Extracranial Sources Research Articles

Headache Management in an Interventional Pain Practice

More than 20 million people in the United States suffer from severe headaches. Most have been diagnosed as "migraines," which have been assumed to be an intracranial process. Recognition of the extracranial sources of headaches (such as supraorbital neuralgia, infraorbital neuralgia, auriculotemporal neuralgia, facial neuralgia, posterior auricular neuralgia, occipital neuralgia, cervical facet pathology, masseter spasm, sternocleidomastoid muscle spasm, trapezius spasm, and interspinous ligament pathology) has led to an expansion of the treatment options available for practitioners skilled in interventional pain procedures. However, unless the clinical presentation is recognized, treatment cannot be offered. Clinical presentation, diagnostic injections, differential diagnosis, and advanced neurolytic techniques are discussed in this article.

FDG-PET in the Staging Work-Up of Patients with Suspected Intracranial Metastatic Tumors

To evaluate the role of positron emission tomography with 2-[18F] fluoro-2-deoxy-D-glucose (FDG-PET) in 31 patients with evidence of intracranial metastatic disease. PET was used to evaluate the intracranial lesions for glucose hypermetabolism to suggest malignancy, mutiplicity of intracranial lesions, and extracranial foci or sources of disease. Patients with proven malignant intracranial lesions subsequently underwent further corroborative radiologic tests and histologic examination to confirm staging and primary location. PET identified focal hypermetabolic abnormalities in 19 of 22 intracranial metastases, 2 hypometabolic lesions, and 1 renal cell tumor embolism that hemorrhaged (hypometabolic lesion). It also identified 82% of extracranial primary tumor sites, of which 55% were found only on PET and not on conventional diagnostic tests. FDG-PET may prove valuable in the initial work-up of patients with suspected intracranial metastases.

Clinical assessment of posttraumatic headaches.

The evaluation of the person with posttraumatic headache remains a difficult clinical task. The rehabilitation clinician seeing the person with posttraumatic headache may encounter a large spectrum of potential etiologies for cephalgia. We believe an ordered approach to the history, physical, and laboratory examination may lead to a more accurate and focused diagnosis in some cases. In an attempt to provide a directed approach to posttraumatic headaches, this discussion is divided into extracranial and intracranial sources. A brief table guide to the etiology of pain by site is presented, and the key eight steps of examination are reviewed.

Cerebrovascular disease risk factors: neuroradiologic findings in patients with activated protein C resistance.

To assess the patterns of abnormal neuroradiologic findings in patients with a hypercoagulable state related to activated protein C (APC) resistance. Records in 23 patients with a hypercoagulable state related to APC resistance (18 women, five men; average age, 44.5 years) were reviewed for cerebrovascular disease risk factors and other causes of a hypercoagulable state. Computed tomographic scans, magnetic resonance (MR) images, angiograms, and transesophageal echocardiograms were also reviewed. Stroke risk factors or other causes of a hypercoagulable state were found in 12 patients. Arterial infarcts were seen in 18 patients. Hyperintense white matter foci were seen on MR images in six patients. Dural sinus thrombosis was found in four patients. Angiograms of intracranial circulation in six patients showed major artery occlusions in four. MR angiograms in four patients showed internal carotid artery occlusion in one. No major abnormalities were seen in extracranial cerebral vasculature in 15 patients. Transesophageal echocardiograms in 11 patients showed a patent foramen ovale in one patient but no systemic source of embolism. Seven patients had non-central nervous system thrombotic events. Patients with APC resistance and stroke appear to differ from the general stroke population in terms of age and frequency of extracranial sources of cerebrovascular disease.

Detection of intracranial emboli in patients with symptomatic extracranial carotid artery disease.

Cerebral embolism from extracranial sources is an important cause of ischemic stroke. The purpose of this limited study using long-term transcranial Doppler ultrasonographic monitoring was to estimate the frequency of clinically silent intracranial embolisms in patients with symptomatic extracranial carotid artery disease. By means of a 2-MHz pulsed-wave transcranial Doppler instrumentation, three consecutive patients with extracranial internal carotid artery stenosis (n = 2) or occlusion (n = 1) and recurrent ipsilateral ischemic events were monitored (19 hours total recording time). In addition, 10 control subjects without cerebrovascular disease were studied (25 hours total recording time). Formed-element emboli were defined as distinct signals within the fast Fourier-transform Doppler spectrum that were < 70 msec in duration and > 9dB greater in intensity than the background signal. Clinically silent formed-element embolism of ophthalmic or cerebral arteries was demonstrated in all three patients. Embolic events occurred only in the territory of the symptomatic internal carotid artery. The average rate of cerebral embolization at transcranial Doppler ultrasonography was 4.1/hr, with a mean signal duration of 47 msec. No emboli were found in control subjects. The observed high frequency of silent embolism of the intracranial arteries detected by transcranial Doppler monitoring in patients with recurrently symptomatic extracranial carotid artery disease should encourage studies of the prognostic and therapeutic implications of this method.

Galanin-positive nerves of trigeminal origin innervate rat cerebral vessels

Galanin (GAL)-positive nerve fibers in rat cerebral vessels were demonstrated by immunohistochemistry, and their origin in the trigeminal ganglia and pathway in the nasociliary nerve to the vessels was shown by retrograde tracer technique and nerve transection. Some fibers in the vertebrobasilar system appear to originate in extracranial sources. With the antiserum used only few GAL fibers could be seen in the vessels, mostly in the vertebrobasilar system. In neonatally sympathectomized animals a rich network could be visualized in most pial arteries - still particularly in the vertebrobasilar system - probably as a result of a diminished competition for nerve growth factor. No vasomotor effect of GAL could be detected in isolated segments of pial arteries, neither in normal nor in sympathectomized animals, which rules out a direct postsynaptic effect on vascular tone. GAL did not display prejunctional modulatory action on the adrenergic nerves present in the vascular preparations. A sensory function of GAL is discussed.

Problem Headaches: Physical Identification of Extracranial Pain Sources.

Excerpt The majority of chronically recurrent severe headaches have their originoutside, rather than inside, the skull. The branches of the external carotid arteries are implicated in vascular head...