Dural sinus collapsibility, idiopathic intracranial hypertension, and the pathogenesis of chronic migraine

Available evidences suggest that a number of known assumption on idiopathic intracranial hypertension (IIH) with or without papilledema might be discussed. These include (1) the primary pathogenetic role of an excessive dural sinus collapsibility in IIH, allowing a new relatively stable intracranial fluids pressure balance at higher values; (2) the non-mandatory role of papilledema for a definite diagnosis; (3) the possibly much higher prevalence of IIH without papilledema than currently considered; (4) the crucial role of the cerebral compliance exhaustion that precede the raise in intracranial pressure and that may already be pathologic in cases showing a moderately elevated opening pressure; (5) the role as "intracranial pressure sensor" played by the trigeminovascular innervation of dural sinuses and cortical bridge veins, which could represent a major source of CGRP and may explain the high comorbidity and the emerging causative link between IIHWOP and chronic migraine (CM). Accordingly, the control of intracranial pressure is to be considered a promising new therapeutic target in CM.

Starling resistors, autoregulation of cerebral perfusion and the pathogenesis of idiopathic intracranial hypertension

Two critical functions for the control of intracranial fluids dynamics are carried on the venous side of the perfusion circuit: the first is the avoidance of cortical veins collapse during the physiological increases of cerebrospinal fluid (CSF) pressure in which they are immersed. The second, is the generation of an abrupt venous pressure drop at the confluence of the cortical veins with the dural sinuses that is required to allow a CSF outflow rate balanced with its production. There is evidence that both of these effects are ensured by a Starling resistor mechanism (a fluid dynamic construct that governs the flow in collapsible tubes exposed to variable external pressure) acting at the confluence of cortical veins in the dural sinus. This implies that, in normal circumstances of perfusion balance, a certain degree of venous collapse physiologically occurs at the distal end of the cortical vein. This is passively modulated by the transmural pressure of the venous wall (i.e. the difference between internal blood pressure and external CSF pressure). The mechanism provides that the blood pressure of the cortical vein upstream the collapsed segment is dynamically maintained a few mmHg higher than the CSF pressure, so as to prevent their collapse during the large physiological fluctuations of the intracranial pressure. Moreover, the partial collapse of the vein confluence also generates a sharp pressure drop of the blood entering into the sinus. The CSF is drained in dural sinus through arachnoid villi proportionally to its pressure gradient with the sinus blood. The venous pressure drop between cortical veins and dural sinus is therefore needed to ensure that the CSF can leave the cranio-spinal space with the same speed with which it is produced, without having to reach a too high pressure, which would compress the cortical veins. Notably, the mechanism requires that the walls of the dural sinuses are rigid enough to avoid the collapse under the external cerebrospinal fluid pressure, and predicts that in the presence of excessively flexible dural sinuses, the system admits a second point of balance between cerebral fluid pressure and dural sinus pressure, at higher values. The second balance state is due to the triggering of a self-limiting venous collapse feedback loop between the CSF pressure, that compresses the sinus, and the subsequent increase of the dural sinus pressure, that further raises the intracranial pressure. The loop may stabilize only when the maximum stretching allowed by the venous wall is reached. Then, a new relatively stable and self-sustaining balance state is achieved, at the price of a higher CSF and dural sinus pressure values. We propose that this model is crucially involved in Idiopatic Intracranial Hypertension pathogenesis with and without papilledema, a condition that could be described as a pathological new balance state, relatively stable, between intracranial and dural venous pressure, at higher absolute values.

Deep Brain Stimulation for Intractable Chronic Cluster Headache: Proposals for Patient Selection

Cluster headache is the most severe of the primary headaches. Positron emission tomography and functional MRI studies have shown that the ipsilateral posterior hypothalamus is activated during cluster headache attacks and is structurally asymmetric in these patients. These changes are highly specific for the condition and suggest that the cluster headache generator may be located in that brain area; they further suggest that electrical stimulation of that region might produce clinical improvement in chronic cluster headache sufferers refractory to medical therapy. In five patients with severe intractable chronic cluster headache, hypothalamic electrical stimulation produced complete and long-term pain relief with no relevant side-effects. We therefore consider it essential to propose criteria for selecting chronic cluster headache patients for hypothalamic deep brain stimulation before this procedure is undertaken at other academic medical centres.

No evidence for an effect on brain atrophy rate of atorvastatin add-on to interferon β1b therapy in relapsing-remitting multiple sclerosis (the ARIANNA study)

BACKGROUND

A previous phase 2 trial has suggested that statins might delay brain atrophy in secondary progressive multiple sclerosis.

