Chronic pain is a widespread healthcare problem with great impact on mental health, professional and family life of the patient. It can be a consequence of many disorders; however, its pathogenesis ...has not yet been fully understood. Neuroplasticity is the ability of the nervous system to adapt to different changes and it is present throughout life, not only in prenatal period, infancy and childhood. However, in the pathophysiology of chronic pain, neuroplasticity shows its "dark side". Due to the central sensitization process, noxious stimuli can produce chronic pain or misinterpretation of non-noxious stimuli (secondary hyperalgesia and allodynia). These changes occur at the level of brain cortex as well at peripheral nerves and receptors. This review summarizes a significant portion of literature dealing with neuroplasticity processes in well known chronic pain conditions such as migraine, chronic posttraumatic headache, low back pain, fibromyalgia, and others. The relevance of this topic lies in providing a new insight in the pathophysiology of chronic pain, while also offering a possibility of new therapeutic approaches including not only pharmacological agents.
Obstructive sleep apnea (OSA) is a common medical problem with numerous comorbidities and high costs. Since the introduction of the Epworth sleepiness scale (ESS), excessive daytime sleepiness (EDS) ...has been considered the most common and prominent symptom of OSA. Aim of this study was to re-evaluate the ESS for detection of OSA in a population at risk compared to the gold standard overnight polysomnography (PSG).
A total of 266 patients (mean age 57.9 ± 11.6 years; 189 men and 77 women), referred to our sleep laboratory for probable OSA, were given ESS followed by an overnight PSG. The ESS values were compared to PSG apnea hypopnea index (AHI) with sensitivity (SE), specificity (SP), positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy (DA) calculated for ESS. The positive cut-off value for ESS was ≥ 10 and for AHI ≥ 5.
Only 92 (34.6%) subjects had a positive ESS. An OSA was diagnosed by PSG in 213 (80.1%) subjects: 46 having mild, 37 moderate and 130 severe apnea. Most subjects with positive ESS (88.0%) were found to have OSA but most subjects with a negative ESS (75.9%) were also positive for OSA (42% with AHI ≥ 30). The area under the receiver operating characteristic (ROC) curve for ESS was 0.60 (95% confidence interval, CI 0.54-0.66; p = 0.020) with SE 38.0%, SP 79.3%, PPV 88.0%, NPV 24.1% and DA 46.2%.
It was found that excessive daytime sleepiness, measured by ESS, is not a valuable screening tool for OSA, especially when the test is negative. Other screening tests that involve additional parameters, beside daytime sleepiness alone, should be considered.
Migrenski status je stanje perzistirajućega migrenskog napadaja trajanja dužeg od 72 sata. Liječenje se temelji na parenteralnoj primjeni analgetika, antimigrenika, antiemetika i nadoknadi tekućine. ...Kortikosteroidi smanjuju rizik od povrata glavobolje. Veća prevalencija migrena u žena objašnjava se povezanošću estrogena i patofizioloških mehanizama migrene. Prava menstrualna migrena javlja se isključivo u danima oko početka ciklusa i nije česta. Migrena povezana s menstruacijom javlja se na početku ciklusa, ali i u drugim danima ciklusa i znatno je češće pojavnosti. U liječenju akutnog napadaja koristi se standardna abortivna terapija. Profilaksa menstrualne migrene i migrene povezane s menstruacijom može biti kratkotrajna (mini-profilaksa) i počinje 2 dana prije i traje obično do 3. ili 4. dana ciklusa, a u tu se svrhu koriste nesteroidni antireumatici (naproksen), triptani ili hormonska terapija. Ako mini-profilaksa nije učinkovita, potrebno je započeti kontinuiranu profilaksu koja može biti klasična ili hormonska. Tijekom trudnoće i dojenja terapijske su mogućnosti ograničene zbog mogućega štetnog utjecaja lijeka na trudnoću i dijete. U akutnoj terapiji sigurni u svim stanjima su paracetamol, sumatriptan te metoklopramid. Profilaksa migrene tijekom trudnoće većinom nije potrebna jer obično nakon prvog tromjesečja dolazi do redukcije broja migrena zbog stabilno visokih razina estrogena, a ako je indicirana, sigurnom se smatra primjena propranolola. Tijekom dojenja moguća je akutna terapija gotovo svim uobičajenim lijekovima za migrenu osim opijatima i ergotaminskim preparatima, a veći je i spektar lijekova koji se mogu primijeniti radi profilakse migrene. Blokatori CGRP-a ili njegovog receptora nisu indicirani za profilaktičku terapiju tijekom trudnoće i dojenja.
Art is a product of human creativity; it is a superior skill that can be learned by study, practice and observation. Modern neuroscience and neuroimaging enable study of the processes during artistic ...performance. Creative people have less marked hemispheric dominance. It was found that the right hemisphere is specialized for metaphoric thinking, playfulness, solution finding and synthesizing, it is the center of visualization, imagination and conceptualization, but the left hemisphere is still needed for artistic work to achieve balance. A specific functional organization of brain areas was found during visual art activities. Marked hemispheric dominance and area specialization is also very prominent for music perception. Brain is capable of making new connections, activating new pathways and unmasking secondary roads, it is "plastic". Music is a strong stimulus for neuroplasticity. fMRI studies have shown reorganization of motor and auditory cortex in professional musicians. Other studies showed the changes in neurotransmitter and hormone serum levels in correlation to music. The most prominent connection between music and enhancement of performance or changing of neuropsychological activity was shown by studies involving Mozart's music from which the theory of "The Mozart Effect" was derived. Results of numerous studies showed that listening to music can improve cognition, motor skills and recovery after brain injury. In the field of visual art, brain lesion can lead to the visuospatial neglect, loss of details and significant impairment of artistic work while the lesions affecting the left hemisphere reveal new artistic dimensions, disinhibit the right hemisphere, work is more spontaneous and emotional with the gain of artistic quality. All kinds of arts (music, painting, dancing...) stimulate the brain. They should be part of treatment processes. Work of many artists is an excellent example for the interweaving the neurology and arts.
