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Purpose: Spontaneous intracranial hypotension (SIH) is suspected in patients presenting orthostatic headache and needs excluding structural or iatrogenic causes. Image studies are required to confirm the diagnosis and define exact locations of cerebrospinal fluid leakage, but currently there is no single study sensitive enough to make identifications among patients with various symptoms., Case Report: We present a 24-year-old young woman having acute orthostatic headache. She denied having previous headache, head trauma, or neuraxial procedures like lumbar punctures. Brain magnetic resonance image (MRI) with gadolinium enhancement reported normal findings on arrival. She received conservative treatment including analgesics and aggressive intravenous hydration, but her headache improved little. Whole spine MRI with gadolinium enhancement revealed no obvious leakage of cerebrospinal fluid but typical dilated epidural veins with ventral displacement of her thoracic spinal cord. After autologous epidural blood patches therapy, her headache relieved completely., Conclusion: We review the typical and uncommon findings of spinal MRI in SIH, which is more sensitive than brain MRI in acute stages. Spinal MRI offers the diagnostic value in SIH especially when cranial images do not respond in time.

Purpose: Migraine is a common, debilitating, primary headache disorder that can cause and be affected by odontalgia., Case Report: A 49-year-old woman(Patient 1) presented with pulsating pain in the left maxillary molar area, and a history of unsuccessful root canal treatment. She was ultimately diagnosed with menstrually related migraine without aura and zolmitriptan was prescribed, which reduced her headache and toothache together. A 45-year-old woman (Patient 2) presented with throbbing pain in the right maxillary molar and cheek area. Past repeated endodontic therapy had been unsuccessful. She was then diagnosed with menstrually related migraine without aura, and sumatriptan significantly reduced her headache and toothache. A 40-year-old woman (Patient 3) presented with pulsating pain near the left maxillary molar region. Pulpectomy was performed after she had previously received a diagnosis of pulpitis in the left maxillary second molar, but her pain did not subside. Patient 2 and 3 were misdiagnosed as pulpitis by dental practitioners and the pain did not relive after pulpectomy. All patients were diagnosed as migraine by headache specialists and were treated with triptans, which resulted in satisfactory pain relief., Conclusion: A thorough history and examination, as well as an understanding of migraine headaches, is necessary to differentiate odontogenic pain and migraine headaches. Key Words: menstrually related migraine, orofacial pain, ICHD-3, headache.

Purpose: Classical trigeminal neuralgia with concomitant persistent facial pain responds poorly to conservative treatment. The authors describe the effects of microvascular decompression and radiofrequency thermocoagulation for patients with classical trigeminal neuralgia and concomitant persistent facial pain., Case Report: Case 1 was a 61-year-old man with dull, continuous, aching pain in the left maxillary and mandibular molar area. Case 2 was a 68-year-old woman with aching pain in the maxillary right molar. Case 3 was a 67-year-old woman with severe pain in the right upper lip and maxillary right second premolar. Case 4 was a 42-year-old man with orofacial pain of 14 months' duration. Cases 1 and 2 underwent radiofrequency thermocoagulation and reported good relief of symptoms. Cases 3 and 4 underwent microvascular decompression and attained excellent relief., Conclusion: Microvascular decompression may be more effective than radiofrequency thermocoagulation for patients with classical trigeminal neuralgia with concomitant persistent facial pain.

In 2015, the American Headache Society (AHS) amended the treatment guideline of acute migraine based on evidence-based medicine (EBM) that all triptans in any form of preparations, acetaminophen, and non-steroid anti-inflammation drugs-NSAID (aspirin, diclofenac, ibuprofen, naproxen), sumatriptan/naproxen, combined acetaminophen/aspirin/caffeine are considered effective (Level A). Previously effective drugs as prochlorperazine, and dihydroergotamine-DHE (excluded inhaled form) were downrated to probable effective (Level B). Taiwan Headache Society published its treatment guideline for acute migraine attack in 2007. It should be updated based on the new available evidence. The Treatment Guideline Subcommittee of Taiwan Headache Society reviewed the recent trials, evaluated the grade of evidence, and appraised the clinical efficacy to reach a new consensus. We also referred to the guidelines from United States, Europe, Canada and other countries to make this one meets our needs and feasible. Acute medications currently available in Taiwan can be categorized into "migraine-specific"and"migraine-nonspecific" groups. Migraine-specific triptans and migraine-nonspecific nonsteroidal antiinflammatory drugs (NSAIDs) have the best levels of evidence, and are recommended as the first-line medications for acute migraine attacks. The administration should follow the concept of "stratified care". For mild to moderate migraine attacks, oral NSAIDs are the first choice; with oral aspirin, combination analgesics, intravenous/intramuscular NSAIDs as alternatives. For moderate to severe attacks, oral or nasal spray triptans and ergotamine/caffeine compounds are recommended and should be administered in the early stage of migraine attacks. Antiemetics can be used as supplement to alleviate nausea and vomiting. Notably, a combination of a triptan and a NSAID yielded a better efficacy compared with either therapy alone. Parenteral steroid and fluid supply are the first choice in treatment of status migrainosus. Acetaminophen is suitable for mild to moderate migraine attacks and remains the first choice for children and pregnant women. Opiates are not recommended for acute migraine treatment at the present time because of serious adverse events. To prevent medication-overuse headache, the use of acute treatment should be limited to a maximum of ten days a month.

