Clinical and neuroimaging evidence of interictal cerebellar dysfunction in FHM2

We used multimodal magnetic resonance (MR) techniques [brain diffusion-weighted magnetic resonance imaging, diffusion-weighted imaging (DWI), proton MR spectroscopy (MRS), 1H-MRS; and skeletal muscle phosphorous MRS, 31P-MRS] to investigate interictal brain microstructural changes and tissue energy metabolism in four women with genetically determined familial hemiplegic migraine type 2 (FHM2), belonging to two unrelated families, compared with 10 healthy women. Brain DWI revealed a significant increase of the apparent diffusion coefficient median values in the vermis and cerebellar hemispheres of FHM2 patients, preceding in two subjects the onset of interictal cerebellar deficits. 31P-MRS revealed defective energy metabolism in skeletal muscle of FHM2 patients, while brain 1H-MRS showed a mild pathological increase in lactate in the lateral ventricles of one patient and a mild reduction of cortical N-acetyl-aspartate to creatine ratio in another one. Our MRS results showed that a multisystem energy metabolism defect in FHM2 is associated with microstructural cerebellar changes detected by DWI, even before the onset of cerebellar symptoms.

Primary headaches in preschool age children: clinical study and follow-up in 163 patients

Although headache frequency is increasing in preschool age children, an extensive evaluation of the clinical features in affected patients has yet to be achieved. This retrospective study examined 243 patients who were separately analysed in two distinct groups according to the age of onset and the age of first clinical evaluation. Group 1 included preschool age children, while Group 2 consisted of pubertal age patients. In all the patients the importance of a positive family history for headache as a risk factor was confirmed. In addition, when compared with Group 2, Group 1 showed greater male gender prevalence and earlier onset of the attacks. Regarding clinical features, in Group 1, compared with Group 2, the attack duration was shorter with lower symptom association such as photo- or phonophobia, nausea and no pain increase during physical activity. In the same group, tension-type headache was the predominant diagnosis, in contrast to the high migraine prevalence of Group 2. This study also showed that the International Headache Society 1988 classification criteria are not fully adequate for juvenile headaches. In fact, the headaches of more than 10% of patients in Group 1 still remained unclassifiable, while those of all the subjects in Group 2 were properly classifiable.

A genetic association study of migraine with dopamine receptor 4, dopamine transporter and dopamine-beta-hydroxylase genes

We assessed the role of some dopamine metabolism genes in the genetic susceptibility to migraine. We performed an association study using three functional polymorphisms: a 48-base-pair (bp) tandem repeat in the D4 dopamine receptor gene ( DRD4), a 40-bp tandem repeat in the dopamine transporter gene ( DAT) and a dinucleotide repeat in the dopamine beta-hydroxylase ( DBH) gene. Allelic and genotypic frequencies for each polymorphism were assayed in two migraine populations (93 individuals with migraine with aura (MA) and 101 with migraine without aura (MO)) and were compared with those in a control group (117 individuals). No significant differences were found between control and migraine groups for DAT and DBH polymorphisms. Instead, the distribution of alleles for the DRD4 gene in the MO group was significantly different from those in both MA and control groups, with the shortest and longest alleles being less frequent in MO. Our data indicate that MO, but not MA, shows significant genetic association with DRD4.

Deficient energy metabolism is associated with low free magnesium in the brains of patients with migraine and cluster headache

We used phosphorus magnetic resonance spectroscopy to assess in vivo the brain cytosolic free magnesium concentration and the free energy released by the reaction of adenosine triphosphate (ATP) hydrolysis (DeltaG(ATPhyd)), the latter being an index of the cell's bioenergetics condition. We studied 78 patients with migraine in attack-free periods (7 with migraine stroke, 13 with migraine with prolonged aura, 37 with migraine with typical aura or basilar migraine, and 21 with migraine without aura), and 13 patients with cluster headache. In the occipital lobes of all subgroups of migraine and in cluster headache patients cytosolic free [Mg(2+)] as well as the free energy released by the reaction of ATP hydrolysis were significantly reduced. Among migraine patients, the level of free energy released by the reaction of ATP hydrolysis and the cytosolic free [Mg(2+)] showed a trend in keeping with the severity of clinical phenotype, both showing the lowest values in patients with migraine stroke and the highest in patients with migraine without aura. These results support our current hypothesis that the reduction in free [Mg(2+)] in tissues with mitochondrial dysfunction is secondary to the bioenergetics deficit, and are against a primary role of low brain cytosolic free [Mg(2+)] in causing the bioenergetics deficit in headache.