Summary
While the mean increase in flow velocities in posterior cerebral artery (PCA) as a response to visual stimuli is well documented, the data on the reaction time as a measurement of the ...vasomotor response of the posterior part of the circle of Willis are still sparse. The aim was to assess the visual evoked response in PCA during white light stimulation by means of functional transcranial doppler in patients with severe internal carotid artery (ICA) stenosis, to introduce a real‐time haemodynamic changes as a measurement of the effect of severe carotid disease on the posterior circulation. The measurements were taken in 49 right‐handed patients with severe ICA stenosis or occlusion and 30 healthy volunteers, simultaneously in left and right PCA using 2‐MHz probes, successively in the dark and during the white light stimulation, during three consecutive repetitive periods of 1 min each. Mean values of mean blood flow velocities (MBFV) and mean reaction time (MRT) with and without visual stimuli were analysed. Linear regression analysis showed no statistically significant correlation between the age, MBFV and a degree of left and right carotid stenosis, and MRT in left and right PCA either in the group of healthy subjects or in the group of patients with severe carotid stenosis, in both test conditions. MRT could be an indicator of compromised cerebral circulation in the presence of haemodynamic significant carotid stenosis as well as an additional and independent haemodynamic parameter of the cerebral visual evoked response.
Craniocervical arterial dissections (CCAD) are being increasingly identified due to growing awareness of diverse clinical picture along with
advances in imaging technologies. Although rare, CCADare ...frequent cause of stroke in young adults. Neurosonological tests serve as an excellent noninvasive screening and monitoring tool, but brainMR andMRA are necessary for confirmation of the diagnosis. Ultrasound examination may show direct or indirect signs. Direct signs are: echolucent intramural hematoma, string sign, double lumen, or stenosis and/or occlusion of an arterial segment usually not affected by atherosclerosis. Indirect signs are: increased or decreased
pulsatility index upstream or downstream of the suspected lesion,
more than 50% difference in blood flow velocity compared to the unaffected side, or detection of intracranial collateral flow.
Since CCAD have been increasingly identified, a whole spectrum of
clinical pictures are been recognizes. Neurosonology showed high sensitivity in CCAD detection.
Optic nerve sheath diameter (ONSD) enlargement is detectable in traumatic brain injury patients with raised intracranial pressure (ICP). The aim was to assess its value in neurological patients ...suspected to have increased ICP. Patient clinical imaging data and hospitalization outcome were analyzed. Patients were divided into groups according to brain pathology and level of consciousness with Glasgow Coma Score (GCS). Poor hospitalization outcome was assessed by modified Rankin scale (mRS) >3. Data obtained by ocular sonography performed in acute setting were compared with data of 100 control subjects. Data were expressed as mean + or - SD. Intergroup comparison was performed by Student's t-test. Data of 34 patients (63+16 years) were suitable for analysis, including 8 primary intracerebral hemorrhage (PICH), 8 subarachnoid hemorrhage (SAH), 12 PICH or SAH and intraventricular hemorrhage (IVH), 4 tumors and 2 ischemic strokes. The mean ONSD was 5.86+0.69 mm in patients versus 4.38+0.41 mm in controls (p<0.01). ONSD was 6.28+0.61 mm in patients with GCS <8 and 5.77+0.55 mm in other patients (p<0.05). ONSD was 5.72+0.59 mm in PICH versus 6.20+0.65 mm in PICH/SAH with IVH (p=0.1). ONSD was 5.73+0.38 mm in SAH in comparison to PICH/SAH with IVH (p=0.05). There was no statistically significant diference in optic nerve diameter between patients and controls (2.48+0.28 mm vs. 2.39+0.33 mm; p>0.05). Pronounced enlargement of ONSD was observed in patients with ICH or SAH with IVH, and in patients with GCS <8. Enlarged ONSD was associated with poor neurological outcome (mRS >3). Key words: Optic nerve; Brain injuries, traumatic; Intracranial pressure; Ultrasonography
In a certain percentage of patients with craniocervical artery dissection, dissections affect multiple arteries. Some investigators consider that the dissections diagnosed as multiple might have ...occurred sequentially within a short time frame. We describe an oligosymptomatic patient with bilateral progressive vertebral artery dissection. Careful history taking added new data on transient left arm weakens two months earlier, as a possibility of the earlier disease onset.
Obesity has been recognized as an isolated risk factor for stroke. In obese patients, other risk factors for stroke such as hypertension, hyperlipidemia, ischemic heart disease and obstructive sleep ...apnea are more frequently present. The aim of this study was to assess the presence of obesity among other risk factors for stroke in younger adult patients with ischemic stroke. It was a pilot study performed in ischemic stroke patients aged 18-55. In addition to the routine diagnostic work-up, body height, weight and waist circumference were measured in study patients. The study included 50 patients, 23 female and 27 male. The mean age of male patients was 39.8 +/- 10.5 and of female patients 41.6 +/- 7.7 years. In control group The mean waist circumference was 94.9 +/- 5.8 cm in the control group and 102.6 +/- 9.8 cm in the male stroke group. There was no significant difference in waist circumference between the control and patient female groups and in body mass index among all groups. In younger males, waist circumference could be considered as an important risk factor for stroke.
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