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Neck - tongue syndrome: rare case report
Get PDFINTRODUCTION: Neck-tongue syndrome (NTS) is a very rare clinical condition defined by the International Headache Society (IHS) as “painful lesions of the cranial nerves and other facial pain”. The headache disorder is often initiated by rapid axial rotation of the neck resulting in unilateral neck and/or occipital pain and transient ipsilateral tongue sensory disturbance. It is still very underrecognized, predominantly affecting children and adolescents. The prevalence is slightly higher in women. The pathophysiology mainly results from ligamentous laxity during growth, leading to transient subluxation of C1-C2 with sudden head movements. In the branch of the lingual nerve, where the anastomosis with the hypoglossal nerve is impacted against the bone, symptoms occur in the tongue. Diagnosis is based on clinical suspicion after a thorough history and physical examination, without a pathognomonic radiologic finding. It is typically treated conservatively with medications, local injections, immobilization with cervical collars, or physical therapy; rarely is surgical intervention pursued.OBJECTIVE: Describing and recognizing a rare pathology. CASE REPORT: Patient: Male, 14 years old, cowboy, student, from Patos. Following a fall from a horse, the patient began to experience discomfort in the neck, occipital region, and shoulder, as well as a sensation of numbness and burning in the tongue, especially when moving his head laterally. The pain has an immediate onset, is unilateral, and is described as tingling or stabbing with moderate to severe intensity in the occipital region, neck, and shoulders, always following sudden lateral neck movement, along with changes in the tongue, such as numbness and a strange sensation. The pain lasts for an average of a few minutes, with complete improvement.Physical and neurological examinations are normal. X-ray and cervical MRI are normal.CONCLUSION: Neck-tongue syndrome, being a rare and still poorly recognized pathology, is difficult to diagnose. This results in significant delays in diagnosis and consequently poor management. Therefore, it is crucial to have more case reports for the recognition of this nosological entity
A rare case of long-standing intracranial hypertension secondary to a lumbosacral extradural tumor
Get PDFIntroduction: Intracranial hypertension (ICH) caused by a spinal cord tumor is a rare but well-known condition. Identifying the disease is particularly challenging when characteristic spinal symptoms or signs are absent. Objective: To report a rare case of long-standing intracranial hypertension secondary to a lumbosacral extradural tumor. Case Report: A 76-year-old male patient, a former smoker and alcohol consumer, with a 10-year history of headache associated with visual impairment and bilateral papilledema, which was diagnosed as idiopathic intracranial hypertension. One year ago, he developed mental confusion, imbalance, and gait disturbances. Sixty days before admission, he presented weakness in the lower limbs, and 15 days before admission, he experienced new-onset seizures. On examination, anisocoria (right larger than the left), sluggish pupillary reaction to light in the left eye, and visual acuity of counting fingers at 4 meters in the right eye and 20/80 in the left eye. Fundoscopy showed optic nerve pallor (grade 2+), papillary edema with 360-degree blurring (Frisen grade 4). Complementary laboratory tests included cerebrospinal fluid (CSF) analysis, collected via suboccipital puncture, with an opening pressure of 35 cmH2O and a protein level of 81 mg/dL. Magnetic resonance imaging (MRI) and angiography of the brain showed a partially empty sella and diffuse proportional cerebral atrophy. The patient underwent optic nerve fenestration and subsequently a ventriculoperitoneal shunt to relieve intracranial pressure and reduce optic nerve suffering. Further investigation for causes of elevated CSF pressure and recent neurological findings, including motor loss, led to a spinal MRI revealing an intradural lesion between L4-S1, approximately 6.1 cm in craniocaudal axis, with posterior bone remodeling between L5-S1 inferring compression of the cauda equina roots, without involvement of the conus medullaris. Spinal arteriography confirmed a hypervascular lesion at levels L4 to S1, with blood supply from the anterior spinal artery and ectasia of the medullary drainage veins. After neurosurgical evaluation, the patient, in clinical stability, chose not to further stratify the lesion. Conclusion: Since intracranial hypertension can lead to a permanent optical loss, spinal MRI may be considered soon after the initial investigation to exclude atypical and rare cases of intracranial hypertension