Background: Myasthenia gravis (MG) is an autoimmune disease caused by antibodies to acetylcholine receptors of the skeletal muscle. Myasthenic crisis (MC) is a complication observed during both early and late stage MG cases. In this study, we examined current treatments and three years outcomes in patients with MG and MC. We also investigated the impact of thymectomy and systemic lupus erythematosus (SLE) in patients with MG and MC., Methods: In this retrospective study, we reviewed the medical records of all patients admitted to one teaching hospital between January 2006 and December 2014 and identified those for whom discharge diagnosis included the International Classification of Diseases, ninth revision (ICD-9) codes corresponding to MG (358.X, all extensions and all positions)., Results: We identified 29 patients and 49 hospitalizations. Among these patients, the cause for initial hospitalization was MG in 16 cases and MC in 13 cases. Six out of the 16 MG patients were readmitted within 3 years; with 2 of the cases due to MC. Eight of the initial 13 MC patients were readmitted within 3 years, and 6 of the cases due to MC. Among these 15 MC patients, 14 were admitted to the intensive care unit (ICU), and 8 were intubation and put on mechanical ventilators. The median ICU stay was 7 days (3-45). Both MG patients who were also diagnosed with SLE experienced MC. One patient died during the first-time hospitalization, and one patient died during re-hospitalization within 2 years., Conclusion: Plasma exchange (PE) is the main treatment modality of MC, and most patients in our cohort had a good response. Infection is the most common trigger of MC and a significant cause of death. Despite significant morbidity and mortality in patients with MC, a favorable long-term outcome is possible with intensive treatment. Key Words: myathenia gravis, myasthenic crisis, systemic lupus erythematosus, outcome.

Purpose: Although different types of headache have been described in Chiari malformation type I, reports of cluster-like headaches are rare., Case Report: We report a 26-year-old man who presented with a two-week history of excruciating headache in the right temporal region after coughing, which was accompanied by autonomic features including right-sided nasal congestion and tearing from his right eye. Sensory deficits in the first branch of the right trigeminal nerve and along C3-5 dermatomes were noted, and brain magnetic resonance imaging was compatible with a diagnosis of Chiari malformation type I., Conclusion: A diagnosis of secondary cluster headache was made due to a lack of typical periodicity, and the presence of anhidrosis and sensory abnormalities and cough headache.

Purpose: If a patient with aortic dissection (AoD) is inadvertently treated with thrombolytic agents, severe complications and poor outcomes are likely to ensue. We reported a case and postulated mandibular pain as warning sign for diagnosing AoD related stroke., Case Report: We report an 81-year-old woman presenting with left mandibular pain followed by left hemiplegia. Extracranial carotid duplex showed dissection of the right common carotid artery and chest CT angiography proved AoD. She did not have any typical chest or back pain., Conclusion: AoD should be carefully considered in patients with acute ischemic stroke presenting with mandibular pain. A high clinical alert and urgent CT angiography may help identify AoD.

