Intracranial Disorder Research Articles

Cranial venous-outflow obstruction promotes neuroinflammation via ADAM17/solTNF-α/NF-κB pathway following experimental TBI

Traumatic brain injury (TBI) is a global public health problem. As an important cause of secondary injury, cerebrovascular reaction can cause secondary bleeding, venous sinus thrombosis, and malignant brain swelling. Recent clinical studies have confirmed that intracranial venous return disorder is closely related to the prognosis of patients, yet the specific molecular mechanism involved in this process is still unclear. This study used an acute subdural hematoma (ASDH) model with cranial venous outflow obstruction (CVO) to explore how CVO aggravates the pathological process after TBI, especially for inflammation and tissue damage. The results suggest that intracranial venous return disorder exacerbates neurological deficits and brain edema in rats with ASDH by aggravating the destruction of endothelial cell tight junctions (TJs) proteins and promoting the expression of inflammatory factors, the activation of microglia and expression of recombinant A disintegrin and metalloprotease 17 (ADAM17) as well as the secretion of solTNF-α, a soluble form of tumor necrosis factor-alpha (TNFα), which in turn increase IκB-α ((inhibitor of the transcription factor nuclear factor-κB) and NF-κB p65. Our study revealed a molecular basis of how CVO aggravates inflammation and tissue damage.

Seizures as the Initial Manifestation of Idiopathic Intracranial Hypertension Spectrum Disorder

ABSTRACT Idiopathic intracranial hypertension (IIH) is a syndrome of isolated elevated intracranial pressure of unknown aetiology. The IIH spectrum has evolved over the past decade making the diagnosis and management more challenging. The neurological examination in IIH is typically normal except for papilloedema and possible cranial nerve 6 palsy. Recent publications have highlighted skull base thinning and remodelling in patients with chronic IIH. Resulting skull base defects can cause meningo-encephalocoeles, which are potential epileptogenic foci. We describe the clinical and radiological characteristics of five IIH patients with seizures and meningo-encephalocoeles as the presenting manifestations of IIH spectrum disorder.

Middle Meningeal Artery Embolization in the Management of Chronic Subdural Hematoma: a Comprehensive Review of Current Literature

Chronic subdural hematoma (cSDH) is a common intracranial hemorrhagic disorder with a high incidence rate among the elderly. While small, asymptomatic cSDH may resolve spontaneously, surgical intervention has been the treatment of choice for larger, symptomatic cases. Surgical evacuation of cSDH may be associated with high rates of recurrence, and even asymptomatic cSDH cases tend to progress. Over the last few years, middle meningeal artery (MMA) embolization has proven to be a safe non-invasive treatment of choice with favorable outcomes and a low recurrence rate. The ensuing paper discusses current treatment modalities for cSDH and reviews existing literature on the anatomy of MMA and its embolization as a treatment option for cSDH. Recent studies show that traumatic head injury leading to subdural hemorrhage can induce neovascularization that may initiate a cycle of recurrent subdural hematoma. Distal branches of MMA supply blood to the dural layers. Several studies have revealed that embolization of the MMA can stop the neovascularization process and blood flow. In addition, patients who underwent MMA embolization had a significantly quicker brain re-expansion and lower recurrence rate. Although the management of cSDH is still very much a dilemma, recent research findings bring MMA embolization to light as a promising treatment alternative and adjunctive therapy.

Post COVID-19 vaccination headache: A clinical and epidemiological evaluation.

