Medicine and Health Sciences Commons^™

Narcotic Analgesics For Acute Migraine In The Emergency Room: Are We Meeting Headache Societies' Guidelines?, Mohammad Wasay, Khawaja Slaman Zaki, Saqib Uddin Khan, Rifat Rehmani

Department of Emergency Medicine

We analysed 161 patients with acute migraine in our emergency room (ER) to identify the use of narcotic analgesics as first-line treatment. Twenty-four percent of patients were treated with opioid analgesics and 76% patients were treated with non-opioid analgesics. Pain was completely relieved in 100 (62%) patients, partially relieved in 50 (31%) patients and was not relieved in 11 (7%) patients at the time of discharge. Pain relief was not related to the use of opioids vs. non-opioids. The treatment of acute migraine in our ER is in line with the guidelines of the Headache Societies and needs further improvement.

Towards A Cure For Traumatic Paraplegia - Is There Cause For Hope?, Rashid Jooma

Section of Neurosurgery

In the past decade, great strides have been made in the field of CNS tissue repair and expectations have been raised that a cure of spinal paralysis is at hand. The two broad categories of investigational approaches to spinal regeneration are: (1) Enhancing the Regenerative Milieu of the Cord and (2) Cellular and Tissue Transplantation. Amongst the latter approaches, the early use of foetal cord tissue has given way to the more sophisticated studies on stem cell therapy and the implants of olfactory ensheating cells. These have engendered considerable public interest and are being offered as commercially available therapies in …

Incidence And Epidemiology Of Cerebral Venous Thrombosis., Fazeel Mukhtar Siddiqui, Ayeesha Kamran Kamal

Department of Medicine

Cerebral venous sinus thrombosis is a disorder whose epidemiology has changed over the past few decades. It is no longer regarded as a uniformly fatal disease. CVST is not a rare disorder. It may have a differential geographic distribution with a higher incidence in the Asian world. It is a disease of neonates, younger women and men, often a hypercoagulable state, either acquired (e.g., cancer) or a genetic prothrombotic condition may be present. Outcome is not uniformly dismal and prognostic criteria that detect patients with a poor outcome have become available from prospective studies. There is a paucity of well …

Complications Associated With Cerebral Venous Thrombosis., Fazeel Mukhtar Siddiqui,, Ayeesha Kamran Kamal

Department of Medicine

Although CVT is associated with a good outcome in the majority of cases, it may be complicated by numerous unique and sometimes rare complications. The purpose of this review is to discuss the acute and chronic complications of CVT in greater detail. Awareness may lead to a more aggressive approach in those in which these complications are anticipated and perhaps avoided.
The complications of CVT may be temporally divided into those unique to the acute stage and those that are associated with the chronic stage of CVT. They are venous infarction and haemorrhage, subarachnoid haemorrhage, a rapid progression and pulmonary …

Heparin In The Treatment Of Cerebral Venous Thrombosis., Saad Shafqat, Ayeesha Kamran Kamal, Mohammad Wasay

Department of Medicine

Cerebral venous thrombosis (CVT) is a potentially life-threatening condition requiring rapid diagnosis and urgent treatment. Heparin anticoagulation is the time-honoured treatment, and is advocated in all cases of CVT, irrespective of etiology or presence of haemorrhage. The supportive evidence is largely observational; data from randomized placebo-controlled trials shows a nonsignificant trend favouring heparin. Current practice is to begin heparin (unfractionated or low-molecular weight) immediately on confirmation of the diagnosis. Newer antithrombotic agents such as ximelagatran may offer advantages over heparin and need to be investigated in the treatment of CVT.

Pathophysiology Of Cerebral Venous Thrombosis--An Overview., Ahmed Itrat, Sana Shoukat, Ayeesha Kamran Kamal

Department of Medicine

Cerebral venous sinus thrombosis is a disorder with a unique pathophysiology which needs to be described. A Medline search of all articles detailing pathophysiology of CVST was done, using keywords: cerebral venous thrombosis and pathophysiology. In addition, major texts were reviewed for additional references. The pathophysiology of CVST depends on two interconnected events, local signs due to venous infarct, e.g., hemiparesis and global signs due to raised ICP from an obstructed venous system--papilloedema and isolated intracranial hypertension being one of them. Pathophysiology of CVST is diverse and makes it easier to understand the diversity of clinical presentations.