Purpose: Abnormal course of the carotid artery (ABCA) is commonly identified during carotid sonography studies. Whether ABCA is related to the risk of stroke and stroke risk factors remains unclear. The purpose of the study is to investigate the prevalence of ABCA and the relationship with stroke and the risk factors of stroke., Methods: Color duplex ultrasound scanning of carotid arteries was performed on 615 subjects (between January 1, 2012 and March 31, 2012). ABCA and intimal thickness were recorded. Risk factors of stroke such as hypertension, diabetes mellitus, dyslipidemia, atherosclerosis, stroke history, and heart disease were recorded. The prevalence of ABCA was analyzed and its relationship with stroke and stroke risk factors was evaluated., Results: ABCA was found in 4.1% (25/615) patients, 6.29% (19/302) in women, and 1.91% (6/313) in men. ABCA in 1 vessel was noted in 18 patients, 2 vessels in 3 patients, 3 vessels in 3 patients, and 4 vessels in 1 patient. The frequency of ABCA was significantly higher in women than in men (6.3% vs 1.9%, p = 0.01). There was no difference in the prevalence of ABCA between stroke patients and nonstroke subjects ( p = 0.60). ABCA was more frequent in patients older than 65 years. (5.91% (22/372) vs. 1.23% (3/243) p = 0.01). Logistic regression analysis did not reveal associations between ABCA and stroke risk factors (hypertension, diabetes mellitus, dyslipidemia, stroke history, heart disease and atherosclerosis). During 1 year follow-up, 2.88% (17/590) of non-ABCA patients and 4.0% (1/25) of ABCA patients had event of stroke or transient ischemic attack (TIA) ( p =0.08)., Conclusion: The prevalence of ABCA in the present study is significantly lower than that in previous studies (Togay-Isikay et al., 24.6%, Del Corso et al., 58%). ABCA is more frequent in women and older patients. ABCA is not related to stroke and stroke risk factors. From our results, we suggest that patients with ABCA be placed under observation unless they exhibit neurological symptoms.

Objective: The reported prevalence of cavum septum pellucidum (CSP) and cavum Vergae (CV) in brain computed tomography (CT) is 5.5% in Great Britain and 1.24% in China but unknown in Taiwan. Moreover, CSP and/or CV has generally been thought to decrease as age progresses, but the evidence of actual prevalence at different age levels is still limited in the literature., Methods: A total of 19,031 patients with brain CT at a regional hospital in northern Taiwan from July 2008 to August 2010 were included in this study. Their radiological official reports were retrospectively reviewed to check for CSP and/or CV. An X2 test was used for statistical analysis (α = .05)., Results: The prevalence of CSP and/or CV in all brain CT was 0.93% (n = 177), which was lower. than that in the Chinese and British studies. Among them, 2.8% (n = 5) had only CSP, 1.7% (n = 3) had only CV, and 95.5% (n = 169) had coexistent CSP and CV. There is a significant difference in prevalence between the age groups (p = .009), and the prevalence is the highest in the group aged 20-29 years (1.56%) and lowest in the group aged above 80. After age 20-29, the prevalence tends to decrease with increasing age., Conclusion: This is not only the first study of CSP and CV in the Taiwanese population but the study population is also larger than those in the literature. The prevalence was found to approximately decrease as age progresses, but would reach the peak in the young adult group rather than the children or adolescent group.

Purpose: Vertebral artery dissection (VAD) is an important and under-recognized etiology of stroke in young patients. No clinical symptoms or signs appear to be specific for VAD. This report describes a representative patient and reviews the headache pattern and imaging findings commonly noted in VAD to help with the early diagnosis of VAD., Case Report: A 44-year-old female presented with severe right posterior neck pain and vertigo followed closely by thunderclap headache that was confirmed as right VAD (V4 segment) with delayed right dorsal medullary infarction two days later. Her headache, vertigo, and truncal ataxia were completely improved one week later., Conclusion: The most common neuroimaging findings of VAD were vertebral artery stenosis, followed by the string and pearls sign, arterial dilation, arterial occlusion, and the less common but most characteristic features of pseudoaneurysm formation, double lumen, and intimal flap. Pain in VAD mostly occurred in the ipsilateral posterior occipitonuchal region, with throbbing features in 50- 60% of the patients. Only one fifth of patients with VAD present with a thunderclap pattern. In stroke among young patients or stroke with pain in the head and neck, angiography study of the craniocervical artery is highly recommended.

Purpose: To investigate whether patients with vestibular migraine (VM) are more susceptible to carsickness than patients with non-vestibular migraine (NVM) or Meniere's disease (MD)., Methods: Consecutive patients with a diagnosis of definite VM, probable VM, NVM, or MD at our Headache and Dizziness clinics were interviewed using the same three questions to investigate the history of carsickness. The patients who had experienced carsickness in their lifetime and those who had still experienced carsickness in the past ten years were identified. The rates of carsickness were compared between groups., Results: 78.4% of the VM patients had experienced carsickness in their lifetime, which was significantly higher than the patients with NVM (43.6%) and MD (18.2%). Both the lifetime rate of carsickness and the rate in the past ten years were highest in the patients with definite VM, followed by probable VM, NVM, and MD (p less than 0.05, chi-square test). The odds ratio of lifetime carsickness for VM versus MD was high (8.7)., Conclusion: Both patients with definite VM and probable VM were more susceptible to carsickness than the patients with NVM or MD. This reinforces the theory of vestibular hypersensitivity in VM. We suggest that a past history of carsickness may help in the diagnosis of VM, and especially in distinguishing VM from MD.