OBJECTIVES

The objective of this study was to evaluate the effect of atorvastatin add-on therapy on cerebral atrophy in relapsing-remitting multiple sclerosis.

METHODS

This randomised, placebo-controlled study compared atorvastatin 40 mg or placebo add-on therapy to interferon β1b for 24 months. Brain magnetic resonance imaging, multiple sclerosis functional composite score, Rao neuropsychological battery and expanded disability status scale were evaluated over 24 months.

RESULTS

A total of 154 patients were randomly assigned, 75 in the atorvastatin and 79 in the placebo arms, with a comparable drop-out rate (overall 23.4%). Brain atrophy over 2 years was not different in the two arms (-0.38% and -0.32% for the atorvastatin and placebo groups, respectively). Relapse rate, expanded disability status scale, multiple sclerosis functional composite score or cognitive changes were not different in the two arms. Patients withdrawing from the study had a higher number of relapses in the previous 2 years (P=0.04) and a greater probability of relapsing within 12 months.

CONCLUSIONS

Our results suggest that the combination of atorvastatin and interferon β1b is not justified in early relapsing-remitting multiple sclerosis and adds to the body of evidence indicating an absence of significant radiological and clinical benefit of statins in relapsing-remitting multiple sclerosis.

Sinus venous stenosis-associated idiopathic intracranial hypertension without papilledema as a powerful risk factor for progression and refractoriness of headache

Data from two recent studies strongly support the hypothesis that idiopathic intracranial hypertension without papilledema (IIHWOP) could represent a powerful risk factor for the progression of pain in primary headache individuals. The first study highlights that an asymptomatic IIHWOP is much more prevalent than believed in the general population and occurs only in central venous stenosis carriers. In the second study, about one half of a large consecutive series of unresponsive primary chronic headache patients shows significant sinus venous stenosis. A continuous or intermittent IIHWOP was detectable in 91% of this subgroup and in no patient with normal venography. Moreover, after the lumbar puncture, a 2- to 4-week improvement in headache frequency was observed in most of the intracranial hypertensive patients. These findings strongly suggest that patients prone to primary headache who carry central venous outflow abnormalities are at high risk of developing a comorbid IIHWOP, which in turn is responsible for the progression and the unresponsiveness of the pain. Based on the available literature data, we propose that central sinus stenosis-related IIHWOP, although highly prevalent among otherwise healthy people, represents an important modifiable risk factor for the progression and refractoriness of pain in patients predisposed to primary headache. The mechanism could refer to up to one half of the primary chronic headache patients with minimal response to treatments referring to specialized headache clinics. Due to the clinical and taxonomic relevance of this hypothesis further studies are urgently needed.

Sinus venous stenosis, intracranial hypertension and progression of primary headaches

The recently advanced hypothesis that idiopathic intracranial hypertension without papilledema (IIHWOP) is a powerful risk factor for the progression of pain in individuals prone to episodic primary headache implies that IIHWOP is much more prevalent than it is believed to be in the general population and that it can run almost asymptomatic in most of the affected individuals. In this review, we discuss the evidence available supporting that: (a) sinus venous stenosis-associated IIHWOP is much more prevalent than believed in the general population and can run without symptoms or signs of raised intracranial pressure in most of individuals affected, (b) sinus venous stenosis is a very sensitive and specific predictor of intermittent or continuous idiopathic intracranial hypertension with or without papilledema, even in asymptomatic individuals, (c) in primary headache prone individuals, a comorbidity with a hidden stenosis-associated IIHWOP represents a very common, although largely underestimated, modifiable risk factor for the progression and refractoriness of headache.

The Italian neurological schools of the twentieth century

This lecture is not a historical lecture, but rather a journey through the "story" of neurology in Italy from its "prehistoric" beginning in the 19th century. The birth of a neurological school is that magical moment in which a founder attracts disciples: the more capable this founder is of transmitting methodology and allowing his pupils intellectual freedom, the longer his memory will live on. On the basis of this idea, the scientific biography of a few leading Italian neurologists of the 20th century is outlined, starting from Leonardo Bianchi, founder of the Italian Neurological Society in 1907.

Brain atrophy evolution and lesion load accrual in multiple sclerosis: a 2-year follow-up study

Background

To investigate in a large cohort of patients with multiple sclerosis (MS), lesion load and atrophy evolution, and the relationship between clinical and magnetic resonance imaging (MRI) correlates of disease progression.