Local Thrombolytic Treatment Of Cerebral Venous Thrombosis In Three Paediatric Patients, Mohammad Wasay, Rohit Bakshi, Alper Dai, Steve Roach

Section of Neurology

There is increasing evidence that local thrombolysis can be used with relative safety and efficacy in adults with superior sagittal sinus thrombosis (SSST). However, little data is available on the use of local thrombolysis in children with SSST. We report three patients who received local thrombolysis for dural sinus thrombosis. Two patients received urokinase and one patient received urokinase followed by local TPA infusion. Recanalization was achieved in two patients.

Cerebral Venous Thrombosis: Recent Advances And Need For An Asian Registry, Mohammad Wasay, Ayeesha K. Kamal

Department of Medicine

No abstract provided.

Isolated Deep Venous Thrombosis--Case Series, Literature Review And Long Term Follow Up., Ayeesha Kamran Kamal, Ahmed Itrat, Sana Shoukat, Asumal Khealani, Kamran Kamal

Department of Medicine

Cerebral Venous Sinus thrombosis may rarely be isolated to a cortical vein or to the deep venous system. When the deep venous system is involved, prognosis is generally poor. In addition, long term follow up is not reported. We conducted a retrospective review of all patients admitted to a major tertiary care center, with the diagnosis of isolated deep venous thrombosis. Two patients were identified with isolated involvement of the deep venous system, they are reviewed in detail with long term follow up. Two young South Asian women in their thirties with rapid onset of neurologic signs and symptoms are …

Thrombolytic Therapy In Cerebral Venous Sinus Thrombosis., Ayeesha Kamran Kamal

Department of Medicine

The use of thrombolytic agents to rapidly lyse the clot has emerged as a therapeutic modality, in concert with interventional neuroradiologic approaches to deliver the agent locally at the site of thrombosis. There are no randomized, double blind, placebo, controlled trials to support thrombolysis as a first line therapy in patients with cerebral venous sinus thrombosis compared to standard therapy using anticoagulation with weight based dose adjusted unfractionated Heparin. Numerous case reports and a single non randomized trial have shown that it is comparatively safe and may rescue patients who are deteriorating despite anticoagulation with unfractionated Heparin. Consideration must be …

Mechanism Of Neuronal Injury In Cerebral Venous Thrombosis, Uzma Usman, Mohammad Wasay

Department of Medicine

The impact of CVT on the brain is wide spectrum, ranging from completely normal parenchyma to brain oedema and/or haemorrhage. Multiple factors relate to neuronal injury in CVT including; dural sinus pressure, increased venous flow velocities, collateralization of venous channels, rate of occlusion, development of cytotoxic and vasogenic oedema, recanalization and accelerated myelination. It is suggested that recanalization of occluded vein, as well as, the presence or absence and the efficiency of intracranial venous collaterals, may have an impact on the extent of brain tissue damage and hence the prognosis of acute CVT.

Role Of Surgery In Cerebral Venous Sinus Thrombosis, S. Ather Enam

Department of Surgery

Cerebral venous sinus thrombosis (CVST) usually is taken care of by medical management or neuro-interventional vascular techniques. Some cases of CVST may take a malignant course if the intracranial pressure increases excessively. This increase in pressure is because of oedema in brain tissue due to impediment in venous return and/or intracerebral haemorrhage. Neurosurgical experience has shown remarkable recovery in these moribund patients if appropriate surgical intervention is done within reasonable time. Emergent decompressive craniotomy or other neurosurgical interventions are the only appropriate treatment in these malignant forms of CVST to prevent mortality and severe morbidity.

Liver Transplant Recipient With Calcineurin-Inhibitor Induced Pain Syndrome: A Case Report, Nethra S. Ankam, Md, Stanley R. Jacobs, Md

Department of Rehabilitation Medicine Faculty Papers

Setting: University Hospital

Patient: 65-year-old female status-post liver transplant secondary to cirrhosis.