Purpose: Symptomatic TN accounts for up to 15% of all TN. Though there are many established "red flag" signs, it is still sometimes difficult to sift symptomatic from classic TN. We herein report two cases of isolated TN with normal neurologic examinations and then tissue proved as epidermoid cyst., Case 1: A 17-year-old girl presented with paroxysmal intense pain mixed dull background pain at right mandibular region for one month. The blink reflex demonstrated brainstem lesion and brain magnetic resonance imaging (MRI) revealed a huge lobulated tumor in right cerebellopontine angle (CPA) with obvious brainstem compression. Her right facial pain was nearly completely disappeared postoperatively., Case 2: The 48-year-old woman had chronic paroxysmal electric-like and burning pain in left V3 region for more than 5 years. Because of refractory pain, brain MRI was arranged and showed a non-enhancing cystic lesion at left CPA. Post operative complications occurred as left multiple lower cranial nerve palsies and Horner syndrome, and truncal ataxia. Her facial pain was completely free after 1 month follow up., Conclusion: In the first patient, teenage onset, abnormal trigeminal reflex, and early developing background pain struck us directly to symptomatic TN. In the second case, we suspected symptomatic TN with uncertainty before image study. TN could be the isolated initial symptom of CPA epidermoid cysts. In consideration about pretty high prevalence of symptomatic TN, physicians should be more alert and straightforward arrange neuroimage when facing TN patients with atypical presentation.

Purpose: Vestibular paroxysmia is defined as paroxysmal, brief, and carbamazepine-responsive vertigo. Although neurovascular cross-compression (NVCC) of the vestibulocochlear nerve is believed to be the cause of vestibular paroxysmia, the mechanism remains controversial. Herein, we describe the case of a man with NVCC who presented with paroxysmal vertigo associated with paroxysmal pulsatile tinnitus., Case Report: A 68-year-old man presented with paroxysmal vertigo for one month. Paroxysmal pulsatile tinnitus in the right ear occurred simultaneously with the vertigo. Magnetic resonance imaging demonstrated that the right anterior inferior cerebellar artery was compressing the right vestibulocochlear nerve. The vertigo and tinnitus completely disappeared within one week after treatment with carbamazepine., Conclusion: The pulsatile nature of the patient's tinnitus implied that the auditory nerve was being compressed by a pulsating artery and was found to consolidate the causal relationship between NVCC and vestibular paroxysmia.

Purpose: To improve and standardize stroke care, the establishment of primary stroke centers (PSCs) has been advised. Thrombolytic therapy has been proved to improve the outcome of acute ischemic stroke (AIS). We assessed the use of thrombolytic therapy before and after setting up a PSC at a community hospital., Methods: In November 2007, a PSC was established at our hospital. Following guidelines based on national recommendations, we administered intravenous tissue plasminogen activator (tPA) to patients who met the criteria. To study the effects of the establishment of the PSC on tPA treatment rates, we examined our database of stroke patients dating back to January 2004., Results: Before the establishment of the PSC, there have been 2,420 patients admitted to our hospital diagnosed with AIS. Only 1.2% of these patients were treated with intravenous tPA. Following the establishment of the PSC, 2.8% of 1151 AIS patients were treated with tPA. Time of patient arrival to patient treatment was also diminished., Conclusion: The establishment of the PSC significantly increases the usage of tPA treatment. Furthermore, response time to patient cases was also quicker. However, for maximum effectiveness, the public still needs to be made more aware of the risks of stroke and the importance of seeking medical care at the first signs of stroke.

