکتومی شریان بازیلر را در مطالعه مربوطه بررسی نکرده اند. ولی مطالعه ای تحت عنوانBASICS  در این زمین انجام گرفته است که در مجموع حتی زمان انجام ترومبکتومی برای شریان بازیلر و پروگنوز آن حتی بهتر از سایر عروق گزارش کرده است و بیشتر نورولوژیست های اینترونشنیست و استروک نسبت به انجام آن دید مثبتی پیدا کرده اند. در مجموع مطالعات فوق حدود 1700 بیمار تحت ترومبکتومی اورژانس قرار گرفتند که میزان موفقیت بدون انجام CTA حدود 40% و در صورت آگاهی از رگ درگیر در CTA میزان موفقیت حدود 70% گزارش شده است. در خصوص تحلیل شرایطی که امکانCTA  وجود ندارد باید یادآوری شود که بعد از فراهم شدن امکان ترومبولیتیک تراپی، استفاده از ترومبکتومی حتی بدون اطلاع از وضعیت عروق درگیر با تکنیکی مانند CTA میزان موفقیت درمان بیماران دچار استروک از حدود 23% به حداقل40% افزایش یافته است. بنابراین به نظر می رسد که فراهم آوری امکانات انجام CTA قبل از ترومبکتومی اورژانسی باید حداقل در تمام بخش های اورژانس بیمارستانهای مرجع کشور مورد حمایت جدی قرار گیرد. همچنین از امکانات فعلی موجود نیز در کشور مثل دستگاه سی تی اسکن و بخشهای نورولوژی و آنژیوگرافی و متخصصین مربوطه به شکل مطلوبی بهره برداری شود. چنانچه بتوان دستگاه سی تی اسکن را به شکلی برنامه ریزی نمود که همزمان با انجام سی تی اسکن مغزی، همزمان سی تی آنژیوگرافی را هم انجام دهد، در نتیجه انتخاب بیمار کاندید انجام ترومبکتومی به نحوی مناسب تر انجام خواهد گرفت و با این تمهیدات ممکن است میزان بهبودی بیمار دچار سکته مغزی و در نتیجه رهایی از یک فلج و مشکل طولانی و ناتوان کننده را به 70% ارتقا داد.Stroke makes up a significant part of causes for emergency department (ED) visits. This complication can be accompanied by a desirable outcome in case of rapid diagnosis and proper treatment intervention. However, in case of delay in treatment, it will bring about many costs for the individual, his or her family and the health care system. Therefore, timely diagnosis is the first and major step in managing these patients in ED and after that, choosing the proper treatment method is the priority. Currently, various treatment methods are available for managing these patients, from palliative care to thrombolytic therapy and endovascular interventions and one of the major questions in treatment of acute brain stroke in ED is which patient is suitable for receiving which treatment? Endovascular intervention is a relatively new treatment method that can extract the blood clot from the brain vessels and various studies have shown that it is one of the most effective treatment interventions in management of brain stroke. Various studies have been published in favor of its benefits in recent years, which have resulted in changes in treatment guidelines of stroke patients in America and Europe and highlighting the role of endovascular interventions in them. However, this interventional treatment is considered an invasive method that can be accompanied by side effects and thus, for reaching maximum success in this method, efforts should be made to select patients who have a higher probably to benefit from this intervention. It has been said that if obstruction of a big vessel is the reason for brain stroke, the patient is the best candidate for intervention and endovascular treatment. In this situation, the most important duty of the ED physician is to identify the obstructed arteries. The most important diagnostic method that existing guidelines suggest in this regard is performing computed tomography (CT) angiography that shows the status of big arteries from the beginning of Aorta to the smallest arteries inside the brain. Some treatment centers do this only for cases with the probability of extensive brain stroke, but it is suggested to perform both brain CT scan and CT angiography for all stroke cases including mild cases; because these patients might be at risk of an upcoming extensive stroke. Some centers add CT perfusion technique to the brain CT scan and CT angiography (CTA) duo. Unfortunately, this technique is not available in most centers in Iran. However, in the advanced centers around the world it can be performed at the same time as brain CT scan and can show an accurate picture regarding the extent of the brain tissue involved and even the reversibility of the tissue involved in the stroke. Proper arteries for thrombectomy are the middle cerebral artery (MCA) branch of intracranial carotid, especially its horizontal part (M1) and in some cases after branching of the carotid (M2). In addition, with the advances made, extracranial carotid thrombectomy can also be done today. But anterior and posterior cerebral arteries (ACA and PCA) are almost never intervention candidates. Extensive studies including IMS-3, MR-CLEN, ESCAPE, EXTEND-IA, SWIFTPRIME, and PREVASCAT have been done with the aim of selecting the proper vessels and candidates of endovascular interventions, almost none of which have evaluated the possibility of performing thrombectomy of basilar artery. However, a study called BASICS has been done in this regard that has even reported the time of thrombectomy for basilar artery and its prognosis even better than the other arteries and most interventionist and stroke neurologists have gained a positive view to performing it. Overall, in the above-mentioned studies about 1700 patients underwent emergency thrombectomy and the success rate without performing CTA was about 40% and if aware of the artery involved via CTA, the success rate has been reported to be about 70%. Regarding processing the situations in which CTA cannot be performed it should be noted that after enabling thrombolytic therapy, using thrombectomy even without knowing the status of the arteries involved with techniques such as CTA, the success rate of treating patients with stroke increased from about 23% to at least 40%. Therefore, it seems that preparing the equipment for performing CTA before emergency thrombectomy should be seriously supported, at least in major hospitals of Iran. In addition, the presently available equipment such as CT scan device and neurology and angiography departments and the specialists in these fields should be employed effectively. If the CT scan device can be programmed in a way that when performing brain CT scan, CT angiography can also be performed simultaneously, the candidate patients for undergoing thrombectomy can be selected more properly and by using these solutions the rate of improvement in patients with brain stroke and thus, being relieved from paralysis and long-term problems might increase to 70%.