Methods

Two hundred and sixty-seven patients with MS were studied at baseline and two years later using the same MRI protocol. Abnormal white matter fraction, normal appearing white matter fraction, global white matter fraction, gray matter fraction and whole brain fraction, T2-hyperintense, and T1-hypointense lesions were measured at both time points.

Results

The majority of patients were clinically stable, whereas MRI-derived brain tissue fractions were significantly different after 2 years. The correlation between MRI data at baseline and their variation during the follow-up showed that lower basal gray matter atrophy was significantly related with higher progression of gray matter atrophy during follow-up. The correlation between MRI parameters and disease duration showed that gray matter atrophy rate decreased with increasing disease duration, whereas the rate of white matter atrophy had a constant pattern. Lower basal gray matter atrophy was associated with increased probability of developing gray matter atrophy at follow-up, whereas gray matter atrophy progression over 2 years and new T2 lesion load were risk factors for whole brain atrophy progression.

Conclusions

In MS, brain atrophy occurs even after a relatively short period of time and in patients with limited progression of disability. Short-term brain atrophy progression rates differ across tissue compartments, as gray matter atrophy results more pronounced than white matter atrophy and appears to be a early phenomenon in the MS-related disease progression.

Towards a definition of comorbidity in the light of clinical complexity

Clinical complexity encompasses multiple levels, including all the disorders and conditions experienced by a person along cross-sectional and longitudinal contexts, the diversity of severity levels and courses of clinical conditions, but also the plurality of values of people experiencing health problems and seeking help for them. The term comorbidity refers to the association of two distinct diseases in the same individual at a rate higher than expected by chance. Looking systematically to comorbidity represents the main road to approach patients' clinical complexity. Once epidemiologically established through population or community surveys, the study of the comorbidity direction and of the chronological patterns of associated clinical entities may offer relevant information from both a clinical and a scientific point of view. Comorbidity profiles of migraine and tension-type headache offer a paradigmatic example to appraise and highlight headache patient clinical complexity, allowing the conversion of diagnosis from a validated cluster of symptoms to a person-centred clinical diagnosis.

Short-term continuous infusion of apomorphine hydrochloride for treatment of Huntington's chorea: A double blind, randomized cross-over trial

We evaluated tolerability and the efficacy of continuous infusion of apomorphine hydrochloride on involuntary movements and mood disorder in Huntington's disease (HD) patients in a pilot, single center, double-blind, randomized, crossover, and controlled versus placebo study. Nine patients with a molecular diagnosis of HD were screened for response to acute apomorphine injection. Four of them, not ameliorating at the acute test, were discontinued. Five patients, responding to acute apomorphine, received continuous infusion of either apomorphine or placebo for 5 days. After 2 days of washout, the alternative treatment was administered. Primary endpoint measures were scores of the Unified Huntington's Disease Rating Scale (UHDRS "motor section") and of the Abnormal Involuntary Movement Scale (AIMS). Secondary endpoint measures were the Hamilton Depression Rating Scale (HAD) score and safety parameters. Both UHDRS and AIMS scores significantly decreased in all patients after apomorphine. The beneficial effect of apomorphine was recorded throughout the 5 treatment days. The HAD score did not change after infusion of either treatment. No serious adverse events were reported by either group during the study. Our results suggest that continuous infusion of apomorphine might be considered for the treatment of involuntary movements in some HD patients.

Neuroimaging follow-up in a case of Rasmussen's encephalitis with dyskinesias

We describe a case of adult-onset biphasic Rasmussen's encephalitis who presented seizures and left dyskinesias at the onset and, after 1 year, language disorder. Serial MRI and [(18)F] FDG-PET scans were performed showing involvement of the right cerebral hemisphere in the first phase and of the contralateral one in the second.

Validation of AIDA Cefalee, a computer-assisted diagnosis database for the management of headache patients

AIDA Cefalee is a database for the management of headache patients developed on behalf of the Italian Neurological Association for Headache Research (ANIRCEF). The system integrates a diagnostic expert system able to suggest the correct ICHD-II diagnosis once all clinical characteristics of a patient's headache have been collected. The software has undergone a multicentre validation study to assess: its diagnostic accuracy; the impact of using the software on visit duration; the userfriendliness degree of the software interface; and patients' acceptability of computer-assisted interview. Five Italian headache centres participated in the study. The results of this study validate AIDA Cefalee as a reliable diagnostic tool for primary headaches that can improve diagnostic accuracy with respect to the standard clinical method without increasing the time length of visits even when used by operators with basic computer experience.