Association of serum metals/metalloids levels with migraine and non-migraine headache types in a 4-year follow-up analysis with 2,662 participants in the ELSA-Brasil study
Get PDFBackground: Migraine disorders are thought to be influenced by a myriad of endogenous and environmental factors, including its association with metals/metalloid levels. However, this intricate relationship has never been comprehensively studied. Objective: We aimed to examine the risk of migraine disorders associated with serum levels of 16 metals/metalloids in the ELSA-Brasil study. Methods: This is a prospective analysis based on the serum levels of metals/metalloids in the baseline wave (2008-2010) and the migraine diagnosis in the inter-wave (2012-2014). Metals quantification was performed by Inductively Coupled Plasma Mass Spectrometry (ICP-MS) and migraine diagnosis was based on ICHD-3, grouped as migraine without aura (MWO), migraine with aura (MWA), and non-migraine headache (NO). Modified Poisson regression models estimated the risk ratios (RR) with [95% confidence interval] for migraine diagnosis, according to metals concentration quintiles (Q), with the median as reference and 1st and 5th quintiles representing the lowest and highest metal levels, respectively. The adjusted models controlled for sex. age, education, race, smoking, alcohol intake, migraine prophylactic medication, and cardiometabolic risk factors. Results: The study included 2,662 adults, with a median (IQR) age: of 51 (45, 58) years and 52.7.0% (n = 1,403) female. In the adjusted models, 5th Q of Cu (RR: .79 [.64, .97]) and 3rd Q of Ba (RR: .86 [.76, .96]) were associated with a lower risk of NO, while 5th Q of Pb (RR: 1.16 [1.00, 1.34]) were associated with a higher risk of NO. The 1st Q of Fe (RR: 1.31 [1.01, 1.69]), 3rd Q of Ba (RR: 1.39 [1.14, 1.70]), and the 5th Q of Cd (RR: 1.35 [1.05, 1.74]) were associated with higher risk of MWO, while 5th Q of Se (RR: .70 [.50, .99]) and 3rd Q of Zn (RR: .78 [.63, .97]) were associated with lower risk of MWO. The extreme levels of Cd and Sr (5th Q and 1st Q) were associated with increased risk of MWA (RR: 1.48 [1.04, 2.10] and RR: 1.41 [1.01, 1.97], respectively). Finally, the 1st Q of Cu was associated with a lower risk of MWA (RR: .65 [.44, .97]). Conclusion: In the ELSA-Brasil, a diverse relationship was observed between metals and headaches with a higher magnitude of associations noticed with higher levels of Cd and both migraine subtypes
BLOQUEIO ESFENOPALATINO BILATERAL E BIOCCIPITAL COMO MÉTODO DE REVERSÃO DA MIGRˆANEA CRÔNICA: UM CASO DE CEFALEIA REFRATÁRIA APÓS CRIPTOCOCOSE MENÍNGEA
No full textINTRODUCTION
Peripheral nerve blocks showed success in treating cervicogenic headache, occipital neuralgia, cluster headache, and migraine. This procedure is notable for its effectiveness in acute pain relief and its cost-effectiveness.
OBJECTIVE
To present a case of peripheral nerve block in a chronic headache refractory to analgesics scenario, exacerbated by a cryptococcal meningitis.
CASE REPORT
INS, a 58-year-old female, presented with sporadic-onset refractory headaches, chronicle and worsened after developing cryptococcal meningitis post-liver transplant 5 years ago. The pain was bilateral, bitemporal, retro-orbital, symmetrical, oppressive, and gradual, peaking within 1 hour. Without analgesics, the pain was continuous, severe, auraless, associated with nausea, vomiting, photophobia, and allodynia. She used 4-6 tablets of 500 mg dipyrone daily. She had late cutaneous porphyria, history of treated breast cancer, cirrhosis secondary to non-alcoholic steatohepatitis and hemosiderosis, treated by transplant, with neurocryptococcosis transmitted from the donor, followed by cytomegalovirus encephalitis and empyema pneumonia. She had immunosuppressive therapy, also use of amitriptyline (25 mg, twice daily), topiramate (50 mg, twice daily), and dipyrone. MRI during meningitis revealed leptomeningeal and ependymal lesions, progressing over 1 year to a right frontal white matter’s lesion, possibly due to immune reconstitution inflammatory syndrome.
