Introduction: Cerebral venous thrombosis is a rare cause of stroke. It can be presented by various clinical symptoms, depending on the location.
Goal: With help of this unusual case we want to pay attention to a headache as a symptom and the consequences it causes.
Material and methods: We present a 67-year-old female patient who experienced a thunderclap headache in the frontal region. A headache occurred suddenly, after coughing, and was accompanied by vomiting. It lasted for several days and was resistant to analgesic therapy. The patient felt exhausted, with vertigo and was unstable when standing and walking. On admission, the patient complained only of a strong headache, otherwise, her neurological status was normal.
Results: Laboratory blood analysis showed hyperthrombotic state, with increased D-dimers (1520 ng/mL). Other investigations (protein C, S, antiphospholipid antibodies, factor V Leiden, genetic mutations) were normal. Fundus oculi was normal. Urgent CT of the brain revealed bilateral hyperdensity of the transverse sinus, finding suspected for venous thrombosis. MRI of the brain and MR venography could not be performed due to the previous implantation of a filter in vena cava after a car accident. The patient was treated with low-molecular heparin for a period of 2 weeks. Control CT of the brain and D-dimers were in normal range. The patient was dismissed in a stable condition with recommendation for peroral anticoagulant therapy.
Conclusion: a Headache may be the only clinical manifestation of cerebral venous thrombosis and therefore every a headache ought to be thoroughly investigated and treated.
Hereditary spastic paraplegia is a hereditary disorder in which lower extremities are affected. HSP is not a single disease entity. It is characterized mainly by lower extremity weakness and spasticity. Studies conducted showed degeneration of corticospinal tract axons. Strumpell first described HSP in 1883.
The following HSP syndromes are commonly recognized:
2)spastic paraplegia associated with motor neuropathy& muscle wasting
3)spastic paraplegia associated with ataxia
4)spastic paraplegia associated with cognitive impairment
5)spastic paraplegia associated with neuroimaging abnormality
6)spastic paraplegia associated with additional neurologic and systemic abnormalities.
The most useful classifications now are based on the mode of inheritance and genetic linkage.HSP is clinically & genetically heterogeneous.”Pure” autosomal dominant HSP is most common and even this is heterogeneous with eight loci identified. With regard to pure, autosomal dominant HSP, SPG4, SPG3A, SPG6 accounts for 70-80% of families. SPG4 HSP is the single most common dominantly inherited HSP. X linked HSP is complex but rare.
In past HSP was also classified as type I or type II, based on the patient’s age at the onset of symptoms and on the amount of spasticity versus weakness. Because both types can appear in the same family, this classification is no longer used.
Patients with HSP may have the following complications:
4)back and knee pain
5)stress and depression
In patients with pure HSP, life expectancy is unaffected. Generalizations about the life expectancy of people with complicated HSP are difficult to make because each patient has unique symptoms.
What is Multiple sclerosis:
Multiple sclerosis also known as Disseminated sclerosis is the most common CNS demyelinating disease. The usual age onset is 20 to 40 years. In this disease there is recurrent attack of focal degenerative neurological disorders with predilection for involvement of the spinal cord , optic nerve and brain. The early attack is like a single symptom or sign ; most commonly optic neuritis followed by recovery.
Prevalence in India:
In India MS is a very common neurological disorders. There is about 1 million case in every year.
- Genetic susceptibility.
- Infectious agent.
- Immunologic mechanism.
The hallmark of multiple sclerosis is the presence of many scattered discreat areas of demyelination termed plaques. Grossly plaques are grey pink , swollen , sharply defined , usually bilateral areas in the white matter .
In histopathologic features; plaques are made up of accumulated lymphocytes and macrophages arround the sites where demyelination is already started. In addition there is loss of oligodendrocytes and presence of reactive astrocytes and lipid laden microglia ( macrophages).
- Stiffness and spasms in muscles.
- Bowel and bladder problem.
Treatment of Multiple sclerosis:
As disease become progressive, remission become infrequent and incomplete. The drugs are used mainly for prolongation of life and delay disease progression. In march ; 2017 FDA approved first drug for multiple sclerosis; that is OCRELIZUMAB.
- Disease modifying drugs: As MS is a autoimmune disease ; causes immune destruction of myelin sheath. These drugs work by curbing the immune system . They also reduce the number of flare-ups….include –
- Interferon beta 1b.
Both cut down the number of flare-up and slow down the advance of MS –
- Dimethyl fumarate.
- Interferon beta 1a
- Peginterferon beta 1a
The interferons are considered as very safe drugs for treating MS. Sometimes self injection can cause redness, warmth, itching and dimpling of skin.
Other Adverse effect of interferons are-
- Flu like symptoms – aches, chills,fatigue , fever.