Correlation between fatigue and brain atrophy and lesion load in multiple sclerosis patients independent of disability

BACKGROUND

Fatigue is a major problem in multiple sclerosis (MS), and its association with MRI features is debated.

OBJECTIVE

To study the correlation between fatigue and lesion load, white matter (WM), and grey matter (GM), in MS patients independent of disability.

METHODS

We studied 222 relapsing remitting MS patients with low disability (scores <or=2 at the Kurtzke Expanded Disability Status Scale). Lesion load, WM and GM were measured by fully automated, operator-independent, multi-parametric segmentation method. T1 and T2 lesion volume were also measured by a semi-automated method. Fatigue was assessed by the Fatigue Severity Scale (FSS), and patients divided in high-fatigue (FSS>or=5; n=197) and low-fatigue groups (FSS<or=4; n=25).

RESULTS

High-fatigue patients showed significantly higher abnormal white matter fraction (AWM-f), T1 and T2 lesion loads, and significant lower WM-f, and GM-f. Multivariate analysis showed that high FSS was significantly associated with lower WM-f, and GM-f. Females and highly educated patients were significantly less fatigued.

CONCLUSION

These results suggest that among MS patients with low disability those with high-fatigue show higher WM and GM atrophy and higher lesion load, and that female sex and higher levels of education may play a protective role towards fatigue. Furthermore, they suggest that in MS, independent of disability, WM and GM atrophy is a risk factor to have fatigue.

Neurodegeneration and Alzheimer's disease: the lesson from tauopathies

The Amyloid Cascade Hypothesis suggests that the decisive event in Alzheimer's disease (AD) is the deposition of fibrils of beta-amyloid protein (Abeta). The main objection to this hypothesis is the weak correlation between plaque load and severity of dementia. The good correlation between synaptic loss and dementia suggests that AD may be regarded as a synaptic failure. The toxicity of Abeta depends on its state of aggregation. The most important implication derived from the studies of tau gene mutations in a familial form of frontotemporal dementia (FTDP-17) is that the mutation itself is sufficient to cause neuronal loss. Several recent data suggest that apoptotic mechanisms may represent the missing link between Abeta deposition and proteolysis of tau, an early event in the pathogenic sequence of AD. Collectively, these observations suggest a model of AD whereby overproduction or reduced clearance of Abeta initiates a cascade of events that lead to neuronal loss directly or through post-translational modification of tau.

Deep brain stimulation in craniofacial pain: seven years' experience

Cluster headache (CH) is a primary headache with excruciatingly painful attacks that are strictly unilateral. About 10% of cases experience no significant remission, and about 15% of these do not respond to medication, so surgery is considered. Neuroimaging studies show that the posterior inferior hypothalamus is activated during CH attacks and is plausibly the CH generator. We report on 16 chronic CH patients, with headaches refractory to all medication, who received long-term hypothalamic stimulation following electrode implant to the posterior inferior hypothalamus. After a mean follow-up of 23 months, a persistent pain-free to almost pain-free state was achieved in 13/16 patients (15/18 implants; 83.3%) a mean of 42 days (range 1-86 days) after monopolar stimulation initiation. Ten patients (11 implants) are completely pain-free. A common side effect was transient diplopia, which limited stimulation amplitude. In one patient, a small non-symptomatic haemorrhage into the 3rd ventricle occurred following implant, but regressed 24 h later. Persistent side effects are absent except in one patient with bilateral stimulation, in whom stimulation was stopped to resolve vertigo and worsened bradycardia, but was resumed later without further problems. Hypothalamic stimulation is an effective, safe and well tolerated treatment for chronic drug-refractory CH. It appears as a valid alternative to destructive surgical modalities, and has the additional advantage of being reversible.

Migraine and epilepsy: clinical and pathophysiological relations

Migraine and epilepsy are both chronic disorders characterised by recurrent neurological attacks, with a partial clinical and therapeutic overlap and frequently occurring together. Although still incompletely clarified, the possible existence of a link between migraine and epilepsy has long been debated. In this paper the epidemiologic evidence of migraine and epilepsy comorbidity, the possible occurrence of both disturbances in close temporal association, possible shared physiopathologic mechanisms and the rationale for antiepileptic drug use in migraine prophylaxis will be discussed.