This study aimed to assess the prevalence and clinical characteristics of headaches, in particular secondary headaches. This observational study was performed at the ASST Spedali Civili of Brescia, Italy. Visits to the Emergency Department (ED) and subsequent hospitalizations regarding a new or worsening headache in the 16 days following the administration of the COVID-19 vaccine between January 2021 and January 2022 were recorded and compared with those of January 2019-January 2020. The ratio between ED admissions due to headaches and total ED admissions was significantly higher in 2021 compared with 2019 (4.84% vs. 4.27%; p < 0.0001). Two-hundred and eighty-nine ED headache admissions (10.8% of all ED headache admissions) were time-correlated to the COVID-19 vaccination, of which 40 were hospitalized in order to exclude a symptomatic etiology. At discharge, 32 patients had a diagnosis of benign headache not attributed to any cranial/extracranial disorder and eight patients of secondary headache, whose diagnoses were the following: Headache attributed to cranial and/or cervical vascular disorder (n = 4); headache attributed to nonvascular intracranial disorder (n = 2); headache or facial pain attributed to disorder of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cervical structure (n = 1); and painful lesions of the cranial nerves (n = 1). The headache most frequently reported by patients had migraine-like characteristics: the localization was predominantly frontal or temporal, the pain was described as throbbing and severe in intensity and it was frequently accompanied by nausea/vomit, and photo-phonophobia. Over half-regardless of the final diagnosis-of hospitalized patients had a history of primary headaches. Following the spread of COVID-19 vaccination, the number of ED admissions due to headaches significantly increased. However, less than 14% of all the ED visits due to a headache time-correlated to the COVID-19 vaccination were actually hospitalized, with most patients documenting a benign headache, possibly related to the generic side effects of the vaccination. Only 8/40 hospitalized patients were diagnosed with a secondary headache. These benign headaches would actually fulfill diagnostic criteria for 8.1 Headaches attributed to the use of or exposure to a substance (ICHD-3), although, at the time being, it does not include vaccines as possible substances.The headache migraine-like characteristics' reported by most patients could suggest activation of the trigeminovascular pathway by all the cytokines and other pro-inflammatory molecules released following the vaccination.

Secondary hypnic headache: A literature review in the last 34 years

Introduction: Hypnic headache is a rare primary headache disorder that occurs during sleep. Its pathophysiology is uncertain, but hypothalamic dysfunction is hypothesized. It is usually a primary headache, but it can have secondary causes.&#x0D; Objectives: We aimed was to review articles published in the last 34 years on hypnic headache and analyze secondary cases.&#x0D; Methods: Based on a literature search in the major medical databases and using the descriptor “hypnic headache” we included articles published between 1988 and 2020. Of the 359 patients found, only 18 met the inclusion criteria and were analyzed.&#x0D; Results: We found 18 patients (6 men and 12 women) with secondary hypnic headache. The mean age of patients was 58.7±15.0 years, ranging from 20 to 84 years. The causes of hypnic headache were attributed to cranial vascular disorder (five), to non-vascular intracranial disorder (six), to a substance or its withdrawal (three) and to disorder of homoeostasis (four).&#x0D; Conclusions: Although most cases of hypnic headache are primary, some symptomatic cases are described in the literature.

Headache in the elderly

Most of the Headaches in the elderly are primary headache such as migraine and tension-type headache which the elderly has suffered from since younger age. Although the prevalence of headache decreases in the elderly, certain types of headaches, for example giant cell arteritis or hypnic headache, are more prevalent in the elderly. If the pattern of the headache changes or there is a newly developed headache, the odds of secondary headache such as headache due to neoplasm and vascular intracranial disorder increase. Also, imaging study in the elderly are more likely to show structural disease in the brain incidentally. Therefore, the proper diagnosis and management of headache in the elderly needs special caution and awareness of the general medical condition including medications and co-morbidity. Also, the desire of the patients should be considered. Many elderly people take a lot of medications. When choosing the medications for headache, use drugs for treating both headache and co-morbidity simultaneously and pay attention to the potential side effects of headache medication that can aggravate co-morbid diseases.

Mortality associated with cysticercosis in a historical cohort from Britain.