- Increase risk of infections due to lowering down of white blood cell count and also decrease immunity.
In relapsing case of MS ; drugs like Teriflunomide causes sideeffects like nausea , hair loss.
Another drug Aubagio ; is detected as” BLACK BOX” warning by FDA due to its serious side effects ..like-
- Hepatitis or other liver disease.
- And may cause serious teratogenic effect if prescribed for pregnant women.
Gilenya ; another drug causes –
- For the treatment of Flare-ups:
1)High dose of steroides are given intravenously.
2)Another technique is plasmapheresis.
- For the Treatments of other symptoms:
1) For muscle stiffness and spasms: muscle relaxant Beclofen or sedative like clonazepam or diazepam.
3) Depression: antidepressants like leupropion or fluoxetine or sertraline.
4) bladder problem:oxybutynin.
Except the above drug therapy the doctor can give advise to have a little exercise and moderate walking everyday. It can relief from the symptoms of MS and gives a comfortable feeling to the patients.
Back pain is one of the most common problem of many people. Among them low back pain is most common reasons for a visit to the doctor these days. Here is the #8 tips for healthy and strong spine.
1. Stand straight– Correct posture can prevent all back pain.
2. Sleep properly– Adequate sleep required for overall health. But beside this, sleeping in a good posture is a valuable thing to maintain spine health. Sleep on your side, not your stomach: Sleeping on your stomach puts too much pressure on your spine. Sleeping on your side also reduces upper airway collapse, helping to prevent sleep apnea symptoms and give you a better night’s rest, according to the National Heart, Lung, and Blood Institute. Or if you sleep on your back try to place pillow under your knees.
3. Lift Right– Lifting an object in a wrong manner can easily damage your back spine. Try to lift a heavy object in this way given here. Direction- When lifting heavy objects, kneel to lift the object, keeping the weight close to your body while using the legs to lift rather than the back.
4. Sitting– We office workers spend most of the time by sitting infront of laptop or PC. But they should maintain a proper postion to eliminate the back pain. Direction-Feet should touch the floor or be supported. Keep Spine straight. Look straight without neck strain
Adjust your chair’s lumbar and armrests. Keep monitor at arms’ length. Position monitor & document holders even or slightly below line of sight.
5. Holding mobile– Hold your mobile devices correctly. Sit up when texting or reading. Keep device at chest or eye level to decrease neck and back stress.Use a hands-free device instead of holder to your ear.
6. Stay hydrated– Our vertebral column is 88% made of water. So dehydration can lead degenaration of discs, herniated discs. According to American academy of orthopedics a herniated disc is the most common cause of sciatica, a specific type of back pain that radiates down one of the leg. So drink more to reduce back pain.
7. Maintain weight– The topmost goal to eliminate back pain is to maintain a healthy weight. Being overweight or obese, or quickly gaining a significant amount of weight, are risk factors for low back pain can put added stress on the muscles, ligaments, and tendons in your lower back.
8. Stay Active– You’ll be at a great risk of back pain if you are not physically active or fit. The best excersice routine for back is one that combines stretching, strengthening, and aerobic activity.
Here are pictures of some exercise examples-
These are a group of disorder in which the patient presents with multiple clinically significant feature and physical symptoms that cannot be explained.These unexplained physical attributes often leads to anxiety of the patient; We don’t actually understand the actual mechanism of these disorders. There can be a problem with the nerve impulse that send signals of pain, pressure and other unpleasant sensation to the brain.They tend to come and go .Though various underlying causes tends to increase the risk of such disorders.
1. Its mostly occurs in subject under 30 years of age.
2. Genetics has a profound influence over such disorders
3. Negative attitude towards life.
4. Unusual sensitivity towards physical and emotional pain.
5. Family history may be positive.
Clinical criteria which are common to all the somatoform disorder are
1. Cannot be explained by medical condition, another mental disorder, or effect of a substance,
2. Not related to factitious disorder and malingering.
3. Cause significant impairment of social functioning and occupational and other functioning.
Characteristics of Somatoform Disorders
1. Hypochondriasis- Subject affected with this type of disorder are always in a false belief that they are suffering from a serious illness.The belief is not fixed and could be removed transiently by explanation and reasoning to have another belief about another organ of the body.The patient expresses fear while discussing their symptom.The patient must have a non delusional preoccupation with their symptoms at least six months before diagnosis can be made.
2. Conversion disorder- The neurological syndrome does not correlate with a medical cause.The symptoms are mainly weakness,tremour,deafness,blindness,etc. It though start as a mental or emotional crisis and converts to a physical problem.Conversion disorder is not conformed to any anatomical pathway or physiological mechanisms, but instead they fit a lay view of physiology. It rarely occurs below 10 years of age or after 35 years of age.It is commonly found in rural population, person of lower socioeconomic status , and those with minimal medical or psychological knowledge.
