Abstract Objective We examined whether the combined use of telemedicine and self‐injection could improve patient satisfaction. Background For patients with migraine, the use of calcitonin gene‐related peptide ‐pathway targeting monoclonal antibodies is associated with concerns, such as the burden of doctor visits and anxiety around self‐injection. Methods At four institutions, patients with migraines who used self‐injectable calcitonin gene‐related peptide ‐pathway targeting monoclonal antibodies attempted telemedicine, and web‐based questionnaires and interviews were conducted thereafter. Results Of the 26 participants, 58% felt that telemedicine helped with self‐injections and 65% wanted to continue using the combination. The average time required per doctor visit was reduced from 158 to 31 min, and the median from 86 to 18 min. The benefits included reduced burden (46%), ease of schedule adjustment (35%), and lower anxiety levels (19%). Conclusion Although there are issues with telemedicine usage, including the burden on healthcare professionals or lower reimbursement points, the combination of self‐injection of calcitonin gene‐related peptide ‐pathway targeting monoclonal antibodies and telemedicine is effective in improving the experience of patients have migraines.
Superficial siderosis results from hemosiderin deposition in the subpial layers of the brain and spinal cord. The chronicity of bleeding is indispensable for the development of siderosis; the condition cannot occur after a single bleeding episode. Extensive deposition of hemosiderin on the surface of cells of the central nervous system (CNS) induces neurological dysfunction (1, 2). Superficial siderosis is clinically diagnosed based on the detection of signal loss at the surface of CNS structures on T2-weighted MRI (3). T2 * weighted MRI is now available for detecting small amounts of iron deposition with greater sensitivity (4). This disease was previously considered to be rare; however, it has recently become more frequently diagnosed in patients with progressive sensorineural hearing loss (5). The auditory nerve, cerebellum and brainstem are likely to be involved in patients with superficial siderosis, resulting in the classic triad of sensorineural hearing loss, cerebellar ataxia and pyramidal tract symptoms (1, 2). The cerebellar cortex is also susceptible to hemosiderin deposition (6). The special vulnerability of the auditory nerve is attributed to the long course of this nerve covered by central myelin in the subarachnoid space (7). Various pathologies have been reported to be possible causes of superficial siderosis. For example, Levy et al. reviewed 270 patients and reported that the underlying causative disorders in these subjects included CNS tumors (21%), trauma (13%), arteriovenous malformations (9%), a post-surgical status (7%) and idiopathic causes (35%) (1). Ependymoma is regarded to be the dominant histological type of tumor of superficial siderosis (2), while spinal intradural extramedullary cavernous angioma is an extremely rare cause of this disease. Cavernous angioma involves vascular malformations created by anomalous vessels without interposition of neural tissue. The typical MRI features include well-defined lesions with mixed signal intensity on both T1- and T2-weighted images, often surrounded by a hypointense ring on T2weighted images, due to hemosiderin deposition (8). Histologically, cavernous angioma consists of large, dilated hyaline vascular channels arranged in a diffuse pattern. These lesions are often associated with thrombosis, perivascular hemosiderin deposition and calcification (9). Cavernous angioma can occur anywhere in the CNS, although these lesions favor the cerebral hemisphere (10). Spinal cavernous angioma involves rare vascular malformations occurring primarily in the vertebral body with or without extradural extension. Only 3% of cavernous angiomas are reported to be intradural (11). Intradural extramedullary cavernous angioma lesions are more rare than corresponding intramedullary lesions. Most cases of intradural-extramedullary cavernous angioma present with symptoms related to spinal cord compression, such as sensorimotor deficits, back pain and/or sphincter dysfunction. Only one case of superficial siderosis (12) and two cases of hydrocephalus (13, 14) have been reported. In this issue of Internal Medicine, Katoh et al. (15) report a case of spinal intradural extramedullary cavernous angioma presenting with superficial siderosis and hydrocephalus. Their patient, with a past history of spontaneous severe headache 11 years earlier, visited an otorhinolaryngologist complaining of a three-year history of progressive bilateral hearing impairment. A neurological examination revealed bilateral sensorineural hearing impairment, hyperreflexia in all limbs, mild ataxia and mild cognitive dysfunction, although no symptoms related to spinal cord compression were observed. Because superficial siderosis and hydrocephalus are the ultimate consequences of chronic bleeding, long-term damage resulting from delayed diagnosis may have made the patient’s neurological deficits irreversible. Clinicians should therefore keep in mind superficial siderosis as an important cause of bilateral hearing impairment and perform
