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Introduction: Central nervous system infections caused by Listeria monocytogenes usually manifest in the form of meningitis or meningoencephalitis, and are more common among immunosuppressed patients. Brainstem encephalitis (rhombencephalitis) is less common and fatal if not recognized and treated early., Case Report: We describe the case of a 40-year-old, immunocompetent male patient, who presented with initial symptoms of high fever and productive cough. Signs of brainstem involvement appeared later. A magnetic resonance imaging of the brain revealed a lesion of inflammatory appearance in the right medulla oblongata, and the cerebrospinal fluid test showed mononuclear pleocytosis. Blood and cerebrospinal fluid cultures were negative. He presented with a significant improvement with the start of ceftriaxone and subsequent association of corticosteroids, until he developed respiratory failure and died. The third blood cultures grew after his death and they were positive for L. monocytogenes. An autopsy was carried out, which showed necrotizing inflammation, with gram-positive bacilli in the brainstem and the cerebellum., Conclusions: A fatal delay in the diagnosis occurred, mainly because of the favorable clinical response to ceftriaxone and corticosteroids. This case reminds us that a febrile clinical presentation with brainstem involvement must generate the suspicion of a Listeria infection, and therefore ampicillin must be a part of the empirical treatment.

Introduction: Topiramate and onabotulinumtoxin A have proven to be effective in chronic migraine with or without medication abuse according to recent criteria of the International Headache Society's Headache Classification., Aims: To show that flunarizine is as effective as topiramate in cases of chronic migraine without medication abuse., Patients and Methods: We conducted a prospective, non-randomised, comparative study of two groups of patients paired by age and sex, with chronic migraine without abuse, who had been treated preventively for the first time with topiramate or flunarizine., Results: Forty patients treated with flunarizine were assigned a patient of their same sex and age who was being treated with topiramate. The mean rate of reduction in intense migraines in the topiramate group was 59% and in the flunarizine group, 58.5% (p = 0.9444); the responder rate at four months of treatment did not show any significant differences either, the figures being 75% for topiramate and 70% for flunarizine (p = 0.6236). The mean reduction of other headaches in the topiramate group was 57% and in the flunarizine group, 64% (p = 0.4261); the responder rate at four months of treatment was similar in the two groups: 76%. The percentage of dropouts from treatment was higher with topiramate (19.5%) than with flunarizine (10%) (p = 0.3493). No serious side effects occurred in either of the groups. In all, 78.9% of the patients who took topiramate said they were satisfied with the drug versus 75% of those in the flunarizine group (p = 0.7903)., Conclusions: Flunarizine proved to be as effective as topiramate in the treatment of chronic migraine without medication abuse.

Introduction: The drop-out rate among patients receiving preventive treatment for migraine is higher than 30%. This situation is not very widely known and the risk factors that lead patients to drop out from treatment have yet to be identified., Aim: To evaluate some of the factors that can predispose patients to drop out of preventive treatment., Patients and Methods: We conducted a prospective study of patients suffering from migraine who required preventive treatment for the first time with one of what are considered the top three first-choice drugs, i.e. a beta-blocker (nadolol), a neuromodulator (topiramate) or a calcium antagonist (flunarizine). Two groups were established according to whether patients dropped out of treatment or not. Different demographic and clinical variables were analysed and compared in the two groups., Results: Of 800 patients with migraine who required preventive treatment for the first time, the drop-out rate was 19.7%. In the drop-out group, the variables 'age', 'number of seizures', 'number of seizures prior to preventive treatment' and 'side effects' showed significant differences with those from the group of patients who did not drop out of preventive treatment., Conclusions: The drug used as preventive treatment, the side effects, a younger age and a lower number of seizures before starting the preventive treatment favoured higher drop-out rates. Whether the migraine was episodic or chronic, the presence of medication abuse and the drugs used to treat the seizures were not related with dropping out of preventive treatment., (© 2011 Revista de Neurología)

Introduction: Topiramate and nadolol with levels A and C of scientific evidence, respectively, would be indicated as preventive treatments of migraine. To date only one study of satisfaction has been carried out to compare the two pharmaceuticals., Aim: To compare the effectiveness parameters in independent groups of patients treated preventively with one of the pharmaceuticals from the study., Patients and Methods: From a database of 700 patients with migraine, those with episodic migraine and who had followed a course of preventive treatment, for the first time, with topiramate or nadolol were selected for the study. The effectiveness variables (reduction in the number of crises at four months of preventive treatment and responder rates) were analysed., Results: Altogether 208 patients with were included for treatment: 140 with topiramate (77.8% females; mean age, 37.9) and 68 with nadolol (69% females; mean age, 36.9). The mean number of crises in the month prior to treatment was: topiramate group, 6.3 +/- 2.6; nadolol group 5.3 +/- 2.0 (p = 0.0066). At four months after starting treatment: topiramate group, 2.69 +/- 2.6; nadolol group 2.6 +/- 2.2 (NS). The percentage of reduction in the number of migraines was 56.6% with topiramate and 51.6% with nadolol (NS). The responder rate (reduction in the frequency of crises by at least 50%) was 71.3% with topiramate versus 69% with nadolol (NS). The excellent response rate (reduction in crises by at least 75%) was 53.3% with topiramate versus 32.2% with nadolol (p = 0.0077). Adverse side effects were reported by 54% of patients treated with topiramate versus 30.8% of those treated with nadolol (p = 0.0015). The rate of satisfaction was 61% for the topiramate group and 71% for the group with nadolol (NS)., Conclusions: Both topiramate and nadolol proved to be effective in the preventive treatment of episodic migraine. Topiramate was found to be more effective than nadolol, although it was used in patients with a higher frequency of crises, and was not tolerated so well.