3. Pseudocyesis- Here the woman feel labour pain along with other indication of pregnancy. Here the somatic symptoms occur less than six months.
4. Body dysmorphic disorder- It is the obsession with with a flaw in his or her appearance which can either be a minor flaw or non-existing.In case of real physical imperfection, the defect is usually slight but the patient’s concern is excessive.The disorder occurs equally in men and women.
5. Somatization disorder- Also known as Briquet disorder, here the patients are
Below 30 years of age and present with unexplained physical symptoms .
The symptoms include-
• One pseudoneurogenic symptom
• One sexual problem
• Four pain symptom
• Two gastrointestinal problem
People with such disorder make frequent clinical visits , have multiple
Diagnostic test done, are referred to multiple doctor due to their myriad
6. Undifferentiated somatoform disorder- it is a less specific version of somatization , here it extends up to six months or longer , with one or more than one unexplained physical complain with other necessary clinical criteria.Chronic fatigue that is unexplained by any relevant clinical criteria is a typical symptom.
7. Pain disorder- It is fairly common. At its onset , the pain is associated with psychological factors. Though its maintenance may be associated with a general medical condition.Though pain is is the the focus of the disorder, but psychological factor are primary to play in the perception of pain.
Here the result of medical test are either normal or fails to explain the person’s symptoms.And the history and physical examination do not reveal any known medical condition.
It is quite a challenge to work with somatoform disorder it requires considering a mental health diagnosis while excluding the medical causes of the physical symptoms.The problem with these type of disorder is the that there is no specific physical examination or laboratory finding that are required for confirmation of the diagnosis.Though appropriate non psychiatric medical condition should be considered by unnecessary laboratory testing should be avoided in such cases.Factitious disorder and malingering though are related disorders should be excluded before diagnosing a somatoform disorder . In factitious disorder the patient has a internal desire to be sick , while in malingering the patient bluff the physical symptoms so that he may have any sort of gain such as financial benefit ,legal benefit , escaping a unfavorable situation. But in somatoform disorder, there is no possible gain for the patient and the physical symptoms are not feigned , rather fear and anxiety stimulates these disorders.
The diagnosis of Somatoform disorders have been assisted by clinical diagnostic tools such as patient health questionnaire .
If the patient is bothered a lot lot by at least three of the symptoms without a medical reason then there is a possibility of somatoform disorder.
The patient have a strong believe that their symptom have a physical cause , though is is contrary .This is due to the false interpretation of the symptoms.
The steps of the treatment are-
1. Discussing the key features of the diagnosis with the patient-
The initial steps in the treatment is to discuss about the disorder to the patient early in the work-up and, after ruling out organic pathology as the primary ethology for the symptom, to confirm the psychiatric diagnosis.The physician must first construct a therapeutic alliance with the patient.then the physician must review with the patient the therapeutic criteria for the suspected somatoform disorder. He must inform the patient that the goal of treatment is management rather than cure.
First and foremost is the treatment of the psychiatric comorbidities , since the psychiatric disorders are generally found in union with the co morbidities.
There is limited effectiveness of the pharmacological interventions.
Cognitive behavior therapy have been found to be effective in the somatoform disorder.It focuses on reducing cognitive distortions , imaginary belief , worry and behavior that lead to anxiety and somatic manifestation.
3. Follow up-
Regular and brief follow up with the physician is an important aspect of treatment.This is important for the maintainable of the therapeutic alliance with the physician .The patient can openly ventilate about their worries and the opportunity to be reassured repeatedly that their symptoms are not due to a physical condition
Practice Management Strategies for Somatoform Disorders:-
Accept that patients can have distressing, real physical symptoms and medical conditions with coexisting psychiatric disturbance without malingering or feigning symptoms
Consider and discuss the possibility of somatoform disorders with the patient early in the work-up, if suspected, and make a psychiatric diagnosis only when all criteria are met
Once the diagnosis is confirmed, provide patient education on the individual disorder using empathy and avoiding confrontation
Avoid unnecessary medical tests and specialty referrals, and be cautious when pursuing new symptoms with new tests and referrals
Focus treatment on function, not symptom, and on management of the disorder, not cure
Address lifestyle modifications and stress reduction, and include the patient’s family if appropriate and possible
Treat comorbid psychiatric disorders with appropriate interventions
Use medications sparingly and always for an identified cause
Schedule regular, brief follow-up office visits with the patient (five minutes each month may be sufficient) to provide attention and reassurance while limiting frequent telephone calls and “urgent” visits
Collaborate with mental health professionals as necessary to assist with the initial diagnosis or to provide treatment