Primary headache disorders such as migraine, tension-type headache, and cluster headache are prevalent and disabling neurological disorders. Although most headache disorders are largely treatable, they are under-recognized, under-diagnosed, and under-treated. Many headache sufferers in Japan do not receive appropriate and effective health care; hence, the illness, which should be relieved, persists and acts as an individual and societal burden. One of the barriers most responsible for this is poor awareness of the disorders. For lifting the burden, health care must be improved. Education is an essential way to resolve these issues at multiple levels. We have a Japanese version of the international headache classification and diagnostic criteria II (ICHD-II) and guidelines for the management of chronic headaches. Utilization of these resources is key for the improvement of headache management in our country. Not only neurologists, but also neurosurgeons and other medical specialists are participating in headache care in Japan. The Japanese Headache Society and the Japanese Society for Neurology should play major roles in health care service, education programs, as well as clinical and basic research for headache disorders. The road map for realizing our aim on headache treatment is as follows: (1) increase the number of units concerning headache in lectures for medical students, implement training programs for residents and neurologists, and offer continuous medical educations for physicians and neurologists; (2) secure more funding for headache research; (3) propagate medical care for headache in primary care settings and regional fundamental hospitals; (4) reform the health care system for headache and incentivize appropriate compensation for headache care in public health insurance; and (5) spread appropriate information on medical and socio-ethical issues related to headache for the sufferers and citizens. The authors expect that many neurologists have an interest in headache and understanding headaches, and better health care for headache disorders will bring great benefits for the sufferers.
Vascular thrombosis is prevalent among patients with polyneuropathy, organomegaly, endocrinopathy M-protein, and skin changes (POEMS) syndrome. The endothelial cells in the endoneurium are often hypertrophied and the lumen is frequently occluded. Consequent local hypoxia may increase vascular endothelial growth factor (VEGF), which induces hypercoagulation and vascular permeability.This study presents two patients in the fifth decade of life, who had rare nerve biopsy findings of vascular occlusion mainly by platelets. Before the cases presented here, we encountered nine confirmed POEMS patients whose nerve biopsies did not show similar findings.A small artery and a vein were occluded, but no atherosclerotic changes were observed. The endothelial cells that adhered to the packed platelets lost their junctions.Platelet aggregation, degranulation, and ischemia may cause a loose endothelial barrier and leak proinflammatory cytokines, such as interleukin-12. This may increase production of VEGF and may cause nerve demyelination. Small vessel platelet thrombosis may contribute to the pathogenesis of this disorder.
Background Because of the burden of migraine in Japan, there is a need for safe and effective preventive treatments. This study assessed the long-term safety and tolerability of galcanezumab in Japanese patients with episodic (EM) or chronic (CM) migraine.Research design and methods In this 12-month open-label study, adult patients with EM who previously completed a 6-month, double-blind, placebo-controlled trial were newly randomized to either galcanezumab dose from placebo or continued their assigned galcanezumab doses (all: 120 mg, n = 120; 240 mg, n = 126). Newly enrolled patients with CM were randomized to 120-mg (n = 32) or 240-mg (n = 33) galcanezumab. The primary outcome was long-term safety and tolerability.Results The incidence of TEAEs was similar between treatment groups. Nasopharyngitis was the most common TEAE, followed by injection site reactions. The discontinuation rate was low (EM = 9.3%; CM = 15.4%) and no deaths were reported. Patients with EM who received galcanezumab in the placebo-controlled trial had sustained efficacy. Both doses reduced the number of migraine headache days in patients with CM.Conclusions Long-term treatment with 120-mg or 240-mg galcanezumab was safe and effective in Japanese patients with EM or CM.Trial registration https://clinicaltrials.gov, identifier: NCT02959190.
