99mTc HM-PAO SPECT in pediatric migraine

Cerebrovascular reactivity to hypercapnia in migraine patients measured with near-infrared spectroscopy

Migraine pain is considered to manifest itself as a result of an impaired cerebrovascular reactivity. Hence, proper quantification and diagnosis of this problem without causing more disturbance has always been a challenge in investigating migraine pathogenesis. Functional near-infrared spectroscopy system (fNIRS) is being proposed as an inexpensive, rapid, safe and accurate technique to monitor cerebrovascular dynamics. We have developed NIROXCOPE 201, a novel multi source and detector device of fNIRS, and attempted to investigate the cerebrovascular reactivity of migraine patients to a breath hold task which produces a metabolic perturbation. Six normals and six migraine patients performed four consecutive breath holding task. A typical brain hemodynamic response (BHR) is observed both for controls and migraineurs with an initial phase, main response and a recovery phase. Hence, fitting to a sum of three sequentially arranged gaussian curves proved that amplitudes of [Hb] and [HbO2] signals acquired by fNIRS are approximately two to five times higher in controls than migraine patients (P<0.01) for all phases. Moreover, amplitude change between successive breath holds tends to converge to a steady value for controls whereas an uncontrolled percent change is observed for migraineurs. Our results confirm an impaired cerebrovascular reactivity in the frontal cortex of migraine patients interictally.

Use of single photon emission computed tomography and magnetic resonance to evaluate central nervous system involvement in patients with juvenile systemic lupus erythematosus

The objective of the present study was to identify the single photon emission computed tomography (SPECT) and magnetic resonance (MR) findings in juvenile systemic lupus erythematosus (JSLE) patients with CNS involvement and to try to correlate them with neurological clinical history data and neurological clinical examination. Nineteen patients with JSLE (16 girls and 3 boys, mean age at onset 9.2 years) were submitted to neurological examination, electroencephalography, cerebrospinal fluid analysis, SPECT and MR. All the evaluations were made separately within a period of 15 days. SPECT and MR findings were analyzed independently by two radiologists. Electroencephalography and cerebrospinal fluid analysis revealed no relevant alterations. Ten of 19 patients (53%) presented neurological abnormalities including present or past neurological clinical history (8/19, 42%), abnormal neurological clinical examination (5/19, 26%), and abnormal SPECT or MR (8/19, 42% and 3/19, 16%, respectively). The most common changes in SPECT were cerebral hypoperfusion and heterogeneous distribution of blood flow. The most common abnormalities in MR were leukomalacia and diffuse alterations of white matter. There was a correlation between SPECT and MR (P<0.05). We conclude that SPECT and MR are complementary and useful exams in the evaluation of neurological involvement of lupus.

Cyclic vomiting and elevation of creatine kinase associated with bitemporal hypoperfusion and EEG abnormalities: a migraine equivalent?

A 13-year-old mentally retarded boy suffered from repeated vomiting attacks since infancy. Each episode lasted 2 to 10 days, and was precipitated by respiratory infection, exercise or stress. During an attack he became irritated, agitated and amnesic, but did not have headaches or seizures. Associated findings were transient elevation of serum creatine kinase (CK) (331-3381 IU/l), and of plasma ACTH and cortisol. The raised CK level was the result of muscle hypertonicity. Ictal EEGs showed delta activity in the front-temporal areas, and inter-ictal IMP-SPECT revealed hypoperfusion in both temporal regions. Unlike the periodic ACTH-ADH discharge syndrome, neither hypertension nor depression developed. These attacks were diagnosed as a migraine equivalent and were suppressed with phenytoin. From the EEG and SPECT findings, we concluded that the vomiting and behavioural changes were related to the paroxysmal vascular abnormality in the temporal regions, but it was not easy to make the distinction between migraine and focal epilepsy. Before a diagnosis of the periodic ACTH-ADH discharge syndrome is made, the possibility of migraine equivalent should be considered.

Pediatric migraine

Migraine headaches are relatively common, affecting approximately 5% of all children. Although the differential diagnosis is extensive, a complete history and physical will usually lead to the correct diagnosis without laboratory or radiologic studies for most children. In cases of migraine complicated by neurologic problems, such as hemiplegia or ophthalmoplegia, neuroradiologic studies may be helpful to establish the diagnosis of complicated migraine. Treatment of migraine in children consists primarily of avoidance of triggers, rest, and simple analgesics. Behavior therapy, including relaxation-response training, has been shown to be an effective adjunct in managing both the frequency and intensity of the migraine attack. Use of pharmacologic agents for abortive and prophylactic therapy has not been extensively supported by well-designed, well-controlled research. In general, use of these agents should be restricted to the small group of children with frequent, severe attacks. Sumatriptan, a 5-HT1 receptor agonist, has shown promise in adult patients but future gains in treatment will be achieved only after a better understanding of the cause and pathogenesis of migraine.

Clinical brain radionuclide imaging studies

A recent survey of the knowledge and practice of both positron-emission tomography (PET) and single-photon emission computed tomography (SPECT) of the brain among referring physicians in Europe (neurologists and psychiatrists) showed a disquieting lack of knowledge of the potential of these methodologies in the investigation and management of patients of their own specialities. The need to bring the knowledge of the potential of these techniques to the practicing physicians is paramount. It is imperative that the methodologies and concepts that preside over the application of these techniques in neurology and psychiatry must become more uniform if an impact is to be felt at a clinical level. There is clear improvement in the instrumentation available with the new state-of-the-art tomographic devices and with the development of new technetium-based radiopharmaceuticals for the study of cerebral perfusion. The constant progress made with ligands that permit the study of neurotransmission, tumor metabolism, and turnover do expand our capability to improve the knowledge concerning neurophysiology, neuropathology, and neuropharmacology of a variety of disease states. PET and SPECT will be progressively included in protocols aimed at stratifying patients with dementia, monitoring therapeutic trials, and improving our ability to determine outcome. Clinical usefulness of PET and SPECT begin to emerge in cerebral vascular disease, in the identification of cerebral death, in epilepsy, in cerebral trauma, in the investigation of HIV-positive patients with cerebral involvement, and in the monitoring of tumor recurrence and postirradiation damage. This review article outlines a current perspective of SPECT and PET as practiced in Europe, its potential, and its limitations.

Case study: dreamy state and temporal lobe dysfunction in a migrainous adolescent

Symptoms of migraine can be very atypical during childhood and adolescence. This article describes a case in which the symptoms of migraine were mainly psychiatric: dreamy state, intermittent confusion, partial amnesia, and childlike regressive behavior with depressive features. Although the results from neurological examinations and electroencephalographic recordings were normal when the individual was symptomatic or not, temporal lobe dysfunction, determined by 99mTc-hexamethyl-propyleneamine oxamine single-photon emission computed tomography, was evident during the migraine.