A novel mutation (D305V) in the early growth response 2 gene is associated with severe Charcot-Marie-Tooth type 1 disease

Hereditary motor and sensory neuropathies (HMSN) comprises a wide clinical spectrum of related disorders with defects in peripheral nerve myelination. Charcot-Marie-Tooth type 1 (CMT1) is the most common form and is usually a mild disease with onset in the first or second decade; however there is a interfamilial and intrafamilial clinical variation, ranging from asymptomatic expression to severe muscular weakness and atrophy. Recently point mutations in the early growth response 2 gene (EGR2/Krox-20) have been associated with hereditary myelinopathies. We investigated for mutations at the EGR2 gene a patient with severe CMT1 phenotype. Direct sequencing of EGR2 gene showed a heterozygous A T transversion at nucleotide 1064 that predicts an Asp305Val substitution within the first zinc-finger domain. The finding of a novel EGR2 mutation associated with a different phenotype confirms that peripheral neuropathies represent a continuum spectrum of related disorders due to an underlying defect in myelination.

Congenital hypomyelination due to myelin protein zero Q215X mutation

Congenital hypomyelination (CH) is a hereditary demyelinating peripheral neuropathy characterized by early infancy onset, distal muscle weakness, hypotonia, areflexia, and severe slowing of nerve conduction velocities. In the present report, the clinical, morphological, and immunohistochemical features of a CH case and the identification of a mutation in the gene (MPZ) for protein zero (P0) associated with this phenotype are described. This "de novo" mutation in a patient presenting with clinical features quite distinct from those of the more frequent Charcot-Marie-Tooth type 1B disease (CMT1B) or Dejerine-Sottas syndrome (DSS) confirms that CH is allelic with other disorders characterized by a less severe phenotype and a different clinical and neuropathological profile.

Exclusion of the ninjurin gene as a candidate for hereditary sensory neuropathies type I and type II

Ninjurin is a protein that is up-regulated in Schwann cells and neurons after peripheral nerve injury. Its role in promoting nerve regeneration and its expression in sensory neurons of dorsal root ganglia, as well as the chromosomal localization of the ninjurin gene, makes this gene a candidate for hereditary sensory neuropathies (HSN). In the present report, the human ninjurin gene was analyzed in 17 unrelated patients with HSN type I, two patients with HSN type II, and 10 normal controls, by single strand conformation polymorphism and by direct sequencing. All three exons and splice junctions of the gene were investigated and no mutations were found in our sample of patients. Our results rule out a mutation in the translated region of the ninjurin gene as a cause of HSN type I and type II.

EEG evaluation in children and adolescents with chronic headaches

In order to establish the usefulness of EEGs for the diagnosis of headache in children and adolescents, we retrospectively reviewed the records of 425 patients referred to our Paediatric Neurology Service because of recurrent headache. EEG was recorded ictally in 40 patients and interictally in 412 subjects.

CONCLUSION

Our results confirm that the EEG is a very helpful tool, particularly in migraine with aura during the ictal phase, because it shows transient abnormalities that may support the diagnosis of this form of headache. On the contrary the EEG performed during the interictal phase is most often normal or it shows aspecific abnormalities with no relationship with to features.

Frequency of factor V Leiden in juvenile migraine with aura

Patients with migraine are known to be at risk for stroke. It has been reported that in a group of patients with cerebral ischemia and the Leiden mutation of factor V, 67% had classical migraine. We have studied the frequency of this mutation in a group of Italian children and adolescents affected by migraine with aura. The Leiden mutation was detected in 2 (3.5%) of 57 patients and in 8 (3.7%) of 219 controls. The 2 patients carrying the mutation had no peculiar characteristics as compared with the rest of the migrainous population. In our study, the frequency of the Leiden mutation in patients was not different from that of controls. These data contrast with those collected in the Finnish population and in a group of northwestern Italian adult patients, but agree with results previously reported from The Netherlands.