Headache and spontaneous low cerebrospinal fluid pressure syndrome

We examined 59 consecutive patients presenting between 1993 and 2006 at our centre diagnosed with headache associated with spontaneous intracranial hypotension syndrome (SIH). Thirty-six (61%) patients were women; the mean age was 47 years (range 20-68). Cerebral MRI with contrast confirmed SIH in all patients. Headache characteristics were obtained by direct semistructured interview; in a minority of cases information was completed retrospectively through a phone call. All SIH patients suffered from headache. Early recognition of SIH may avoid dangerous worsening due to delayed diagnosis. Orthostatic headache, the main symptom, suggests the diagnosis.

Functional neuroimaging and headache pathophysiology: new findings and new prospects

In the last ten years pathophysiology of primary headaches has received new insights from neuroimaging studies. Positron emission tomography (PET) showed activation of specific brain structures, brainstem in migraine and hypothalamic grey in trigeminal autonomic cephalalgias. This brain activation suggests it may intervene both in a permissive or triggering manner and as a response to pain driven by the first division of the trigeminal nerve. Voxel-based morphometry has suggested that there is a correlation between the brain area activated specifically in acute cluster headache - the posterior hypothalamic grey matter - and an increase in grey matter in the same region. New insights into mechanisms of head pain have emerged thanks to neuroimaging obtained in experimentally induced headaches, and during peripheral and central neurostimulation.

The end of the central dogma of neurobiology: stem cells and neurogenesis in adult CNS

Until the 1990s, neurologists were practising their profession under the doctrine established in the late 19th to early 20th century by the prominent histologist Ramon y Cajal: "Once the development was ended, the founts of growth and regeneration of the axons and dendrites dried up irrevocably. In the adult centers, the nerve paths are something fixed, ended, and immutable. Everything may die, nothing may be regenerated. It is for the science of the future to change, if possible, this harsh decree." Similarly, Giulio Bizzozero, the most prominent Italian histologist and mentor of Camillo Golgi, classified the tissues of the human body into "labile, stable and perennial". Among the latter were the nerve cells, believed to be unable to proliferate in the postnatal brain. This classification was taught until a few years ago to generations of medical students and biologists all over the world. We have investigated the historical, methodological and technical reasons why this "central dogma of neurology", so influential in clinical and experimental neurology, has lasted so long. We examined how this dogma was broken and who contributed, and the difficulties encountered by the "heretical" researchers who contributed to this goal, especially between the 1960s and the early 1990s, when at last neurogenesis in the adult brain could no longer be denied. Finally, we propose that the understanding of the mechanisms underlying various neurological diseases and the interpretations of clinical syndromes, as well as the design of new therapies, are being revolutionised by the breaking of this dogma and the discovery of the presence of neural stem cells in the adult brain.

Hypnic headache: an update

Hypnic headache (HH) is a rare sleep-associated primary headache disorder, usually affecting aged people, first described by Raskin in 1988. The headache attacks, single or multiple in one night, occur exclusively during sleep and tend to present at a consistent time each night, sometimes during a dream. Compared to the original description, newly reported cases have expanded the clinical spectrum of the disorder to include unilateral forms (about 40%, half of which are side-locked), forms with a longer duration (up to 3 h) and cases with onset in juvenile/adult age. The male predominance found in Raskin's series has not been confirmed by subsequent observations. To date the reported F/M ratio is 1.7/1. Pain is of severe intensity in less then one-third of cases and mild-moderate in about two-thirds. The location of pain is fronto-temporal in over 40% of cases; headache is throbbing in 38% of cases, dull in 57% and stabbing in less than 5%. Nausea is reported in 19% of cases; photophobia, phonophobia or both are present in 6.8%. Mild autonomic signs (lacrimation, nasal congestion, ptosis) may rarely be present. In 2004, HH was included in Group 4 of the International Classification of Headache Disorders-II (Other primary headaches). Sufficient evidence, mainly from polysomnographic studies, indicates that HH is a primary rapid eye movement (REM) sleep-related headache disorder of chronobiological origin. Lithium, melatonin, indomethacin and caffeine at bedtime are among the most effective therapeutic options. The pathophysiology of HH is still unclear. Available data allow speculation that, in predisposed subjects, an age-related impairment of suprachiasmatic nucleus could cyclically activate a disnociceptive mechanism leading to both a sudden awakening and headache. The mechanism may be precipitated by neurophysiologic events such as the strong reduction of firing occurring in the dorsal raphe nucleus during a REM sleep phase.

