Ultrasonography of occipital arteries to diagnose giant cell arteritis: a case series and literature review

Clin Rheumatol. 2017 Dec 12. doi: 10.1007/s10067-017-3946-5. [Epub ahead of print]

We describe four cases of giant cell arteritis (GCA) that presented with occipital headache in the last 6 months. Typical ultrasound features of GCA were found in the occipital arteries which helped to confirm the diagnosis. One patient had already suffered significant visual loss by the time the diagnosis was made, reflecting the similarity in prognosis to the more typical GCA patients. These cases prompted a review of the literature to evaluate the evidence regarding the use of occipital artery ultrasonography in the investigation of GCA. We searched PubMed, Google Scholar and Web of Science and identified 17 papers but only four of these were relevant studies. The studies available show that typical features of GCA can be detected in the occipital arteries using ultrasonography. They also suggest that ultrasonography can detect changes in the occipital arteries when temporal arteries are not involved. However, occipital artery abnormalities were less common than temporal artery abnormalities in GCA. We advocate maintaining a high index of suspicion for GCA in patients presenting with atypical features, such as occipital headache. Ultrasonography has a vital role to play in the diagnosis of these patients. We recommend priority imaging of the affected area to facilitate prompt and accurate diagnosis of GCA, especially when atypical vessels are involved.

UHCW Research: Pinnell J, Tiivas C, Perkins P, Blake T, Saravana S and Dubey S.

PO179 Aggressive disseminated intracranial anaplastic astrocytoma

Association of British Neurologists (ABN) Annual Meeting 20172,3–5th May 2017 ACC, Liverpool

A 21-year-old male immigrant from Afghanistan presented with seizures 2 years previously. MRI brain was suggestive of a possible low-grade glioma affecting the right temporal lobe. After 2 years, he re-presented with symptoms of headache, intermittent pyrexia, raised intracranial pressure (opening pressure of >42 cm/H2O) requiring ventriculoperitoneal shunt to preserve his vision. MRI head revealed slight progression in appearance within the right medial temporal lobe and extension into the right cerebral peduncle with enhancement of the basal meninges as well as 7th and 8th nerve complexes. CSF consistently showed two-digit lymphocytes, with raised protein and moderately reduced glucose ratio. Large CSF samples for cytology and flow-cytometry, Acid-Fast-Bacilli, and IgG subtypes remained negative. He had lymphopaenia. CT body/PET scans revealed no lymphadenopathy. Originally, tuberculosis was considered and quadruple anti-tuberculosis therapy was given along with oral Prednisolone. His first negative tuberculosis culture after 6 weeks coincided with increasing widespread leptomeningeal spread into the intradural spinal cord. Brain biopsy from the basal leptomeninges and temporal lobe confirmed anaplastic astrocytoma.

UHCW Research: Akram A Hosseini, Fizzah Ali and Holger Allroggen

Galcanezumab for the prophylaxis of episodic and chronic migraine

Galcanezumab is being developed as one of a class of specific anti-migraine preventative drugs. By stopping a very specific protein in the brain and nervous system, galcanezumab reduces migraine attacks. Additionally as it is given once-a-month as treatment, it avoids the need to take numerous pills per day. If marketed, galcanezumab may be more preferable to current treatment options for episodic migraine and chronic migraine prevention.

From the NIHR Innovation Observatory

Fremanezumab for chronic and episodic migraine

Fremanezumab is a new medicine under development for preventative treatment of chronic and episodic migraine. It acts by targeting a very specific type of protein called the human calcitonin gene-related peptide (CGRP) which is a well-known to be involved in migraine. Therefore, if licensed it will offer a potential new treatment option for patients with migraine.

From the NIHR Innovation Observatory

Latest Pharmacological Technology Briefings - March 2017

NIHR Horizon Scanning Research and Intelligence Centre's latest batch of briefings on pharmacological technologies in development is now available:

• SQ HDM SLIT-tablet for house dust mite allergic asthma
• Pembrolizumab (Keytruda) for locally advanced or metastatic urothelial carcinoma in adults who are not eligible for cisplatin-containing chemotherapy – first line
• Pembrolizumab (Keytruda) for endometrial carcinoma – second line
• Ipilimumab (Yervoy) for unresectable malignant melanoma in paediatric patients
•  Inotersen (Ionis TTRRx) for hereditary transthyretin amyloidosis with polyneuropathy (hATTR-PN) – first line
• Galcanezumab for prevention of chronic cluster headache 
• Dupilumab for persistent asthma – add on therapy 
• DNX-2401 for recurrent glioblastoma – in combination with pembrolizumab 
• Cefiderocol for severe gram-negative infections 
• Cannabidiol (Epidiolex) for Dravet syndrome – second and subsequent line 
• Cabozantinib (Cabometyx) for advanced or metastatic renal cell carcinoma – first line 
• Atezolizumab (Tecentriq) with gemcitabine and carboplatin for advanced bladder cancer 
• Atezolizumab (Tecentriq) in combination with carboplatin and paclitaxel, alone or in combination with bevacizumab, in patients with metastatic non-squamous non-small cell lung cancer – first line 
• ATA129 for Epstein-Barr virus-associated post-transplant lymphoproliferative disorder

Acupuncture shows promise for preventing episodic migraines

Acupuncture was about as effective as long term medication in reducing the number of migraines. There were fewer adverse events amongst people receiving acupuncture (16-17%) compared to drug treatment (34%).

Migraines affect around one in seven people in the UK. Their unpleasant symptoms last between four and 72 hours and can impact on people’s ability to do everyday tasks, such as going to work.

This systematic review looked at acupuncture delivered at least once a week for up to six sessions, similar to the NICE recommendation of up to ten sessions over five to eight - weeks.

From NIHR Dissemination Centre

“Triptans” can relieve migraines in children and adolescents

Triptans, a migraine medication, relieve migraine headache completely within two hours compared toplacebo. Ibuprofen was also effective but less well studied. This review was also reassuring in that any side effects of treatment were mild.

Most evidence identified in this Cochrane review was for sumatriptan, a commonly prescribed treatment for adults, compared to placebo or dummy pills. A few studies examined other triptans or other painkillers, such as ibuprofen or paracetamol against placebo in children and adults.

The findings support current guideline recommendations to prescribe nasal triptans for migraine in adolescents. Only nasal preparations are currently licensed for adolescents, whereas oral administration and use for children under 12 years, is an ‘off-label’ use. There were some mild adverse effects in the triptan groups that highlight the need for an informed discussion between clinicians and parents or patients and monitoring in this group.

From the NIHR Dissemination Centre

Paracetamol is a weak painkiller for regular tension headaches

Paracetamol is only slightly more effective than dummy tablets (placebo) at relieving pain in people who experience regular tension-type headaches.

A Cochrane review found that 24 out of 100 people who took paracetamol for regular tension-type headaches were pain free at two hours, compared with 19 out of 100 who took an inactive placebo.

There was no difference in risk of side effects between paracetamol and placebo.

From the NIHR Dissemination Centre