Dževdet Smajlović

Does the Volume and Localization of Intracerebral Hematoma Affect Short-Term Prognosis of Patients with Intracerebral Hemorrhage?

The aim of this study was to determine whether volume and localization of intracerebral hematoma affects the six-month prognosis of patients with intracerebral hemorrhage (ICH). Patients and Methods. The study included 75 patients with ICH of both sex and all age groups. ICH, based on CT scan findings, was divided in the following groups: lobar, subcortical, infratentorial, intraventricular haemorrhage and multiple hematomas. Volume of intracerebral hematoma was calculated according to formula V = 0.5 × a × b × c. Intracerebral hematomas, according to the volume, are divided in three groups (0–29 mL, 30–60 mL, and >60 mL). Results. The highest mortality rate was recorded in the group with multiple hematomas (41%), while the lowest in infratentorial (12.8%). The best six-month survival was in patients with a volume up to 29 mL, 30 of them (64%) survived. The highest mortality rate was recorded in patients with the hematoma volume >60 mL (85%). Kaplan-Meiers analysis showed that there was statistical significance between the size of the hematoma and the six-month survival (P < 0.0001). More than half of patients (61.1%) who survived 6 months after ICH were functionally independent (Rankin scale ≤2). Conclusion The volume of hematoma significantly affects six-month prognosis in patients with intracerebral hemorrhage, while localization does not.

Interarm skin temperature differences: manifestation of subclavian steal syndrome?

Dear Editor-in-Chief Federico, Subclavian steal syndrome (SSS) is a fascinating vascular phenomenon in which a steno-occlusive lesion of the proximal subclavian artery causes retrograde flow in the vertebral artery away from the brain stem, subsequently causing vertebrobasilar insufficiency [1]. Subclavian stenosis is a marker of atherosclerotic disease and presents an increased risk for cardiovascular and cerebrovascular events [2]. In the 1960s, Contorni recognized and described SSS using angiography in a patient with absent radial pulse [3]. We present unusual occurrences of an 80-year-old male Caucasian. He experienced ischemic stroke of the left frontoparietal region with contralateral hemiparesis, as a result of the arterial hypertension, diabetes, as well as active smoking for more than 55 years. Simultaneously, he developed what he described as Bcold, cold winter in the whole left arm,^ and the unusual sensation gradually worsened over a course of few days. With the exception of deregulation of blood sugar values, laboratory findings were normal. During the examination, he had the absence of ipsilateral radial pulse and discrepant brachial systolic arterial blood pressure (BP gradient), approximately 35 mmHg—grade 2 (each time out of five measurements) [4]. Moreover, symptoms and signs were provoked with vigorous exercise of the left arm (supination/pronation and making a fist) and physical maneuvers that compress the vertebral artery (like raising the left arm and rotation of the head towards opposite side). The pulses in lower extremities were intact. There was no history of armclaudication, arm-pain (at rest), syncope, light-headedness, hearing loss, fingers-cyanosis, or evident vascular bruits on the neck regions. Doppler sonography demonstrated characteristic continuous reversed flow in the left vertebral artery. Our patient met criteria for SSS. Due to tremendous and growing problem with uncommon sensation of coldness in the left arm, we came to an idea and decided to measure local skin temperature at symmetric positions of upper extremities. Our patient was lying supine in the bed, without a blanket, and at usual room temperature. We used three accurate digital thermometers for three repetitive measurements—from side to side and from proximal to distal regions. We placed atop of the thermometer: on the medial part of the supraclavicular region, deep in the axillary region, on the medial part of the cubital region (with flexion of the elbow), and on the thenar of the palmar region (with flexion of fingers to fist). We repeated three measurements under the same conditions, with a 5-min break between each. Surprisingly, interarm skin temperature (IST gradient) differences in supraclavicular, axillary, and cubital regions were lower on the left side (approximately 0.6/0.7/0.3 °C), while it was equal in palmar regions. There were no evidence of local skin lesions (ulcers, trophic changes, etc.) or visible local skin diseases. Practically, IST gradients have been identified on three out of four positions of measurements. According to the recent literature, BP gradient was related to severity of SSS. While only 1.4% of patients with a BP gradient of 20 to 30 mmHg were symptomatic, Labropoulos et al. reported that this percentage rose to 38.5% of patients with BP gradient ≥ 50 mmHg [5]. However, asymptomatic and atypical presentation of this unique entity represents a challenge for physicians who require a high index of suspicion [1]. In the case of our patient, we presume that prolonged atherosclerosis and hidden chronic ischemic process in the left arm may have had an unrecognized consequences on local skin temperature. We This paper has not been sent or accepted for publication in any other journal.