Neuropsychological assessment, quantitative MRI and ApoE gene polymorphisms in a series of MS patients treated with IFN beta-1b

Few trials issued the effect of disease-modifying medications on cognitive functions in multiple sclerosis. We designed an open-label longitudinal study to evaluate, during 2 years, cognitive performance and its relationship with MRI data and ApoE polymorphism findings in a group of relapsing-remitting (RR) multiple sclerosis (MS) Interferon (IFN) beta-1b-treated patients (median age 30 years, median disease duration 3.4 years). Complete neuropsychological battery was grouped into attention, information learning/memory, language and visuo-spatial functions. Fifty-two patients (33 females) were enrolled in the study. Six patients (11.5%) dropped out, mainly due to side effects. At baseline neuropsychological evaluation, we found 54% normal, 42% mildly impaired and 4% moderately impaired patients. At 2 years follow-up, cognitive status was stable in 65%, improved in 33% and worsened in 2% of patients. No significant relations were found between global cognitive outcome vs. EDSS change, clinical disease activity, MRI data or ApoE gene polymorphisms over the 2 years follow-up. EDSS and MRI fractional volumes were found to correlate with the performance at single tests. Twenty-one patients (45.6%) showed active MRI scans throughout the study, without any worsening at the corresponding neuropsychological examination. This ongoing trial suggests a possible beneficial effect of IFN beta-1b treatment on cognitive functions in RRMS patients. Extension of follow-up and further data analyses are needed to confirm and clarify these findings.

Brain atrophy and lesion load in a large population of patients with multiple sclerosis

OBJECTIVE

To measure white matter (WM) and gray matter (GM) atrophy and lesion load in a large population of patients with multiple sclerosis (MS) using a fully automated, operator-independent, multiparametric segmentation method.

METHODS

The study population consisted of 597 patients with MS and 104 control subjects. The MRI parameters were abnormal WM fraction (AWM-f), global WM-f (gWM-f), and GM fraction (GM-f).

RESULTS

Significant differences between patients with MS and control subjects included higher AWM-f and reduced gWM-f and GM-f. MRI data showed significant differences between patients with relapsing-remitting and secondary progressive forms of MS. Significant correlations between MRI parameters and between MRI and clinical data were found.

CONCLUSIONS

Patients with multiple sclerosis have significant atrophy of both white matter (WM) and gray matter (GM); secondary progressive patients have significantly more atrophy of both WM and GM than do relapsing-remitting patients and a significantly higher lesion load (abnormal WM fraction); lesion load is related to both WM and even more to GM atrophy; lesion load and WM and GM atrophy are significantly related to Expanded Disability Status Scale score and age at onset (suggesting that the younger the age at disease onset, the worse the lesion load and brain atrophy); and GM atrophy is the most significant MRI variable in determining the final disability.

Acetazolamide efficacy and tolerability in migraine with aura: a pilot study

The study was an open uncontrolled pilot trial to test the efficacy and the tolerability of acetazolamide in a group of 22 outpatients suffering from migraine with aura (MA) with at least one aura episode in the last 2 months.

Treatment of nocturnal disturbances and excessive daytime sleepiness in Parkinson's disease

Nocturnal disturbances are common in Parkinson's disease (PD) patients, with almost 70% of these patients reporting nocturnal disturbances. The etiology of sleep disturbances in patients with PD is still controversial. They might be dependent on dopaminergic drugs, on disease progression, or on a combination of these two factors. Nocturnal disturbances can be categorized in four groups: 1) PD-related motor symptoms, including nocturnal akinesia, early-morning dystonia, painful cramps, tremor, and difficulty turning in bed; 2) treatment-related nocturnal disturbances; 3) psychiatric symptoms, including hallucinations, vivid dreams, depression, dementia, insomnia, psychosis, and panic attacks; 4) other sleep disorders, including insomnia, REM behavioral disorder (RBD), restless legs syndrome (RLS), periodic leg movements (PLMS), and excessive daytime sleepiness (EDS). Specific treatment options are supplied for every group. A global evaluation of nocturnal disturbances would provide clinicians with a valuable tool to establish an optimal regimen that could positively influence all nocturnal disturbance categories and thus improve PD management on. However, it is important to consider that management of some nocturnal disturbances in a group may worsen nocturnal symptoms of another group or may increase EDS. PD-related symptoms can be treated with long-acting DA agonists to obtain continuous DA receptor stimulation during the night. Both treatment-related nocturnal disturbances and psychiatric symptoms may be related to drug treatment, and therefore, in both cases, drug reduction or discontinuance should be considered. Some sleep disorders, such as RLS and PLMS, may be controlled by DA agents, and others, such as insomnia and EDS, may be improved by reducing dopaminergic stimulation.