The burden of premature mortality associated with human cysticercosis is largely ignored mainly due to poor record-keeping in Taenia solium endemic regions. To document mortality and survival characteristics of an historical cohort with cysticercosis. The years of onset of symptoms and death untill 1957 were extracted from published reports of a British military cohort (n=450) examined in London in the early twentieth century. Data were entered into a Kaplan Meier survival analysis with the presence (or absence) of clinical manifestations as independent variables, which were then fitted into a Cox proportional hazards model to determine their significance. Cysticercosis was responsible for 24 (52.2%) of 46 deaths in the first 15 years of follow-up in comparison to 7 (19.4%) of 36 deaths in the 20-40 years of follow-up period. In the univariate and Cox analyses, intracranial hypertension (hazard ratio [HR]: 8.26; CI: 4.71, 14.49), ocular cysticercosis (HR: 6.60; CI: 3.04, 14.33), and mental disorder (HR: 3.98; CI: 2.22, 7.13) but not epilepsy (HR: 0.66; CI: 0.20, 2.18) were associated with mortality. Over half of all deaths in the first 15 years of follow-up were attributed to cysticercosis. Several deaths occurred early after acquiring cysticercotic infection. Intracranial hypertension, ocular cysticercosis, and mental disorder but not epilepsy were predictors of mortality in this cohort.

Peiyuan-Huayu Formula Suppresses Proliferation Migration and Angiogenesis of Human Microvascular Endothelial Cells-1 Through Activating MEK/ERK Signaling Pathway

Chronic subdural hematoma is identified as an intracranial hemorrhagic disorder of human. Presently, neither surgical nor symptomatic treatment of Western medicine has achieved good curative effects. This study aimed to clarify efficacy of Peiyuan-Huayu formula on neovascularization and explore associated mechanisms. Rats were intragastricly administrated with Peiyuan-Huayu formula and drug containing serum was harvested. Cell counting kit 8 assay was used to determine proliferation of human microvascular endothelial-1 cells. Human microvascular endothelial-1 cells were divided into negative group, blank-serum group and drug-serum group. In vitro scratch healing assay was employed to evaluate migration distance of human microvascular endothelial cells-1. Tube-like structures formation based on human microvascular endothelial-1 cells was conducted using tube formation assay on matrigel. Expression of vascular endothelial growth factor A, mitogen-activated protein kinase kinase, phosphorylation of mitogen-activated protein kinase kinase and phosphorylation of extracellular signal-regulated kinase was determined with western blotting. The 15 % drug-serum is optimal concentration for inhibiting human microvascular endothelial cells-1 proliferation. Peiyuan-Huayu formula drug-serum remarkably inhibited migration of human microvascular endothelial cells compared to Blank-serum group (p<0.05). Peiyuan-Huayu formula drug-serum obviously suppressed angiogenesis compared to blank-serum group (p<0.05). Peiyuan-Huayu formula drug-serum down-regulated vascular endothelial growth factor A expression, activated phosphorylation of mitogenactivated protein kinase kinase and induced phosphorylation of extracellular signal-regulated kinase 1/2 in human microvascular endothelial-1 cells. In conclusion, Peiyuan-Huayu formula inhibited proliferation, migration and angiogenesis of human microvascular endothelial-1 cells. Effects of Peiyuan-Huayu formula were mediated by reducing expression of mitogen-activated protein kinase kinase 1/2, phosphorylation of mitogen-activated protein kinase kinase 1/2, phosphorylation of extracellular signal-regulated kinase 1/2 and vascular endothelial growth factor molecule.

Secondary Headache: Current Update

The purpose of this paper is to review some of the causes of secondary headache particularly focusing on the subcategories of secondary headache in the International Classification of Headache Disorders, 3rd edition, the clinical features of these headaches, and their associated features and management. Headache attributed to trauma or injury to the head and/or neck, headache attributed to cranial or cervical vascular disorder, headache attributed to non-vascular intracranial disorder, headache attributed to a substance or its withdrawal, headache attributed to infection, headache attributed to disorder of homeostasis, and headache or facial pain attributed to disorder of the cranium, neck, eye, ears, nose, sinuses, teeth, mouth, or other facial or cervical structure are discussed in this paper. Headache is a common symptom of multiple medical conditions. Although a minority of headache patients have a secondary basis for their headaches, it is important to identify clinical features of secondary headache disorders including both the headache and non-headache features of the condition, diagnose the secondary etiology correctly, and treat them appropriately.

Comparative Study of the Effectiveness of Lumboperitoneal and Ventriculoperitoneal Shunting with Neuronavigation in the Treatment of Idiopathic Intracranial Hypertension.