Deficit of brain and skeletal muscle bioenergetics and low brain magnesium in juvenile migraine: an in vivo 31P magnetic resonance spectroscopy interictal study

We used phosphorus magnetic resonance spectroscopy (31P MRS) to investigate in vivo the brain and skeletal muscle energy metabolism of 15 children with migraine with aura in interictal periods. Brain 31P MRS disclosed low phosphocreatine and high inorganic phosphate contents, and high intracellular pH in all patients. Calculated [ADP] and the relative rate of mitochondrial oxidation were higher in the brain of patients than in control subjects, whereas the phosphorylation potential was lower. Brain intracellular free Mg2+ concentration was reduced by 25% in patients. Abnormal skeletal muscle mitochondrial respiration was also disclosed in 7 of 15 patients as shown by the slow rate of phosphocreatine postexercise recovery. The multisystem bioenergetic failure found in patients with juvenile migraine is comparable to that found in adults with different types of migraine.

Endozepine stupor in children

Recurring episodes of stupor in adults have been shown to be related to increased levels of endozepines, which are endogenous ligands for the GABAA receptors. We report here two children presenting with recurrent episodes of stupor associated with fast EEG activity who had increased levels of endozepine-4 in plasma. Mass spectroscopy did not reveal commercially available benzodiazepines. Interictal endozepine-4 levels were normal. In one of the patients, administration of flumazenil (0.25 mg i.v.), a benzodiazepine inverse agonist, induced improvement of consciousness and attenuation of EEG fast activity. In conclusion, children presenting with recurrent episodes of stupor and EEG fast activity should be evaluated for endozepine levels and can be effectively treated with i.v. flumazenil.

Searching for migraine genes: exclusion of 290 cM out of the whole human genome

A linkage and association analysis was made on 14 Italian families with recurrent migraine. We analyzed five chromosomal regions surrounding the candidate genes 5HT1D (1p36.3-34.3), 5HT1B (6q13), 5HT2A (13q14-21), 5HT transporter (17q11.2-12), CACNLB1 (17q11.2-22) and FHM (19p13), using 29 DNA polymorphic markers. All two-point lod scores were negative, and the chi 2 sib-pair analyses were not significant, thus indicating the probable exclusion of these regions as sites of migraine genes in our population.

Interictal and ictal phase study with Tc 99m HMPAO brain SPECT in juvenile migraine with aura

Single photon emission computed tomography (SPECT) was performed on 30 juvenile patients suffering from different types of migraine with aura. SPECT was carried out only during the pain-free interval in 11 patients. The other 19 patients underwent SPECT ictally and 9 of them also interictally. During the pain-free interval, the investigation was normal in 16 of 20 cases and revealed hypoperfused areas in 4 of 20 cases. Ictally, regional cerebral blood flow (rCBF) abnormalities were found in 14 of 19 cases; hypoperfusion in 11 patients and hyperperfusion in 3 patients. In most cases, rCBF abnormalities corresponded to the topography of neurologic symptoms. Our interictal period results do not agree with the previous studies in juvenile migraineurs, while during the ictal phase we demonstrated, for the first time, significant rCBF abnormalities in juvenile patients suffering from migraine with aura.

Juvenile idiopathic stabbing headache

We report on 83 juvenile patients with idiopathic stabbing headache, subjectively perceived as lasting from a fraction of a second to a few minutes. This sample was selected from among 2543 outpatients referred because of recurrent headache to the Paediatric Neurology Services of Ferrara and Padua (Italy). Other painful syndromes were excluded by clinical examination and appropriate tests. Idiopathic stabbing headache in the pediatric age group, contrary to the adult form, is usually not associated with other primary headache syndromes. We suggest that this clinical picture should be more clearly defined in the future, in order to better understand its relationships with other primary headaches.