Introduction: Patients with headache and medication abuse (HMA) are difficult to treat, have a greater tendency towards chronification and a poorer quality of life than those with other types of headache. AIM. To evaluate the indicators showing that these patients are responding to ambulatory treatment., Patients and Methods: From a series of patients with migraine, we selected those who satisfied HMA criteria according to the appendix of the 2006 International Classification of the Headache Disease (ICHD-2) and who had never previously undergone treatment. As outpatients, they were advised to stop taking the drug that they were abusing. The treatment of their seizures was adjusted with the most efficient drugs and preventive treatment was started from the outset with topiramate or flunarizine. Patients were grouped according to whether they continued with HMA or not. Comparisons were made between the number of days with headache during the previous month and after four months of treatment and the persistence of abuse., Results: HMA criteria were met by 178 patients (mean age 40.9; 88.7% females). Results showed that 68.5% (122 patients) responded and no longer met HMA criteria after treatment. The treatment used for their seizures (triptans, nonsteroidal antiinflammatory drugs, analgesics) and preventive treatment (topiramate or flunarizine) were similar in both groups. The average number of days with headache prior to treatment was 18.52 in the group that responded and 20.87 (p = 0.0263) in the group that did not respond to treatment. In the group of responders 7.3% dropped out of preventive treatment compared with 35% (p = 0.0001) in the group of non-responders., Conclusions: A higher number of days with headache during the previous month and withdrawing from preventive treatment were indicators of a bad progression.

Introduction: The antiepileptic drug gabapentin has begun to be used successfully in some cases of neuropathic pain. Its mechanism of action is still unknown, but seems to be related to a positive effect on the synthesis and liberation of the neurotransmitter GABA., Clinical Cases: Based on the observations of other authors, we used this drug in dosage varying between 900 and 1,200 mg/day, in three patients with neuropathic pain, of both central and peripheral origin, and in whom the usual treatments had been unsatisfactory or could not be tolerated because of side-effects. The patients had been diagnosed as having trigeminal neuralgia, post-herpetic neuralgia in the area of the first branch of the trigeminal nerve and a thalamic infarct which gave rise to a contralateral Déjerine-Roussy syndrome, respectively. In all three cases, administration of gabapentin was followed by such a striking improvement of the pain that co-adjuvant treatment could be reduced or stopped, with excellent tolerance and a minimal incidence of side-effects., Conclusions: Gabapentin should be borne in mind in the treatment of this type of pain, particularly when the usual treatment cannot be given or is insufficient to control pain, especially in elderly patients in whom there is often reduced tolerance of drugs.

Some non-steroid anti-inflammatory drugs, and especially diclofenac, may, in some susceptible patients bring about the appearance of segmentary myoclonic symptoms, which in some cases where there is kidney failure may cause real myoclonic encephalopathy. We present the case of a patient admitted into the nephrology service suffering from prerenal kidney failure as a result of dehydration. Once her kidney problems had been overcome and analytical parameters normalized, during treatment with diclofenac for inflammation of the lower left extremity arthritic in origin, she showed generalized myoclonic symptoms of action and attitude especially in the upper extremities. Neurologic examination showed no abnormalities other than certain drowsiness. General analysis and kidney function were normal, as was brain CT scan, EEG showed only a general tendency towards slowing down. Myoclonic symptoms completely disappeared in the next 24 hours after giving diclofenac up, the patient remaining neurologically asymptomatic and not showing a similar clinical picture in any subsequent check-up.

Given evidence that ischemic heart disease is the most frequent cause of death in patients with cerebrovascular disease, we used ergometrics to screen 80 patients with TIA for silent myocardial ischemia (SMI) at the neurological unit of Hospital Clínico Universitario in Zaragoza, Spain. The patients were compared with a control group of 80 with no signs of heart disease. Neither the patients nor the controls had ever shown clinical signs of coronary ischemia and their baseline electrocardiograms were normal. Stress test results were positive in 25 (31%) of the TIA patients, and in 4 (5%) (p < 0.001) of the controls, showing that the prevalence of SMI is significantly higher in TIA patients than in the general population. Hiperlipidemia (75% testing positive versus 43% negative, p < 0.01) and diabetes (31% testing positive versus 13% negative, p < 0.01) were the risk factors statistically related with a positive stress test.

The authors describe 6 cases of giant aneurysm of the basilar artery diagnosed in the Neurology Department of the Hospital Clínico Universitario of Zaragoza over the last 8 years by cerebral CT, arteriography and NMR with the clinical, diagnostic, and evolutive features of the same being reported. In 2 cases the clinical manifestations initiated as subarachnoid hemorrhage, in another two as AIT, in the fifth case as cerebral infarction and in the sixth case with pseudotumoral clinical manifestations with a necropsy study being available in the latter case. Three of the 6 patients died and of the remaining three only one was, successfully operated on. Anatomopathologic, clinical, therapeutic and diagnostic aspects of giant aneurysms of the basilar trunk are also reviewed with NMR being recommended as the technique of choice in diagnosis.