Objective: To discuss the ethical challenge in thrombolytic therapy., Background: Thrombolytic therapy with recombinant tissue-type plasminogen activator (rt-Pa) has been found to be beneficial to the outcome of patients who had a stroke. However, the ethic issue that is related to intravenous rt-Pa infusion has not been discussed., Patients: Four patients with a middle cerebral artery (MCA) infarct arrived at the emergency department (ER) of our hospital within 3 hours of stroke onset. All of them violated the guidelines of thrombolytic therapy for patients. The families of three patients insisted on the thrombolytic therapy. Two patients received rt-Pa infusion and two did not., Results: Two patients who received rt-Pa infusion experienced hemorrhagic transformation. One died on the fifth day after stroke, and the other one had a poor outcome with a modified ranking scale (mRS) of 5. One of the two patients who did not receive rt-Pa infusion suffered from hemorrhagic transformation and died on the third day after stroke, and the other one had a poor outcome with mRS of 5., Conclusions: These 4 cases highlight the complexity of thrombolytic therapy in patients who violate the guidelines because the families insisted on thrombolytic therapy. No one is sure that the family's decision was the patient's wish. When a stroke patient violates the guidelines of thrombolytic therapy and the family of the patient insists on the thrombolytic therapy, a conversation between patients, patients' families and clinicians is necessary. Physician should tell patient and their families about the high risk of hemorrhagic transformation and mortality. If the family wants to make a decision, physician should request patient or patient's families to sign an against medical advice form and follow the patient's or their family's decision for the outcome.

Background and Purpose: Tissue plasminogen activator (tPA) is a standard therapy for acute ischemic stroke (AIS) but only limited data are noted in Taiwan. The purpose of this study was to assess the safety, feasibility, and efficacy of treatment in a community hospital setting., Methods: We retrospectively reviewed the medical records of all patients who had received intravenous tPA therapy from 1998 to 2007 in our hospital. We compared the characteristics, complications, and outcomes in our patients with those of patients in the National Institute of Neurological Disorders and Stroke (NINDS) trial., Results: A total of 43 patients were reviewed with a mean age of 63 years and a male predominance (64%). The median pretreatment National Institutes of Health Stroke Scale score was 18. In our patients, cardioembolism was the leading course of the strokes. The mean time from stroke onset to treatment was 134 minutes, and the mean door-to-computed tomography-time was 34 minutes while the mean door-to-needle time was 93 minutes. Within 36 hours symptomatic intracerebral hemorrhage occurred in two patients (4.7%). Four patients (9.3%) developed brain herniation with fatality. At follow-up, fourteen patients (33%) had a favorable outcome on the modified Rankin Scale (0-1). Patient outcome was not significantly different from that in the NINDS trial., Conclusion: Although the number of patients with AIS receiving tPA in this study was small, thrombolytic therapy can be performed safely and effectively by physicians in the community hospital setting.

Background/purpose: Silent infarcts (SIs) are commonly found in brain computed tomography (CT) or magnetic resonance imaging (MRI) of elderly subjects. However, the prevalence of this silent infarction (SI) and risk factors for this entity are not entirely known. This study was aimed to evaluate the prevalence of silent infarcts in brain CT and risk factors in patients admitted with first-ever ischemic stroke or transient ischemic attack (TIA)., Methods: From July 2003 to May 2005, a prospective study was performed for 446 patients admitted to our neurology service with a diagnosis of TIA or stroke. Two hundred and twenty-six patients did not have a history of stroke or TIA prior to the event. All patients received a brain CT on the day when they arrived at the hospital. Risk factors that are monitored included age, history of hypertension, diabetes mellitus, cardiovascular disease, stroke, smoking and alcohol use. Cholesterol and triglyceride levels were measured on the second day of admission., Results: The results showed that the frequency of SI among 226 patients with first-ever stroke or TIA was 20%. Most of the SIs were small and deep. Small-artery disease was more frequently observed in patients with silent infarction. Age, hypertension, diabetes mellitus, hypercholesterolemia, hypertriglyceridemia, alcohol habit, smoking and atrial fibrillation were not significantly different between patients with silent infarct and patients without silent infarct., Conclusions: The study shows small-artery disease is more frequent in patients with silent infarction. The clinical significance of silent infarct needs further study.

Aortic dissection, which typically manifests as sudden tearing or migratory pain, is a well-known medical emergency. However, in 5% of aortic dissection patients, there is no pain. In these patients, the diagnosis depends on the development of neurologic complications. After analyzing the initial symptoms of a series of patients with aortic dissection, we found 4/211 (1.9%) patients suffered from paraparesis. We suggested that the mid- or low thoracic cord be most vulnerable site during acute aortic dissection. This report highlighted the importance of considering the diagnosis of aortic dissection in a patient with a history of acute onset of transient or permanent neurological symptoms in the lower limbs. Whether paraparesis can be an indicator of the prognosis of aortic dissection requires further researches.