Migraine aura without headache and ictal fast EEG activity in an 11-year-old boy

A case of an 11-year-old boy with recurrent migraine auras without headache is reported. Aura was preceded by an anisocoria and was characterized, besides other brain-stem signs, by confusional state. Ictal EEG recordings showed fast activity. Recognition of this finding may prevent an inappropriate diagnosis of drug ingestion. However, whether non-reactive beta activity is typical for basilar migraine remains to be determined.

Magnetic resonance angiography in moyamoya disease

Spontaneous occlusion of the circle of Willis, i.e., moyamoya disease (MMD), is a clinical disease entity angiographically characterized by progressive and bilateral stenosis of the carotid bifurcation, with a hazy collateral network at the base or convexity of the brain. Although the importance of computed tomography (CT) and conventional magnetic resonance (MR) imaging in diagnosing MMD has already been determined, conventional arteriography is still regarded as necessary for definitive diagnosis. Magnetic resonance angiography (MR-A) is a very recent vascular imaging technique which allows noninvasive and direct imaging of vessels without the use of contrast medium. We present four pediatric cases of MMD, evaluated by conventional angiography, CT, MR imaging, and MR-A. Our data demonstrate that MR-A is successful both in allowing detection of occlusive disease of the basal portion of the internal carotid artery and large branch basal cerebral vessels and demonstrating the collateral vessels at the base of the brain. As a noninvasive procedure, MR-A promises to become a valuable alternative to classical angiography in the diagnosis of MMD.

Serum and red blood cell magnesium levels in juvenile migraine patients

Recently an important role for magnesium in establishing the threshold for migraine attacks has become evident. Accordingly, we measured serum and red blood cell magnesium levels in juvenile migraine patients with and without aura interictally. In comparison with normal subjects, migraineurs had significantly lower serum and red blood cell magnesium levels.

Multicenter study of childhood headache

This multicenter study reports the results obtained between 1990 and 1991 by the Study Group for Childhood Headache of the Italian Neuropediatric Society. Standardized computerized case sheets were used in order to increase the number of young patients studied and obtain more homogeneous results. A clinical diagnosis of headache was made in 600 patients (314 female and 286 male) between 4 and 12 years of age, in accordance with the classification set down by the International Headache Society. Clinical symptoms and follow-up were more severe in children with migraine as opposed to headache. No sequence of associated neurological and neurovegetative symptoms was observed at onset of headache, and some (phono-photophobia, pallor, drowsiness, abdominal pains) were much more prevalent than others. Because of the patient's age we studied only the treatment of acute attack and did not take account of chronic treatment. In childhood the clinical course of primary headache tends to improve spontaneously, and we believe that prevention of headache attacks should be carried out only in very rare individual cases.

Uncommon EEG pattern in an 8-year-old boy with recurrent migraine aura without headache

A case of an 8-year-old boy with recurrent migraine auras without headache, precipitated by minor head trauma, is reported. Aura was characterized, besides other brain-stem signs, by confusional state. An uncommon electroencephalographic pattern recorded during the episodes, characterized by diffuse continuous beta activity, is described. Recognition of this finding may prevent an inappropriate diagnosis of drugs ingestion.

Moyamoya disease in childhood: a familial case report

Moyamoya is an obstructive cerebrovascular disease characterized by a cerebral angiographic picture of stenosis or occlusion of main cerebral arteries with an abnormal vascular network at the base of the brain. No definitive cause has been found for this disease and opinion is still divided between a congenital and an acquired etiology. Hemiplegia of sudden onset and epileptic seizures are the prevailing presentation in childhood, while subarachnoid bleeding occurs more frequently in adults. We report a new case of childhood moyamoya with clinical onset of the neurological symptoms within the 3rd year of life; during the child's illness the maternal grandmother presented with moyamoya disease too. Antiaggregating and calcium-antagonist drugs seem effective in preventing further vascular accidents, while a surgical approach is not possible. Computed tomography, single positron emission computed tomography, and magnetic resonance imaging are very useful in the diagnosis of this rare disease.

