The trigeminovascular system in humans: pathophysiologic implications for primary headache syndromes of the neural influences on the cerebral circulation.
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Primary headache syndromes, such as cluster headache and migraine, are widely described as vascular headaches, although considerable clinical evidence suggests that both are primarily driven from the brain. The shared anatomical and physiologic substrate for both of these clinical problems is the neural innervation of the cranial circulation. Functional imaging with positron emission tomography has shed light on the genesis of both syndromes, documenting activation in the midbrain and pons in migraine and in the hypothalamic gray in cluster headache. These areas are involved in the pain process in a permissive or triggering manner rather than as a response to first-division nociceptive pain impulses. In a positron emission tomography study in cluster headache, however, activation in the region of the major basal arteries was observed. This is likely to result from vasodilation of these vessels during the acute pain attack as opposed to the rest state in cluster headache, and represents the first convincing activation of neural vasodilator mechanisms in humans. The observation of vasodilation was also made in an experimental trigeminal pain study, which concluded that the observed dilation of these vessels in trigeminal pain is not inherent to a specific headache syndrome, but rather is a feature of the trigeminal neural innervation of the cranial circulation. Clinical and animal data suggest that the observed vasodilation is, in part, an effect of a trigeminoparasympathetic reflex. The data presented here review these developments in the physiology of the trigeminovascular system, which demand renewed consideration of the neural influences at work in many primary headaches and, thus, further consideration of the physiology of the neural innervation of the cranial circulation. We take the view that the known physiologic and pathophysiologic mechanisms of the systems involved dictate that these disorders should be collectively regarded as neurovascular headaches to emphasize the interaction between nerves and vessels, which is the underlying characteristic of these syndromes. Moreover, the syndromes can be understood only by a detailed study of the cerebrovascular physiologic mechanisms that underpin their expression. (+info)
Cortical lesions in multiple sclerosis.
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Although previous studies have shown that the lesions of multiple sclerosis may involve the cerebral cortex, there is little published research on the prevalence and distribution of such lesions. Using neuropathological techniques and MRI, a series of studies has been undertaken in order to assess this, in particular to identify their relationship to cortical veins. A serial MRI study showed that the use of gadolinium proffered an increase in cortical lesion detection of 140% and showed that 26% of active lesions arose within or adjacent to the cortex. In a post-mortem study, MRI under-reported lesions subsequently analysed neuropathologically, particularly those arising within the cortex. In a further 12 cases examined, 478 cortical lesions were identified, of which 372 also involved the subcortical white matter. Seven different lesion types were identified; the majority arose within the territory of the principal cortical veins, whilst the remaining quarter arose within the territory of the small branch or superficial veins. Small cortical lesions are common in multiple sclerosis and are under-reported by MRI. Investigation of the cortical venous supply shows how such lesions may arise, and why the majority also involve the underlying white matter. (+info)
Nitric oxide is the predominant mediator for neurogenic vasodilation in porcine pial veins.
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The innervation pattern and the vasomotor response of the potential transmitters in the porcine pial veins were investigated morphologically and pharmacologically. The porcine pial veins were more densely innervated by vasoactive intestinal polypeptide (VIP)- and neuropeptide Y-immunoreactive (I) fibers than were calcitonin gene-related peptide (CGRP)-I, choline acetyltransferase-I, Substance P (SP)-I, and NADPH diaphorase fibers. Serotonin (5-HT)-I fibers, which were not detected in normal control pial veins, were observed in isolated pial veins after incubation with 5-HT (1 microM). 5-HT-I fibers, however, were not observed when incubation with 5-HT was performed in the presence of guanethidine (1 microM), suggesting that 5-HT was taken up into the sympathetic nerves. In vitro tissue bath studies demonstrated that porcine pial veins in the presence of active muscle tone relaxed on applications of exogenous 5-HT, CGRP, SP, VIP, and sodium nitroprusside, whereas exogenous norepinephrine and neuropeptide Y induced only constrictions. Transmural nerve stimulation (TNS) did not elicit any response in pial veins in the absence of active muscle tone. However, in the presence of active muscle tone, pial veins relaxed exclusively on TNS. This tetrodotoxin-sensitive relaxation was not affected by receptor antagonists for VIP, CGRP, 5-HT, or SP but was blocked by L-glutamine (1 mM) and abolished by Nomega-nitro-L-arginine (10 microM) and Nomega-nitro-L-arginine methyl ester (10 microM). The inhibition by L-glutamine, Nomega-nitro-L-arginine, and Nomega-nitro-L-arginine methyl ester was reversed by L-arginine and L-citrulline but not by their D-enantiomers. These results demonstrate that the vasomotor effect of all potential transmitters except 5-HT in the pial veins examined resembles that in cerebral arteries. Although porcine pial veins receive vasodilator and constrictor nerves, a lack of constriction on TNS suggests that the dilator nerves that release nitric oxide may play a predominant role in regulating porcine pial venous tone. (+info)
Cerebral veins: comparative study of CT venography with intraarterial digital subtraction angiography.