To alleviate the pain, bilateral blockade of the greater and lesser occipital nerves and sphenopalatine ganglion was performed, administering 2 mL of 0.2% ropivacaine and 50 mcg clonidine per nerve, and 12 mL of the solution via intranasal gauze to the ganglia, volumes selected by safety parameters. The patient reported a 90% reduction in pain intensity and frequency after 4 sessions, reducing the analgesics’ necessity. However, during the 5th session, vertigo, nausea, asthenia, and presyncope occurred, leading to temporary treatment interruption. Nonetheless, the patient reported symptom improvement after using common analgesics, which was previously unattainable.
CONCLUSION
Peripheral blocks are highly effective in treating various types of headaches, including refractory cases as the one reported, secondary to meningeal infection. However, even after well-succeeded sessions, it is crucial to monitorate the patients due to the possible collateral effects, such as vertigo, nausea, asthenia and presyncope. Further studies are necessary to investigate the relevance of these effects and their causes
SIDEROSE IDIOPÁTICA DO SNC: UM RELATO E REVISÃO
No full textSuperficial siderosis (SS) of the central nervous system (CNS) is a potentially disabling disorder characterized by the deposition of ferrous iron and hemosiderin, products of hemolysis, in the leptomeninges and superficial layers of the cerebral and cerebellar cortexes, as well as the brainstem and spinal cord. Persisting in the subarachnoid space, accumulation leads to demyelination, axonal loss and subsequent atrophy and neurodegeneration mediated by free radicals. In most cases, a potentially causative spinal or cranial dural abnormality is identified. The classification of SS is based on anatomical distribution, etiology and clinical manifestations, resulting in distinct subtypes: Classical infratentorial (i) SS (type 1), secondary SSi (type 2) and cortical SS (c). The classical clinic manifests with sensorineural hypoacusis, cerebellar ataxia and occasionally myelopathic and radicular signs. Although it is not a classic symptom of SS, infrequently some patients develop chronic intracranial hypertension, which is believed to be associated with obstruction of the interventricular foramen and/or malabsorption of cerebrospinal fluid (CSF). When present, the headache is usually a consequence of intracranial hypotension and its intensity varies according to the type of dural defect and the rate of bleeding or CSF leakage through a fistula. Diagnosis is established by means of magnetic resonance imaging (MRI) of the entire neuroaxis combined with clinical assessment. As alternatives aimed at preventing the progression of the disease and preserving the patient\u27s functional integrity, in addition to controlling the deficits generated by siderosis, surgical closure of the dura mater and chelation are the main therapeutic alternatives.A siderose superficial (SS) do sistema nervoso central (SNC) é um distúrbio potencialmente incapacitante caracterizado pela deposição de ferro ferroso e hemossiderina, produtos da hemólise, nas leptomeninges e camadas superficiais dos córtices cerebral e cerebelar, além do tronco encefálico e medula espinhal.2,1,4,5,6 Persistindo no espaço subaracnóideo, o acúmulo leva à desmielinização, perda axonal e subsequente atrofia e neurodegeneração mediada por radicais livres.2,5 Na maioria dos casos, identifica-se uma anormalidade dural espinal ou craniana potencialmente causal.2 A classificação da SS baseia-se na distribuição anatômica, etiologia e manifestações clínicas, resultando em subtipos distintos: SS infratentorial (i) clássica (tipo 1), SSi secundária (tipo 2) e SS cortical (c).1,2 A clínica clássica manifesta-se com hipoacusia neurossensorial, ataxia cerebelar e ocasionalmente sinais de mielopatia e radiculares.3,2,1 Apesar de não ser um sintoma clássico da SS, infrequentemente, alguns pacientes desenvolvem hipertensão intracraniana crônica, onde acredita-se estar associada à obstrução do forame interventricular e/ou má absorção do líquido cefalorraquidiano (LCR).4 Quando presente, a cefaleia geralmente é consequência de hipotensão intracraniana e sua intensidade varia de acordo com o tipo de defeito dural e da taxa de sangramento ou vazão liquórica por uma fístula.1,2,6 O diagnóstico é estabelecido por meio da ressonância nuclear magnética (RNM) de neuroeixo em associação com a avaliação clínica1. Como alternativas visando prevenir a progressão da doença e preservar a integridade funcional do paciente, além do controle dos défices gerados pela siderose, o fechamento cirúrgico da fistula dural e a quelação são as principais alternativas terapêuticas.3,2 