Idiopathic intracranial hypertension is an uncommon intracranial disorder in which intracranial pressure is increased without radiological evidence of lesions. Surgery is indicated when severe optic neuropathy is present or medical treatment fails. To assess the comparative effectiveness of lumboperitoneal (LPS) and ventriculoperitoneal shunt (VPS) with neuronavigation. A retrospective study was performed based on our database. We analyzed demographics, pre and postoperative parameters, and follow-up data on patients who had undergone either LPS or VPS between January 2007 and December 2017. Group I consisted of 17 VPS patients, of which 16 were female, and group II consisted of 29 LPS patients, of which 26 were female. The number of surgeries performed in the LPS group was higher (due to recurrence) than that in the VPS group. Moreover, the rate of complications was higher in the LPS group. VPS is safer and has a lower rate of complications and reinterventions compared to LPS.

D-Dimer Elevation as a Blood Biomarker for Detection of Structural Disorder in Mild Traumatic Brain Injury

CT scans are useful in patients with traumatic brain injury (TBI), but the potential risks associated with ionizing radiation are unknown. Further, CT scans are not commonly available in developing countries. In this study, coagulopathy and abnormal fibrinolysis were investigated as blood biomarkers for detection of structural disorder in mild traumatic brain injury (TBI). A total of 88 patients with mild and isolated TBI (Glasgow Coma Scale [GCS] score 14-15) were admitted to Kenwakai Ootemachi Hospital between October 2014 and March 2016. After exclusion of those treated with oral antiplatelet agents and anticoagulants, 73 patients were included in this study. Patients were classified into those with (lesion [+]) and without (lesion [-]) intracranial structural disorder, based on CT scans at admission and follow-up CT or MRI. Age, GCS score, and blood test findings (platelet count, international normalized ratio of prothrombin time [PT-INR], activated partial thromboplastin time [APTT], fibrinogen, fibrin/fibrinogen degradation products [FDP], and D-dimer) on admission were compared between the two groups. The lesion(+) and lesion(-) groups comprised 54 (74%) and 19 patients (26%), respectively. In multivariate logistic regression analysis, D-dimer (3.6 vs. 0.8 μg/mL) was the only significant independent risk factor for structural disorder (p < 0.001). Platelet counts (23.9 vs. 23.5 × 104 /μL), PT-INR (1.05 vs. 1.07), APTT (29.3 vs. 31.7 sec), FDP (12 vs. 2.4 μg/mL), and fibrinogen levels (260.6 vs. 231.3 mg/dL) were not associated with structural disorder. These results show that D-dimer is associated with intracranial structural disorder in mild TBI.

Coagulation management in patients undergoing neurosurgical procedures.

Management of coagulation in neurosurgical procedures is challenging. In this contest, it is imperative to avoid further intracranial bleeding. Perioperative bleeding can be associated with a number of factors, including anticoagulant drugs and coagulation status but is also linked to the characteristic and the site of the intracranial disorder. The aim of this review will be to focus primarily on the new evidence regarding the management of coagulation in patients undergoing craniotomy for neurosurgical procedures. Antihemostatic and anticoagulant drugs have shown to be associated with perioperative bleeding. On the other hand, an increased risk of venous thromboembolism and hypercoagulative state after elective and emergency neurosurgery, in particular after brain tumor surgery, has been described in several patients. To balance the risk between thrombosis and bleeding, it is important to be familiar with the perioperative changes in coagulation and with the recent management guidelines for anticoagulated patients undergoing neurosurgical procedures, in particular for those taking new direct anticoagulants. We have considered the current clinical trials and literature regarding both safety and efficacy of deep venous thrombosis prophylaxis in the neurosurgical population. These were mainly trials concerning both elective surgical and intensive care patients with a poor grade intracranial bleed or multiple traumas with an associated severe traumatic brain injury (TBI). Coagulation management remains a major issue in patients undergoing neurosurgical procedures. However, in this field of research, literature quality is poor and further studies are necessary to identify the best strategies to minimize risks in this group of patients.

Spectrum of Magnetic Resonance Imaging Features in Unilateral Optic Tract Dysfunction.