We report a case of pseudomigraine with pleocytosis (PMP) characterized by temporary neurological deficits and elevated cell counts in cerebrospinal fluid (CSF). A 28-year-old woman was admitted to our hospital with a second episode of right side throbbing headache accompanied by hemianopsia without scintillating scotoma of left side, hand numbness and weakness of left hand. Two months before the admission, she experienced a first identical episode, which lasted several hours. On admission to our hospital, neurological examination showed left hemianopsia, mild left hemiparesis, dysesthesia of left hand, exceeded tendon reflex of left upper limb, stiff-neck and positive Kerning's sign. CSF examination showed mild elevation of mononuclear cell counts. No abnormal findings on brain CT and MRI (including diffusion weighted image) were observed. 99mTc-HMPAO single photon emission computed tomography (SPECT) demonstrated extensive hypoperfusion at right cerebral hemisphere, corresponding to her neurological deficits. Her electroencephalography (EEG) showed reduced amplitude on the right occipital area. The reduced amplitude of cortical component of somatosensory evoked potential (SEP) by left median nerve stimulation were observed. On the third day after the admission, her symptoms improved and cell count of CSF was normalized. One week after the onset her SEP, EEG and SPECT were normalized on their retrials. She has never recurred these symptoms. We established a diagnosed of psedomigraine with pleocytosis as the first Japanese case.
Abstract Background The objective of this analysis was to gain new insights into the patient characteristics and other factors associated with lasmiditan usage and clinical outcomes under conditions resembling the real-world setting. Methods This was a post hoc analysis of data from the 12-month, open-label extension (OLE) of the phase 3, double-blind, randomized, controlled CENTURION trial, which examined the efficacy and safety of lasmiditan as acute treatment across four migraine attacks. Patients completing the main study who treated ≥ 3 attacks could continue in the OLE. The initial lasmiditan dose was 100 mg, with dose adjustments to 50 mg or 200 mg allowed at the investigator’s discretion. Patient and clinical characteristics were summarized by dosing pattern and completion status. Safety was assessed based on adverse event (AE) frequency by number of doses. Results In total, 445 patients treated ≥ 1 migraine attacks with lasmiditan during the OLE, 321 of whom (72.1%) completed the study. Forty-seven percent of patients remained on the 100-mg initial dose during the OLE whereas 20.2% used both 100 mg and 50 mg, 30.6% used both 100 mg and 200 mg, and 6 (1.3%) used multiple dose levels. All dosing patterns were associated with clinical and patient-reported improvement; however, the 100-mg group had the highest proportion of patients reporting improvement in the Patient Global Impression of Change – Migraine Headache Condition (56.5% vs 33.4%–52.2%). In comparison, all three groups that made dose adjustments had higher rates of completion compared to the 100-mg group (72.1%–83.3% vs 68.9%). The frequency of AEs decreased with continued use of lasmiditan. Concomitant triptans and lasmiditan use did not increase AE frequency. Conclusions Based on high persistence and patient satisfaction rates, the 100-mg dose appears optimal for most patients. For those who adjusted dose levels, dose adjustments appeared beneficial to improve efficacy or tolerability, retaining patients on treatment. Collectively, the data suggest that patients who experienced efficacy continued to use lasmiditan regardless of the occurrence or frequency of AEs, and continued use appeared associated with fewer AEs. Trial registration European Union Drug Regulating Authorities Clinical Trials Database (EudraCT): 2018–001661-17; ClinicalTrials.gov: NCT03670810; registration date: September 12, 2018. Graphical Abstract