Propranolol: Um profilático para enxaqueca desde a década de 1960
No full textIntroductionPropranolol was the first non-selective beta-adrenergic blocker to be developed. Initially it was used in the treatment of cardiovascular diseases, but since the 60\u27s it has been used in the prevention of migraine.ObjectiveThe objective of this study was to know the history of propranolol and its use as a migraine prophylactic.MethodsThis study was an integrative literature review using articles with historical data on propranolol, from its origin in cardiology to its indication in the preventive treatment of migraine.ResultsPropranolol was described in 1962 for the treatment of cardiovascular diseases. In the same decade, it was prescribed for the preventive treatment of migraine and, recently, included in the consensus of the Brazilian Headache Society.ConclusionAlthough propranolol was initially synthesized for the treatment of heart disease, it has proved to be an effective drug in preventing migraine attacks.IntroduçãoO propranolol foi o primeiro bloqueador beta-adrenérgico não seletivo a ser desenvolvido. Inicialmente era utilizado no tratamento de doenças cardiovasculares, mas desde a década de 60 passou a ser utilizado na prevenção da enxaqueca.Objetivo O objetivo deste estudo foi conhecer a história do propranolol e seu uso como profilático para enxaqueca.MétodosEste estudo foi uma revisão integrativa da literatura utilizando artigos com dados históricos sobre o propranolol, desde sua origem na cardiologia até sua indicação no tratamento preventivo da enxaqueca.ResultadosO propranolol foi descrito em 1962 para o tratamento de doenças cardiovasculares. Na mesma década, foi prescrita para o tratamento preventivo da enxaqueca e, recentemente, incluída no consenso da Sociedade Brasileira de Cefaleias.ConclusãoEmbora o propranolol tenha sido inicialmente sintetizado para o tratamento de doenças cardíacas, ele provou ser um fármaco eficaz na prevenção de crises de enxaqueca
Síndrome de Hemicrania-Nevralgia do Trigêmeo Paroxística (PH-Tic) sem lesão estrutural em uma mulher brasileira: o primeiro relato de caso
No full textIntroductionIn Brazil there is only one case report of a patient diagnosed with Paroxysmal Hemicrania-Trigeminal (PH-Tic) syndrome reported, however it was observed in a patient with Chiari I malformation.ObjectiveHere, we describe the first case of primary PH-Tic syndrome in the country.MethodCase report. CARE guideline was used to guide the structuring of this article. This case report was approved by the ethics committee and has been registered under the protocol number 70705623.7.0000.5440 on “Plataforma Brasil”.ResultsA 72-year-old woman with a five-month history of headaches was admitted at our headache outpatient clinic. The pain was sharp, intense, localized in the periorbital and left temporal regions. Blood counts, liver, renal and thyroid function were normal, as well as brain magnetic resonance imaging. Despite using carbamazepine, the patient had pain in only the left side of the face. Indomethacin was added until the dose of 100 mg a day and resulted in improvement of headache frequency.ConclusionPH-Tic should be hypothesized in patients with short-lasting headaches associated with facial pain that partially improve with carbamazepine or indomethacin.IntroduçãoNo Brasil, há apenas um relato de caso de paciente com diagnóstico de síndrome de Hemicrânia-Trigêmeo Paroxística (PH-Tic), porém foi observado em paciente com malformação de Chiari I.ObjetivoAqui, descrevemos o primeiro caso de síndrome de PH-Tic primária no país.MétodoRelato de caso. A diretriz CARE foi utilizada para orientar a estruturação deste artigo. Este relato de caso foi aprovado pelo comitê de ética e registrado sob o número de protocolo 70705623.7.0000.5440 na “Plataforma