Optic tract dysfunction may be the predominant or only clinical manifestation of an intracranial disorder including mass legion, ischemic infarct, inflammatory disease, and trauma. Documentation of the neuroimaging features of these lesions is limited to reports mostly published before the availability of MRI. This study was undertaken to document the spectrum of MRI features in patients presenting with optic tract dysfunction. A retrospective study from 2004 to 2015 at a single tertiary care neuro-ophthalmology service of 24 patients who had unilateral optic tract dysfunction defined by a homonymous hemianopia and a relative afferent pupil defect that could not be attributed to optic neuropathy or retinopathy. Two institutional neuroradiologists, who were privy to the presence of optic tract dysfunction but not to its side or cause, independently documented the MRI abnormalities on a standard data collection form and then convened for a consensus review of the imaging abnormalities with the 2 clinician authors. The clinical diagnoses were 6 ischemic strokes, 5 malignant brain tumors, 5 postoperative neurosurgical cases, 4 intracranial hemorrhages, 2 traumatic brain injuries, 1 midbrain/optic tract primary demyelination, and 1 temporal lobe herpes simplex encephalitis. In their independent review, both neuroradiologists identified MRI abnormalities in 20 (83%) cases that were extrinsic to the optic tract in the neighboring temporal lobe, midbrain, thalamus, basal ganglia, or suprasellar space. In 5 of those cases, the extrinsic abnormality included features suggesting compression of the optic tract, but these compressive features were not appreciated by either neuroradiologist until the consensus conference. In 15 cases, MRI abnormalities intrinsic to the optic tract itself were eventually identified, including T2 or fluid-attenuated inversion recovery image (FLAIR) hyperintensity (9 cases) or hypointensity (1 case), thinning (6 cases), thickening (2 cases), and contrast enhancement (1 case). However, none of these intrinsic MRI abnormalities was identified during the independent review, being detected only in the consensus conference. Neuroradiologists aware of unilateral optic tract dysfunction but not of its side detected extrinsic (neighborhood) MRI abnormalities in most cases but did not appreciate that these extrinsic features sometimes included compression of the optic tract. MRI abnormalities intrinsic to the optic tract were entirely overlooked during independent review, being recognized only in a consensus conference with clinician authors. Neuroradiologists are more likely to detect MRI abnormalities pertinent to optic tract dysfunction once they have more complete clinical information and with higher resolution imaging, especially T1 postcontrast axial and coronal sequences and T2 or FLAIR coronal scans.

Cerebral Vasculitis

Introduction:Vasculitis is an inflammation systems may be involved of blood vessels due to various origins. Vessels of the peripheral and/or central nervous. Vasculitis of the CNS is rare and occurs in the context of systemic diseases or as primary angiitis of the CNS.Epidemiology:The overall incidence of primary vasculitis is about 40/1,000,000 persons [excluding giant cell (temporal) arteritis, GCA]. Its incidence increases with age. The incidence of GCA is much higher (around 200/1,000,000 persons in the age group[50 years).Clinical Presentation:Clinical and pathological presentation in CNS vasculitis represents a wide spectrum. Among others, headache, cranial nerve affections, encephalopathy, seizures, psychosis, myelitis, stroke, intracranial haemorrhage and aseptic meningoencephalitis are described. Primary and secondary vasculitides leading more frequently to CNS manifestations are discussed.Primary and secondary Vasculitides:Including Giant Cell (Temporal) Arteritis , Takayasu arteritis, Polyarteritis nodosa, Primary angiitis of the CNS, Wegener’s granulomatosis, and Connective tissue diseases, such as systemic lupus erythematosus (SLE), scleroderma, rheumatoid arthritis, mixed connective disease and Sjögren syndrome, are systemic immune-mediated diseases that lead to multiple organ affections.Cerebral Vasculitis: Imaging and Differential Diagnosis:Vasculitides represent a heterogeneous group of inflammatory diseases that affect blood vessel walls of varying calibers (inflammatory vasculopathy). Since the devastating symptoms of CNS vasculitis are at least partially reversible, early diagnosis and appropriate treatment are important. In order to establish a differential diagnosis clinical features, disease progression, age of onset, blood results, as well as CSF examinations have to be taken into consideration. Neuroimaging techniques, such as MRI and DSA, play a central role in the diagnosis and disease monitoring .The diagnostic protocol for cerebral vasculitis should include initial MRI to assess the degree of parenchymal damage and to detect vessel wall changes, in particular in large-vessel vasculitis. If the results are ambiguous or medium-sized arteries are affected (beyond the spatial resolution of MRI) DSA should follow. Small-vessel vasculitides entirely evade detection by vascular imaging and consequently require brain or leptomeningeal biopsy . Exclusion of differential diagnoses: Important differential diagnoses include RCVS, intracranial atherosclerosis Moyamoy disease, autoimmune encephalopathies and infectious disorder such as varicella zoster virus (VZV) vasculopathies or endocarditis.Therapy:Vasculitis is a serious disease that is potentially fatal or leads to permanent disability and requires rapid institution of immunosuppressive treatment. Possible therapeutic options include glucocorticoids, cyclophosphamide, azathioprine, intravenous immunoglobulins and mycophenolate mofetil.