Case Description: Prior to the rehabilitation consult on post-operative day 42, she had an episode of acute rejection requiring rapid escalation of cyclosporine dosage, later changed to high dose tacrolimus for immunosuppression, resulting in high blood levels of both calcineurin inhibitors. She then complained of paroxysms of 10/10 pain over her entire body not relieved by opioids despite escalation in medication by the acute pain service. She was not participating in a rehabilitation program because of pain. Examination revealed an anxious woman for whom any tactile stimulation …

Rehabilitation Of A Patient With Diabetic Myonecrosis: A Case Report, Nethra S. Ankam, Md, Vishal Kancherla, Do, Stanley R. Jacobs, Md

Department of Rehabilitation Medicine Faculty Papers

Setting: Inpatient rehabilitation unit at a university hospital

Patient: 37-year-old male with diabetic myonecrosis.

Case Description: The patient had a long-standing history of uncontrolled diabetes mellitus with multiple comorbidities, including end-stage renal disease on dialysis and diabetic myonecrosis of the left biceps femoris diagnosed by biopsy and magnetic resonance imaging (MRI.) On this admission, he presented with right leg pain and swelling, found to be a reoccurrence of diabetic myonecrosis in the vastus lateralis, medialis, and intermedius, diagnosed by MRI only. Prior to admission, he lived alone in a wheelchair inaccessible duplex and required minimal assistance with housekeeping.

Assessment/Results: …

Oral Contraceptives And Cerebral Venous Thrombosis: Case Report And A Brief Review Of Literature, Mughis Sheerani, Mian Zainul Sajadeen Urfy

Section of Neurology

Cerebral venous thrombosis remains an important and sometimes an elusive cause of strokes. Oral contraceptives seem to have a strong causative association with this entity. We describe a case that highlights the importance of asking specific questions about oral contraceptive use in patients with strokes due to cerebral venous sinus thrombosis, especially, where the cause remains cryptic.

Prognostic Indicators In Cerebral Venous Sinus Thrombosis, Bilal Hameed, Nadir Ali Syed

Section of Neurology

Cerebral venous sinus thrombosis (CVT) can affect all age groups, particularly women of childbearing age. Overall prognosis for survival and functional independence is better than it was believed. Mortality usually ranges from 6-15% and transtentorial herniation is the major cause of death. Approximately 80% of patients are functionally independent in the long term. Altered mental status and cerebral haemorrhage at presentation are the strongest predictors of death and disability. Patients with CVT related to pregnancy and puerperium generally do better than patients with other causes. Septic CVT carries a worse prognosis than aseptic CVT and of the latter, patients with …

Treatment Of Spinal Tuberculosis: Role Of Surgical Intervention, Ather Enam, Ahmed Ali Shah

Section of Neurosurgery

The treatment of tuberculosis of the spine (Pott's disease) is essentially conservative and a vast majority of patients can be successfully managed on antituberculo us therapy (ATT) alone.1 Surgery is indicated in a few specific cases where deformity of spine, pain, or neurological compromise is becoming a serious issue. In cases where surgery is indicated the benefits are almost immediate and excellent. Tuberculosis (TB) is one of the leading causes of infectious disease-related deaths in under-developed countries and it has had a resurgence in developed countries as well. The most common site of bony dissemination of this disease is in …

Botulinum Toxin Type-A In The Management Of Cerebral Palsy: Low Or High Dose?, Alper I. Dai, Mohammad Wasay

Department of Medicine

Cerebral palsy is the most common cause of severe physical disability in childhood. Spasticity is a common and disabling symptom for many patients with cerebral palsy. Therapy for spasticity is symptomatic with the aim of increasing functional capacity and relieving discomfort. Spasticity treatment by orally administered drugs and intramuscular chemodenervation agents has become more frequent. Most oral medications to treat spasticity have been inadequately studied in children, especially those with cerebral palsy. Since its first use in pediatric patients, reported in 1993, botulinum toxin (BTX-A), a relatively recent addition to the available medical interventions for children with cerebral palsy, has …

Preventive Treatment Of Migraine, Stephen Silberstein

Department of Neurology Faculty Papers

Migraine is a common episodic pain disorder, the treatment of which can be acute to stop an attack or preventive to reduce the frequency, duration or severity of attacks. Preventive treatment is used when attacks are frequent or disabling. Many different medication groups are used for preventive treatment, including β-blockers, antidepressants and antiepileptic drugs. Their mechanisms of action include raising the threshold to migraine activation, enhancing antinociception, inhibiting cortical spreading depression, inhibiting peripheral and central sensitization, blocking neurogenic inflammation and modulating sympathetic, parasympathetic or 5-HT tone. In this article, I review evidence of the effectiveness of migraine preventive drugs. I …