A clinical comparison of trigeminal neuralgic pain in patients with and without underlying multiple sclerosis

Despite clinical similitude, there is a tendency to consider trigeminal pain in multiple sclerosis (MS) as a distinct condition. To evaluate clinical differences in trigeminal pain presentation in patients with and without underlying MS, we compared clinical characteristics of facial pain found in 15 consecutive MS patients with those reported by 13 consecutive subjects diagnosed with classical trigeminal neuralgia. The only significant difference between MS and non-MS neuralgic patients was the age of onset of pain (43.4+/-10.5 in MS vs. 59.6+/-11.50 in non-MS patients, p=0.000629, unpaired Student's t-test). No differences were observed for side, duration and quality of pain, trigeminal branches involved, presence of trigger areas or factors, pain refractive period, remitting-relapsing or chronic course. There was only a trend without statistical significance in interval pain and trigeminal hypoesthesia, more frequent in MS population. Only one patient in the MS group presented with long-lasting episodes (45-60 min) of atypical odontalgia. Our findings support the view of a common pathogenetic mechanism underlying TN in the two groups, possibly related to demyelination of the trigeminal entry root in the pons. Typical TN in MS patients should be considered as "symptomatic trigeminal neuralgia".

Sudden re-opening of collapsed transverse sinuses and longstanding clinical remission after a single lumbar puncture in a case of idiopathic intracranial hypertension. Pathogenetic implications

The aetiopathogenetic role of sinus venous obstructions carried by most idiopathic intracranial hypertension (IIH) patients is controversial. We report the case of a young woman diagnosed with IIH with papilloedema and narrowing of transverse sinuses, in which lowering of intracranial pressure by a single 20 ml cerebrospinal fluid (CSF) resulted in a strong dimensional increase of the transverse sinuses. Changes were followed by clinical remission and normalisation of optical nerve calibre, maintained after a 2-month follow-up. Our findings indicate that, although secondary to CSF hypertension, venous sinuses compression may have an important role in hypertensive status maintenance. Pathogenetic implications of venous sinus compression by hypertensive CSF in IIH are discussed.

Validation of the Guidelines for the Diagnosis of Dementia and Alzheimer's Disease of the Italian Neurological Society. Study in 72 Italian neurological centres and 1549 patients

The objective of this study was to verify the adherence of Italian family physicians and neurologists to the Guidelines on Diagnosis of Dementia of the Italian Society of Neurology. A multicentre survey was carried out, in 72 neurological centres. The centres included at least 15 consecutive subjects suspected of having a dementia. The adherence of family physicians to the guidelines was poor. Neurologists performed a complete neuropsychological evaluation in a minority of the cases. Patients who had a decrease of Mini Mental Status Examination scores after six months higher than or equal to 4 were more represented among those patients for whom one or more recommendations were not respected. In Italy the adherence to the Guidelines on Diagnosis of Dementia and AlzheimerValidation studys Disease of the Italian Society of Neurology is very poor for family physicians (GPs) and satisfactory, albeit improvable, on the part of neurologists. Respect for the guidelines might improve the outcome of patients with dementia.

Imaging of dopaminergic dysfunction with [123I]FP-CIT SPECT in early-onset parkin disease

OBJECTIVE

To investigate whether the presence of parkin gene mutations is associated with different nigrostriatal impairment than other early-onset parkinsonism.

METHODS

Eighteen consecutive early-onset Parkinson disease (PD) patients (nine parkin and nine nonparkin patients) and six controls were studied with [123I]FP-CIT SPECT.

RESULTS

Parkin patients had longer disease duration (15 +/- 9 vs 6 +/- 2 years, p = 0.008) and higher Unified Parkinson's Disease Rating Scale (UPDRS) motor score (35.8 +/- 13.7 vs 22.8 +/- 7.9, p = 0.025) than nonparkin patients. Caudate and putamen DAT density were reduced by 60% and 79% in parkin and by 43% and 70% in nonparkin patients. Multiple regression analysis showed that the UPDRS and the presence of parkin gene mutations, but not the disease duration, were significantly correlated with the striatal DAT density. Parkin patients showed a more symmetric DAT loss in both caudate and putamen as compared with nonparkin patients.

CONCLUSIONS

Parkin-related disease may be associated with a higher degree of nigrostriatal impairment, independently of the clinical severity of the disease, and a more symmetric involvement as compared with non-parkin early-onset disease.