Prayer and pain catastrophizing coping strategies on headache intensity prediction in patients with headache

Introduction: Headaches are the most common cause of absence from work and school and one of the most common reasons of referring to neurologist. The present study aimed to investigate the role of prayer and pain catastrophizing as coping strategies in prediction of headache intensity. Methods: In this research we selected 124 patients (89 female and 35 male) with headache as comparison group via available sampling method and 53 individual (30 female and 23 male) as control group. The patients were chosen after the diagnosis of headache by a neurologist in a neurology clinic. The patients completed demographic questionnaire, visual analogues scale (VAS), prayer subscale of coping strategies questionnaire (CSQ) and pain catastrophizing scale (PCS). Results: The analysis of regression showed that rumination as one of the subscale of pain catastrophizing and prayer could account for 9% of variation for headache intensity. Conclusion: The results show that prayer and rumination, which is one of catastrophic components, are effective in prediction of pain. In other words, prayer can predict low intensity of headache, and rumination can predict high intensity of headache and this result which prayer predicted low intensity of pain, can explain the role of spirituality in mental health, especially in our country with religious background. Declaration of Interest: None

International Normalized Ratio Response Subsequent to Modest Increase in Vitamin K Intake in Patients Treated with Warfarin

Background: Warfarin is an effective oral anticoagulant which exert its effect by blocking the utilization of vitamin K. Warfarin therapy requires ongoing monitoring using the international normalized ratio (INR). In this study, effect of modest increase in vitamin K intake from vegetables on INR values was evaluated in warfarin treated patients. Methods: A single-center study involving 24 outpatients (mean age, 62 years) with two last INR in therapeutic range in which INR variations was less than 0.5. Patients were selected based on their VKORC1 1639G→A polymorphism so that 8 patients from each of GG, AA or GA genotypes were recruited. Patients were asked to consume a vegetable mix (including lettuce, peeled cucumber and tomato) containing approximately 100 µg vitamin K (divided in two meals, lunch and dinner) daily for one week when INR response was measured. Results: Daily consumption of vegetable mix decreased patient’s INR from 2.43±0.51 to 2.08± 0.46 (P<0.001). INR value had a significant decrease in each VKORC1 genotypes (from 2.55± 0.55 to 2.21± 0.54 in GG, 2.35± 0.33 to 2.00± 0.25 in AA, and  2.39± 0.65 to 2.00± 0.25 in GA) but the values did not differ between genotypes. Conclusions: Daily increase in vegetable salad containing approximately 100 µg, decreased INR of patients. Therefore, avoiding variation in consumption of foods with even moderate content of vitamin K could help to prevent INR fluctuations in warfarin treated patients

CLIPPERS: Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive To Steroids

A novel type of brainstem-predominant encephalomyelitis was first described as chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) in 2010 by Pittocket al and then few additional patients were reported. Here we report a 50-year-old Iranian male who presented with a number of clinical features described as typical for CLIPPERS. The association of typical clinical presentation and typical MR imaging could be sufficient for a reliable diagnosis of CLIPPERS