Three-dimensional assessment of the effects of high-density embolization material on the absorbed dose in the target for Gamma Knife radiosurgery of arteriovenous malformations.

OBJECTIVE Arteriovenous malformation (AVM) is an intracranial vascular disorder. Gamma Knife radiosurgery (GKRS) is used in conjunction with intraarterial embolization to eradicate the nidus of AVMs. Clinical results indicate that patients with prior embolization tend to gain less benefit from GKRS. The authors hypothesized that this was partly caused by dosimetric deficiency. The actual dose delivered to the target may be smaller than the intended dose because of increased photon attenuation by high-density embolic materials. The authors performed a phantom-based study to quantitatively evaluate the 3D dosimetric effect of embolic material on GKRS. METHODS A 16-cm-diameter and 12-cm-long cylindrical phantom with a 16-cm-diameter hemispherical dome was printed by a 3D printer. The phantom was filled with radiologically tissue-equivalent polymer gel. To simulate AVM treatment with embolization, phantoms contained Onyx 18. The material was injected into an AVM model, which was suspended in the polymer gel. The phantom was attached to a Leksell frame by standard GK fixation method, using aluminum screws, for imaging. The phantom was scanned by a Phillips CT scanner with the standard axial-scanning protocol (120 kV and 1.5-mm slice thickness). CT-based treatment planning was performed with the GammaPlan treatment planning system (version 10.1.1). The plan was created to cover a fictitious AVM target volume near the embolization areas with eleven 8-mm shots and a prescription dose of 20 Gy to 50% isodose level. Dose distributions were computed using both tissue maximum ratio (TMR) 10 and convolution dose-calculation algorithms. These two 3D dose distributions were compared using an in-house program. Additionally, the same analysis method was applied to evaluate the dosimetric effects for 2 patients previously treated by GKRS. RESULTS The phantom-based analyses showed that the mean dose difference between TMR 10 and convolution doses of the AVM target was no larger than 6%. The difference for GKRS cases was 5%. There were small areas where a large dose difference was observed on the isodose line plots, and those differences were mostly at or in the vicinity of the embolization materials. CONCLUSIONS The results of both the phantom and patient studies showed a dose reduction no larger than 5% due to the embolization material placed near the target. Although the comparison of 3D dose distributions indicated small local effects of the embolic material, the clinical impact on the obliteration rate is expected to be small.

P040. Primary Valsalva maneuver headache without primary cough headache.

Background The uncommon headache related to a Valsalva maneuver (VM) is coded within the International Headache Society Classification (ICHD-3beta) among “Other primary headaches”, 4.1 “Primary cough headache” (PCH). This chapter deals with headaches precipitated by coughing or straining in the absence of any systemic or intracranial disorder. The clinical features of the pain are characterized by sudden onset, lasting from 1 s to 2 hours, and brought on by and occurring only in association with coughing, straining, and/or a VM. Neuroimaging plays an important role in differentiating secondary forms.