Osmotic resistance of urinary red cells in glomerular and non-glomerular haematuria

The determination of glomerular or non-glomerular origin of urinary red blood cells (U-RBC) is an important goal in the management of haematuric children. Morphological changes of glomerular RBC are secondary to cell membrane damage, due, in part, to the hypotonic osmotic stress to which U-RBC are submitted during their passage through tubular segments. This study was performed on 2 urine specimens obtained from 30 patients with a known cause of haematuria. After centrifugation, both sediments were resuspended in two saline solutions (at 200 mosm/l and at 300 mosm/l) where they remained for 90 min. The number of U-RBC per microliters in each (U-RBC 200 and U-RBC 300) was determined by microscopic count in Burker's chamber. The U-RBC 200/U-RBC 300 ratio was calculated for all patients. We found that in non-glomerular haematuria the ratio was near to 1, whereas cases of glomerular origin had lower values. The discriminant threshold between this ratio was 0.76 (p < 0.001). We suggest that determination of osmotic resistance of U-RBC may be a reliable method to differentiate the origin of bleeding in haematuric children.

Effectiveness of partial splenic embolization as treatment for hypersplenism in thalassaemia major: a 7-year follow up

Partial splenic embolization is an alternative procedure to total splenectomy in patients with hypersplenism, and was performed in 10 patients with beta-thalassaemia major who were then followed for 5 to 7 years. The results were compared with those of a 7-yr follow-up of 6 splenectomized thalassaemics. The blood consumption decreased and the leucocyte counts increased in both groups of patients. However, after partial splenic embolization, severe thrombocytosis--which is typical of splenectomized patients--did not develop and there were no severe complications from the operation, such as infections or reappearance of hypersplenism. In addition, the minor surgical injury and avoidance of abdominal scars were further advantages of partial splenic embolization over total splenectomy.

Acquired hyperoxaluria and haematuria in children

Two children with extensive ileal resection are reported. They developed gross haematuria of "non-glomerular origin", without stones or nephrocalcinosis. Previous reports indicate that acquired hyperoxaluria is common in children with a variety of intestinal disorders. Our patients had hyperoxaluria. We think that hyperoxaluria may be the cause of haematuria through a pathogenetic mechanism similar to the one ascribed to haematuria secondary to hypercalciuria and hyperuricosuria.

[Radioisotope evaluation of splenic hemocatheretic activity in a group of thalassemic patients after embolization]

Seven patients with thalassemia major underwent splenic embolization in order to assess splenic mass and function before and after treatment. Red blood cells, marked "in vitro" and chemically denatured with BMHP were also used to assess the blood parameters related to splenic function i.e. pretransfusional haemoglobin (Nb) and mean blood consumption (BC). The results show a statistically significant difference (p less than 0.01) for Hb and erythrocyte clearance before and after embolization. Before embolization no statistically significant correlations were found between the parameters examined, whereas after embolization there was a linear correlation at the limit of significance between BC and clearance half-time. The radionuclide method is proposed as safe and reproducible. Unlike blood chemical tests it also provides immediate information on the effects of embolization and a reliable parameter for follow-up.

[Juvenile hypertension: a comparison between 2 student populations in the provinces of Ferrara and Rovigo]

The Authors have investigated the frequency of hypertension (systolic, diastolic, systo-diastolic, severe and borderline, sustained and labile) in 2 groups, respectively of 738 and 1041 school children between 11 and 14 years of age, from the provinces of Ferrara and Rovigo. The percentile graphic representations and the frequency of different types of hypertension have been compared in these two parallel studies; a correlation of statistical significance has been shown between hypertension and obesity in the Ferrara group, while a similar correlation between hypertension and familiarity for hypertension has been demonstrated in the Rovigo group.

[Intestinal invagination and Yersinia enterocolitica infections]

After a short review of literature about the few previous reports a case of intussusception associated with Yersinia enterocolitica in a 11 month-old infant is reported. The causal significance of mesenteric lymphoadenomegaly is discussed. Intussusception as the first clinical sign of Yersinia infection is suggested.

[Contribution to the study of some plasma protein clearances in children]

Renal clearances of transeferrin, IgG and C'3 were determined by the immunodiffusion method in 51 healthy children. Statistical elaboration shows the great dispersion around the mean values. The results of other Authors in healthy adults are confirmed.