Brain Tumor Stem Cells: Role In Neuro-Oncogenesis And Therapeutic Implications, Muhammad Zeeshan Ozair, Adil Hameed Khan, Ather Enam

Department of Biological & Biomedical Sciences

Malignant brain tumors are notorious for high morbidity and mortality. Our deficient understanding of brain tumor pathogenesis is reflected in our inability to cure this disease. Treatment remains palliative at best. The cancer stem cell hypothesis of brain tumors promises to consolidate many observations which have previously eluded neuroscientists and may reveal why aberrations in developmental programs are among the commonest findings in brain tumors. It is ironic that brain ontogeny and cancer - two processes with very different outcomes - exploit similar mechanisms to multiply, migrate,and survive. Implications of this hypothesis extend beyond mere academic interest. It may explain …

Central Nervous System Involvement In Dengue Viral Infection, Romasa Channa, Mohammad Wasay

Department of Medicine

Neurological manifestations of dengue infection are rare. This review includes data regarding the epidemiology of the disease, neurological manifestations,pathogenesis, diagnosis and prognosis. It is based on 9 original articles and 10 case reports, adding up to 200 cases of dengue fever with neurological manifestations. Relevant cases have been reported from Asia, the Pacific rim, the Americas, the Mediterranean region, and Africa. A wide range of neurological manifestations has been reported. Altered consciousness and seizure are among the more common manifestations. The exact pathogenesis of this disease has not yet been established. However, recent studies hypothesize that the virus is neurotropic. …

Comparison Of Dynamic (Brush) And Static (Pressure) Mechanical Allodynia In Migraine, C. Lopinto, W. B. Young, Avi Ashkenazi

Department of Neurology Faculty Papers

Allodynia has been described in migraine but has not been fully investigated for the different sensory modalities. The aim of this study was to compare the prevalence of dynamic (brush) and static (pressure) mechanical allodynia in migraine patients and to suggest a practical method of testing them in a clinical setting. Patients with International Headache Society-defined episodic migraine (EM) or with transformed migraine (TM) as defined by Silberstein and Lipton were prospectively recruited from the Jefferson Headache Center out-patient clinic. A questionnaire of migraine features and symptoms of allodynia was administered. Brush allodynia (BA) was tested by cutaneous stimulation with …

Botulinum Toxin Type A In The Prophylactic Treatment Of Chronic Tension-Type Headache: A Multicentre, Double-Blind, Randomized, Placebo-Controlled, Parallel-Group Study, Stephen D. Silberstein, H. Göbel, R. Jensen, A. H. Elkind, R. Degryse, J. M.C.M. Walcott, C. Turkel

Department of Neurology Faculty Papers

We studied the safety and efficacy of 0 U, 50 U, 100 U, 150 U (five sites), 86 Usub and 100 Usub (three sites) botulinum toxin type A (BoNTA; BOTOX); Allergan, Inc., Irvine, CA, USA) for the prophylaxis of chronic tension-type headache (CTTH). Three hundred patients (62.3% female; mean age 42.6 years) enrolled. For the primary endpoint, the mean change from baseline in the number of TTH-free days per month, there was no statistically significant difference between placebo and four BoNTA groups, but a significant difference favouring placebo vs. BoNTA 150 was observed (4.5 vs. 2.8 tension headache-free days/month; P …

Dissociation Of Automatic And Strategic Lexical-Semantics: Functional Magnetic Resonance Imaging Evidence For Differing Roles Of Multiple Frontotemporal Regions, Brian T. Gold, David A. Balota, Sara J. Jones, David K. Powell, Charles D. Smith, Anders H. Andersen

Neuroscience Faculty Publications

Behavioral research has demonstrated three major components of the lexical-semantic processing system: automatic activation of semantic representations, strategic retrieval of semantic representations, and inhibition of competitors. However, these component processes are inherently conflated in explicit lexical-semantic decision tasks typically used in functional magnetic resonance imaging (fMRI) research. Here, we combine the logic of behavioral priming studies and the neurophysiological phenomenon of fMRI priming to dissociate the neural bases of automatic and strategic lexical-semantic processes across a series of three studies. A single lexical decision task was used in all studies, with stimulus onset asynchrony or linguistic relationship between prime and …