Confusional state as first symptom of HaNDL syndrome.

HaNDL (transient headache and neurological deficits with cerebrospinal fluid lymphocytosis) syndrome is an infrequent condition included at group 7 "headache attributed to non-vascular intracranial disorder" in the recent International Classification of Headache Disorders (ICHD-3), code 7.3.5. The description states "migraine-like headache episodes (typically 1-12) accompanied by neurological deficits including hemiparaesthesia, hemiparesis and/or dysphasia, but positive visual symptoms only uncommonly, lasting several hours. There is lymphocytic pleocytosis. The disorder resolves spontaneously within 3 months". In this description confusional state is not considered as a main symptom, even if in the literature this aspect is frequently reported. Here, we report the cases of two young boys presenting with confusional state as the main complaint. The possible pathogenesis of the different clinical presentation is discussed.

Beyin Omurilik Sıvısı Lenfositozu ve Geçici Nörolojik Bulguların Eşlik Ettiği Baş Ağrısı Sendromu

The syndrome of headache accompanied with transient neurologic deficits and cerebrospinal fluid lymphocytosis (HaNDL), is a rare, benign and self limiting syndrome. In the 2nd Edition of the International Classification of Headache Disorders, HaNDL syndrome was defined in secondary headache group as "Headache attributed to non-vascular intracranial disorder". The etiology of HaNDL is still unknown. In recent years, some authors have shown that ion channel autoimmunity might at least partially contribute to HaNDL pathogenesis. In this paper, the definition of HaNDL syndrome, clinical picture and epidemiology of HaNDL syndrome, etiopathogenesis, differential diagnosis and treatment will be reviewed with the recent literature.

Vein of galen aneurysmal malformation in children: Challenges of imaging in an African setting

Aneurysmal malformations of the vein of Galen (VGAM) are a rare congenital intracranial vascular disorder. It is known to occur in two main forms. We present two children with classic demonstrations of broadly recognized categories. It typically results in high-output congestive heart failure or may present with developmental delay, hydrocephalus and seizures. Our aim is to demonstrate the challenges of imaging and management in an African setting of a rare congenital intracranial vascular disorder presenting in older African children with infrequently recognized associations using limited imaging techniques. Computed tomography (CT) showed extensive gyriform hyperdensities at the grey-white matter junction, dilatation of a portion of the superior sagittal sinus with erosion of the inner table of the calvarium, multiple abnormal tortuous vessels in the suprasellar region, and a markedly dilated vein of Galen and ventricular system. Magnetic resonance imaging (MRI) showed a tortuous dilated pontomesencephalic vein in the quadrigeminal cistern, dilated vein of Galen and straight sinus. A network of vessels in the quadrigeminal cistern draining into dilated vein of Galen thinning of the corpus callosum is seen. Chest radiograph and electrocardiographic chart showed evidence of cardiomegaly and cardiac failure in one patient. We review the literature and discuss the challenges of imaging and management in our African setting. The VGAM is a recognized rare anomaly, however, knowing the true prevalence and improving its management in our African environment is limited due to the challenges of available imaging technology, lack of personnel in interventional neuroradiology, and inaccessibility to care of a large poor population.

Challenging Pyogenic Cerebral Abscess Complicated by Subdural Empyema

Brain abscesses develop in response to a parenchymal infection with pyogenic bacteria, beginning as a localized area of cerebritis and evolving into a suppurative lesion surrounded by a well-vascularized fibrotic capsule. The leading etiologic agents of brain abscess are the streptococcal strains and S. aureus. Abscesses may also be secondary to fungal or parasitic organisms. Brain abscess represents a significant medical problem, accounting for one in every 10,000 hospital admissions in the United States, and remains a serious situation despite recent advances made in detection and therapy. These lesions often produce complex clinical and radiologic findings and require prompt recognition and treatment to avoid a fatal neurologic outcome. Subdural empyema represents an important type of intracranial suppurative infectious-inflammatory disorder. Clinically, these patients initially have signs and symptoms of meningitis, but this course might be complicated later by the development of seizures and focal neurologic signs.