Ropinirole as a treatment of restless legs syndrome in patients on chronic hemodialysis: an open randomized crossover trial versus levodopa sustained release

OBJECTIVE

Restless legs syndrome (RLS) is a common neurologic condition characterized by uncomfortable and unpleasant sensations in the legs, occurring primarily at rest, which are usually worse in the evening and are alleviated by movement. RLS is present in 20-40% of patients with renal failure. This study was a 14-week open, randomized, crossover trial of ropinirole vs. levodopa sustained release (SR) in 11 patients with RLS on chronic hemodialysis.

METHODS

Eleven patients (7 men, 4 women) were enrolled in the study. They received either levodopa SR or ropinirole for 6 weeks, followed by a washout week, then the alternate treatment for 6 weeks. Patients rated the severity of RLS by means of a 6-item questionnaire developed by the International Restless Legs Study Group (6-item IRLS), by the Clinical Global Impression (CGI) scale, and by sleep diaries.

RESULTS

Under treatment with levodopa SR, 1 patient presented severe vomiting, leading to study discontinuation. The 10 patients who completed the study reported a 33.5% improvement (from 16.7 +/- 3.2 to 11.1 +/- 4; P < 0.001) of the 6-item IRLS scores during levodopa SR treatment and a 73.5% improvement (from 16.6 +/- 2.8 to 4.4 +/- 3.8; P < 0.001) during ropinirole treatment. By the end of the study the mean levodopa SR dosage was 190 mg/d and the mean ropinirole dosage was 1.45 mg/d. Ropinirole was superior to levodopa SR in reducing 6-item IRLS scores (P < 0.001) and in increasing sleep time (P < 0.001). The patient CGI scale showed a significant difference favoring ropinirole (P < 0.01). There was no significant carryover or period effect for any outcome measure. Four patients reported a complete reversion of RLS symptoms during ropinirole treatment at doses ranging from 0.25-2 mg/d.

CONCLUSIONS

These results suggest that ropinirole is more effective than levodopa SR in the treatment of RLS in patients on chronic hemodialysis.

Towards the computerisation of ANIRCEF Headache Centres. Presentation of AIDA CEFALEE, a computer assisted diagnosis database for the management of headache patients

Because of the lack of biochemical or neuroradiological markers, the diagnostic assessment of primary headaches rests on a clinical history collected by an experienced physician; the articulated criteria of the International Headache Society (IHS) represent the only available tool to test objectively the diagnostic hypothesis rising from clinical interview. However, the complexity reached by IHS criteria still represents its major limit to extensive application, at least in common clinical settings. The use of modern information technology (IT), which is specifically designed to manage complex problems with a large number of variables, seems to be the best choice to counteract the complexity of IHS classification. In this paper AIDA CEFALEE, a user-friendly client-server database for the management of headache patients, is presented. The system integrates a computer assisted diagnosis module, which may help to extend the correct use of IHS diagnostic criteria to any clinical setting. The interoperability of the system may represent the possible infrastructure of a National Network of ANIRCEF Headache Centres.

Headache and neurology

The aim of this lecture is to analyse the position of headaches and especially of migraine within the body of neurological knowledge. Historical, clinical and pathophysiological data have been selected for discussion.

Physical therapy in Parkinson's disease: an open long-term rehabilitation trial

The aim of this study was to evaluate the effects of prolonged physical therapy on disability in patients with Parkinson's disease. The study was designed as an open long-term trial over 20 weeks. Twenty slightly to moderately affected parkinsonian patients were included (Hoehn & Yahr stages: 1.5-3). A comprehensive rehabilitation program was applied three times a week in all patients. Pharmacological treatment was kept stable. Evaluations were performed at baseline, at the end of treatment and after 3 months. Following physical rehabilitation, there was a significant improvement in UPDRS (ADL and motor sections) scores, Self-assessment Parkinson's disease Disability Scale, Ten-Meter Walk test and Zung scale for depression. At 3-month follow-up clinical improvements were largely maintained. A sustained improvement of motor skills in PD patients can be achieved with a long-term comprehensive rehabilitation program.

Treatment of migraine with aura: comments and perspectives

Migraine with aura (MwA) is a primary headache that affects about 30% of migraine sufferers. The main questions for the physician caring for the patient who has MwA are: when to use preventive medications, what medications to use in acute and preventive treatment, and whether the aura should be treated. The aim of this paper is to review the various therapeutic options for MwA proposed in the current literature and to evaluate their efficacy.