Wernekink Comissure Syndrome: A Rare Midbrain Syndrome Secondary To Stroke, Alper I. Dai, Mohammad Wasay

Department of Medicine

Wernekink commissure involves the decussation of superior cerebellar peduncle (SCP) in midbrain. We report an elderly hypertensive, diabetic man who developed slurred speech, ataxia, and internuclear ophthalmoplegia. MRI examination revealed an unusual ischemic stroke involving Wernekink commissure. This rare stroke pattern involving decussation of SCP occurs in the setting of small arterial disease. The association between the anatomic location of the stroke and clinical findings is noteworthy.

Light During Darkness And Cancer: Relationships In Circadian Photoreception And Tumor Biology, Samar A. Jasser, David E. Blask, George C. Brainard

Department of Neurology Faculty Papers

The relationship between circadian phototransduction and circadian-regulated processes is poorly understood. Melatonin, commonly a circadian phase marker, may play a direct role in a myriad of physiologic processes. The circadian rhythm for pineal melatonin secretion is regulated by the hypothalamic suprachiasmatic nucleus (SCN). Its neural source of light input is a unique subset of intrinsically photosensitive retinal ganglion cells expressing melanopsin, the primary circadian photopigment in rodents and primates. Action spectra of melatonin suppression by light have shown that light in the 446–477 nm range, distinct from the visual system’s peak sensitivity, is optimal for stimulating the human circadian system. …

Ms In Asian Countries, M Wasay, I A. Khatri, B Khealani, M Sheerani

Section of Neurology

This paper reviews all available English language literature on MS from Asian countries published between 1970 and 2005. Although limited data are available, the review reveals that western Asia--including the Middle East--has the highest prevalence of MS across the continent, and that MS in Asia largely resembles conventional MS in western countries. Opticospinal MS (a distinct clinical entity from conventional MS) is more common in eastern Asian regions. Larger epidemiological and genetic studies, with more complete ascertainment in various Asian populations, are needed so that we can understand the diversity of Asian MS.

Spontaneous Intracranial Arterial Dissection In The Young: Diagnosis By Ct Angiography, William C. Robertson, Curtis A. Given

Neurology Faculty Publications

BACKGROUND: Spontaneous carotid artery dissections have been rarely reported in children. Diagnosis has traditionally been confirmed by catheter arteriography. More recently diagnosis has been made by magnetic resonance imaging and magnetic resonance angiography; however the sensitivity of these techniques has yet to be determined. The authors are unaware of reports of carotid dissection confirmed by dynamic computed tomography (computerized tomographic arteriography) in the young.

CASE PRESENTATION: We recently evaluated a fourteen year-old male following the development of transient neurologic symptoms. There was no antecedent illness or trauma. Dynamic computed tomography revealed an intracranial dissection involving the supraclinoid segment of the …

Surgery For Prolactinomas, Ashfaq A. Razzaq, Rashid Jooma

Section of Neurosurgery

A large proportion of prolactin secreting tumours of the pituitary gland are treatable by dopamine agonist drugs. however certain subgroups of these patients are better managed by surgical excision. the indications for surgery in prolactinomas remain controversial and this paper attempts to clarify these with illustrative cases. the factors favouring a surgical approach include poor tolerance of long term medical therapy, progression of visual deficits or recurrence while on medical treatment, cystic change in the tumour with pressure effects, csf fistula secondary to tumour shrinkage and prophylactic surgery in tumours anticipated to cause csf leak following medical therapy. the size …

Trans-Mastoid Approach To Otogenic Brain Abscess, Ashfaq A. Razzaq, Rashid Jooma, Shahid Ahmed

Section of Neurosurgery

The treatment of otogenic brain abscess initially involves excision or aspiration of the abscess through a temporal or sub-occipital route depending on its location. This is followed by a mastoidectomy by the ENT surgeon to eradicate the primary source of infection. During the last three years, we have approached such lesions through a mastoidectomy followed by excision of the abscess through the same approach. This trans-mastoid approach is technically feasible in following the tract of suppuration, and clearing the cause and effect of pathology, at the same sitting. This paper describes our initial experience with the trans-mastoid approach to otogenic …