Brasil”.ResultadosUma mulher de 72 anos com história de cefaléia há cinco meses foi admitida em nosso ambulatório de cefaléia. A dor era aguda, intensa, localizada nas regiões periorbitária e temporal esquerda. Hemogramas, função hepática, renal e tireoidiana normais, assim como ressonância magnética cerebral. Apesar do uso de carbamazepina, o paciente apresentava dor apenas no lado esquerdo da face. A indometacina foi adicionada até a dose de 100 mg ao dia e resultou em melhora da frequência das cefaléias.ConclusãoA hipótese de HP-Tic deve ser levantada em pacientes com cefaleias de curta duração associadas a dor facial que melhoram parcialmente com carbamazepina ou indometacina
Enxaqueca com aura e acidente vascular cerebral - o papel dos sinais de alerta no contexto das cefaleias secundárias: relato de caso
No full textIntroductionHeadache is a very common complaint in doctors\u27 offices, with primary causes being the majority in relation to secondary ones. Despite this, the identification of secondary headaches is very relevant in clinical practice, since these can be a life-threatening condition, functionality or even a reversible cause. However, imaging screening for all individuals with headache is costly and unrewarding. Therefore, it is important to know the warning signs that, together with the clinical context, lead to a more precise indication of these exams and early and well-targeted therapeutic interventions.Clinical caseThis is a 60-year-old man, previously dyslipidemic and smoker, with migraine with aura reported since childhood, who underwent treatment with sodium valproate, with headache attack suppression. About 4 months before admission, he presented with an alteration in the pain pattern, amaurosis fugax in the right eye, dizziness and mild paresis and hypoesthesia in the left side of the body, primarily treated by him as migraine crises, without improvement with the use of triptans. A new outpatient investigation was carried out, which showed multiple small infarcts in the right hemisphere secondary to atheromatous plaque in the right carotid bulb with an obstruction of approximately 85%. Diagnostic and therapeutic arteriography was performed, with stent implantation, uneventfully.ConclusionThe differential diagnosis between migraine with aura and a cerebrovascular event has already been widely reported in the literature and constitutes a pitfall in the routine of headaches, since a serious and potentially disabling condition can be overlooked. The joint evaluation of the alarm signs with the global context becomes an important tool in the propaedeutics of these patients, with knowledge of this casuistry being something relevant within clinical practice.IntroduçãoCefaleia é uma queixa muito comum em consultórios médicos, com causas primárias sendo maioria em relação às secundárias. Apesar disso, a identificação das cefaleias secundárias são muito pertinentes na prática clínica uma vez que estas podem se constituir de condição ameaçadora à vida, funcionalidade ou até mesmo uma causa reversível. No entanto, a triagem com exames de imagem para todos os indivíduos com cefaléia mostra-se dispendiosa e pouco recompensadora. Sendo assim, torna-se importante o conhecimento dos sinais de alarme que, conjuntamente ao contexto clínico, levam a indicação mais precisa destes exames e intervenções terapêuticas precoces e bem direcionadas.Caso ClínicoTrata-se de paciente de 60 anos, previamente dislipidêmico e tabagista, portador de migrânea com aura desde a infância, tendo realizado tratamento com Valproato de Sódio, apresentando supressão das crises. Há cerca de 4 meses antes da admissão, apresentou quadro de alteração do padrão álgico, amaurose fugaz em olho direito, tonturas e leve paresia e hipoestesia em dimídio esquerdo, primariamente tratadas por ele como crises migranosa, sem melhora com o uso de triptanos. Realizada nova investigação ambulatorial que demonstrou pequenos infartos múltiplos em hemisfério direito secundária a placa ateromatosa em bulbo carotídeo direito com obstrução de cerca de 85%. Fora realizada arteriografia diagnóstica e terapêutica, com implante de Stent, sem intercorrências.ConclusãoO diagnóstico diferencial entre aura migranosa e evento cerebrovascular já é muito relatado na literatura e constitui-se de uma armadilha na rotina em cefaléias uma vez que pode se deixar passar uma condição grave e potencialmente incapacitante. A avaliação conjunta dos sinais de alarme com o contexto global torna-se ferramenta importante na propedêutica destes pacientes, sendo o conhecimento desta casuística algo relevante dentro da prática clínica