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BACKGROUND AND PURPOSE: Our objective was to compare the reliability of CT venography with intraarterial digital subtraction angiography (DSA) in imaging cerebral venous anatomy and pathology. METHODS: In 25 consecutive patients, 426 venous structures were determined as present, partially present, or absent by three observers evaluating CT multiplanar reformatted (MPR) and maximum intensity projection (MIP) images. These results were compared with the results from intraarterial DSA and, in a second step, with the results of an intraobserver consensus. In addition, pathologic conditions were described. RESULTS: Using DSA as the standard of reference, MPR images had an overall sensitivity of 95% (specificity, 19%) and MIP images a sensitivity of 80% (specificity, 44%) in depicting the cerebral venous anatomy. On the basis of an intraobserver consensus including DSA, MPR, and MIP images (415 vessels present), the sensitivity/specificity was 95%/91% for MPR, 90%/100% for DSA, and 79%/91% for MIP images. MPR images were superior to DSA images in showing the cavernous sinus, the inferior sagittal sinus, and the basal vein of Rosenthal. Venous occlusive diseases were correctly recognized on both MPR and MIP images. Only DSA images provided reliable information of invasion of a sinus by an adjacent meningioma. CONCLUSION: CT venography proved to be a reliable method to depict the cerebral venous structures. MPR images were superior to MIP images. (+info)
Cerebellar infarct caused by spontaneous thrombosis of a developmental venous anomaly of the posterior fossa.
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Spontaneous thrombosis of a posterior fossa developmental venous anomaly (DVA) caused a nonhemorrhagic cerebellar infarct in a 31-year-old man who also harbored a midbrain cavernous angioma. DVA thrombosis was well depicted on CT and MR studies and was proved at angiography by the demonstration of an endoluminal clot. (+info)
Frontal bone windows for transcranial color-coded duplex sonography.
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BACKGROUND AND PURPOSE: The use of the conventional temporal bone window for transcranial color-coded duplex sonography (TCCS) often results in difficulties in obtaining angle-corrected flow velocity measurements of the A2 segment of the anterior cerebral artery, the posterior communicating artery, and the midline venous vasculature because of the unfavorable insonation angle. The same applies to B-mode imaging of the frontal parenchyma. However, transorbital TCCS raises problems with the insonation of the orbital lens. To overcome these drawbacks, we studied the feasibility of frontal bone windows for TCCS examinations. METHODS: In 75 healthy volunteers (mean age, 45.3+/-17.0 years; age range, 17 to 77 years), the circle of Willis and the venous midline vasculature were insonated through a lateral and paramedian frontal bone window. Insonation quality of parenchymal structures (B-mode) was graded on a 3-point scale depending on the visibility of typical parenchymal landmarks. In a similar manner, the quality of the color-/Doppler-mode imaging of the arteries of the circle of Willis and the internal cerebral veins was assessed. In 15 patients (mean age, 62.7+/-13.7 years; age range, 33 to 83 years), the color-/Doppler-mode imaging quality of the intracranial vessels before and after application of an ultrasound contrast-enhancing agent was compared. RESULTS: B-mode insonation quality was optimal to fair in 73.3% of cases using the lateral and in 52.0% of cases using the paramedian frontal bone window, with defined parenchymal structures used as reference. Insonation quality decreased in those older than 60 years. In those younger than 60 years, angle-corrected flow velocity measurements of the A2 segment of the anterior cerebral artery and the internal cerebral vein were possible in 73.6% and 60.0%, respectively. Contrast enhancement resulted in a highly significant improvement in the imaging quality of the intracranial vessels. CONCLUSIONS: The transfrontal bone windows offer new possibilities for TCCS examinations, although the insonation quality is inferior to the conventional temporal bone window in terms of failure of an acoustic window. This can be compensated for by application of an ultrasound contrast-enhancing agent. (+info)
Color Doppler study of the venous circulation in the fetal brain and hemodynamic study of the cerebral transverse sinus.
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OBJECTIVES: To describe the venous circulation in the fetal brain; to describe the normal blood flow velocity waveform in the transverse sinus and to establish normal reference ranges for the second half of gestation. POPULATION: A total of 126 pregnant women with uncomplicated pregnancies at 20-42 weeks of gestation. METHODS: A combination of color-coded Doppler and two-dimensional real-time ultrasound was used to identify the main venous systems in the fetal brain. Blood flow velocity waveforms of the transverse sinus were obtained from a transverse plane of the head at the level of the cerebellum. RESULTS: A waveform could be obtained in the cerebral transverse sinus in 98% of the cases. The waveform obtained was triphasic with a forward systolic component, a forward early diastolic component and a lower forward component in late diastole. Reverse flow during atrial contraction was seen before 28 weeks and the diastolic flow increased with gestation thereafter. Pulsatility and resistance indices decreased and flow velocities increased in the transverse sinus throughout gestation. CONCLUSION: The venous circulation of the fetal brain can be identified by color Doppler. The gestational age-related decrease in resistance and increase in flow velocities suggest that hemodynamic studies of the cerebral transverse sinus might have clinical implications in studying compromised fetuses. (+info)
Successful radiosurgical treatment of arteriovenous malformation accompanied by venous malformation.
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We present a patient with a rare cerebrovascular malformation consisting of a typical arteriovenous malformation (AVM) with a nidus and a venous malformation (VM) in a single lesion. The AVM component was successfully obliterated by radiosurgery, whereas the VM was completely preserved. Radiosurgery can be an effective treatment technique for treating this type of malformation because it allows targeted obliteration of the AVM yet carries a low risk of damaging the venous drainage toward and away from the VM. (+info)