Uma transformação da neuralgia do trigêmeo em SUNCT/SUNA: relato de caso e revisão literária
No full textIntroductionTrigeminal neuralgia and Short-lasting Unilateral Neuralgiform Headache with Conjunctival injection and Tearing (SUNCT)/Short-lasting Unilateral Neuralgiform Headache Attacks with Cranial Autonomic Symptoms (SUNA) are characterized by similar clinical manifestations, which may lead to diagnostic confusion. However, the transformation of trigeminal neuralgia into SUNCT/SUNA is a rare phenomenon. This report describes a case of trigeminal neuralgia transformation into SUNCT/SUNA due to neurovascular compression and reviews all previously published cases of trigeminal neuralgia to SUNCT/SUNA transformation in the literature.Case presentationA 49-year-old Thai male patient presented with progressive right facial pain for a period of three months. One year prior, he developed trigeminal neuralgia along the maxillary branch of the trigeminal nerve, characterized by electrical shock-like pain in the right upper molar, exacerbated by eating. His symptoms were effectively managed with carbamazepine. Nine months later, he began experiencing recurrent electrical shock-like pain along the ophthalmic division of the right trigeminal nerve, accompanied by lacrimation, which failed to respond to continued treatment with carbamazepine. Three months prior to presentation, his symptoms evolved into SUNCT/SUNA, characterized by electrical shock-like pain in the right periorbital area and conjunctival injection, lacrimation. Neuroimaging revealed high-grade neurovascular compression of the right trigeminal nerve by the right superior cerebellar artery. The patient\u27s symptoms resolved following microvascular decompression.ConclusionClinicians should be aware that patients with longer disease duration of trigeminal neuralgia who develop new neuralgic pain in the ophthalmic branch division with mild autonomic symptoms may be at risk for transformation into SUNCT/SUNA.IntroduçãoNeuralgia do trigêmeo e cefaleia neuralgiforme unilateral de curta duração com Injeção e lacrimejamento conjuntival (SUNCT)/crises de cefaleia neuralgiforme unilateral de curta duração com sintomas autonômicos cranianos (SUNA) são caracterizadas por manifestações clínicas semelhantes, que podem levar a confusão diagnóstica. No entanto, a transformação da neuralgia do trigêmeo em SUNCT/SUNA é um fenômeno raro. Este relato descreve um caso de transformação de neuralgia do trigêmeo para SUNCT/SUNA devido à compressão neurovascular e revisa todos os casos publicados anteriormente de neuralgia do trigêmeo para transformação de SUNCT/SUNA na literatura.Apresentação do casoPaciente do sexo masculino, tailandês, 49 anos, apresentou dor facial progressiva à direita por um período de três meses. Há um ano, desenvolveu neuralgia do trigêmeo ao longo do ramo maxilar do nervo trigêmeo, caracterizada por dor tipo choque elétrico no molar superior direito, exacerbada pela alimentação. Seus sintomas foram efetivamente controlados com carbamazepina. Nove meses depois, ele começou a sentir dor recorrente do tipo choque elétrico ao longo da divisão oftálmica do nervo trigêmeo direito, acompanhada de lacrimejamento, que não respondeu ao tratamento continuado com carbamazepina. Três meses antes da apresentação, seus sintomas evoluíram para SUNCT/SUNA, caracterizados por dor tipo choque elétrico na região periorbitária direita e injeção conjuntival, lacrimejamento. A neuroimagem revelou compressão neurovascular de alto grau do nervo trigêmeo direito pela artéria cerebelar superior direita. Os sintomas do paciente desapareceram após a descompressão microvascular.ConclusãoOs médicos devem estar cientes de que pacientes com duração mais longa da neuralgia do trigêmeo que desenvolvem nova dor nevrálgica na divisão do ramo oftálmico com sintomas autonômicos leves podem estar em risco de transformação em SUNCT/SUNA