Cognitive syndromes after the first stroke

AimThe aim of this study is to determine impairments of certain cognitive functions in certain vascular cognitive syndromes and to identify predictors of dementia.Patients and methodsOne-year prospective study included 275 patients, who were hospitalized at the Department of Neurology Tuzla and therefore fulfilled certain criteria. Patients were divided into following subgroups of vascular cognitive impairment (VCI): dementia of strategic infarct (DSI), cortical dementia (CD), sub cortical dementia (SCD), hemorrhagic dementia (HD), and patients without dementia. Each of the patients underwent the clinical examination and scoring with appropriate measurement scales.ResultsSome of the types of VCI were verified in 190 (69%) patients, and the most common was SCD (58%). There was statistically significant connection between the level of intelligence and occurrence of VCI in patients after stroke (p < 0.001). We found significant connection between occurrence of dementia and impairment in narrative memory, numerical memory, visual perceptive, and visual constructive functions in patients with dementia compared with non-demented (p = 0.0001). The executive functions were statistically impaired in patients with CD (p = 0.004) and SCD (p < 0.001). Patients without dementia have significantly better quality of life than the demented ones (p < 0.0001). The algorithm “tree of decision” can help us in the prediction of dementia based on the impairment of certain cognitive functions.ConclusionVascular cognitive syndromes are common after stroke. Some of the cognitive functions are significantly impaired in patients with dementia. Impairment of the certain cognitive functions can help in predicting the onset of dementia. Patients without dementia have better quality of life.

THE EFFECT OF FATIGUE SYNDROME ON COGNITIVE FUNCTIONING AND QUALITY OF LIFE OF A PATIENT AFTER AN ISCHEMIC STROKE

Background: Fatigue is usually defined as a subjective lack of physical and/or mental energy necessary for doing everyday activities. Fatigue is a subjective condition, and there is not a valid definition of fatigue after a stroke at the moment. Aim: The analysis of frequency of fatigue syndrome in 200 patients after an ischemic stroke and its effect on cognitive functioning and quality of life after an ischemic stroke was conducted. The measuring instruments for the assessment of fatigue used were the Chalder Fatigue Scale, for cognitive functioning the Mini-Mental State Examination, and for the quality of life SF-36, scale for measuring quality of life. Neurological and neuropsychological testings of the participants were conducted three months after an ischemic stroke – first testing, six months after an ischemic stroke – second testing, and twelve months after an ischemic stroke – third testing. Results: Fatigue syndrome was noted in 68% of the patients three months after an ischemic stroke, in 71% in testing after six months, and 70% after twelve months. The mean values of MMSE score in the patients with and without fatigue syndrome was between 28 and 29 in all testings, which indicates that they had normal cognitive functioning. The significance of differences in the MMSE score in the patients with and without fatigue syndrome in the first, second and third testing was tested using HI-squared test and the results showed that there were no statistically significant differences (p>0.005). In comparison of quality of life between the patients with and without fatigue the results showed that the patients without fatigue syndrome had significantly better quality of life in comparison with the patients with fatigue syndrome in the field of mental and physical health (p< 0.0001). Conclusion: Fatigue syndrome after an ischemic stroke has a significant frequency (68-71%) and duration. Fatigue syndrome does not affect cognitive functioning of patients after an ischemic stroke but it leads to impaired quality of life of patients in all areas.

Neurobrucellosis and cerebral venous sinus thrombosis: a case report

Objectives: To present a case of co-occurrence of neurobrucellosis and cerebral venous sinus thrombosis. Methods: Case report. Clinical presentation: We presented 49-year-old Caucasian domicile female-farmer with a history of headache, weakness, and vomiting for a period of three months. Also, she had significant papilledema. We diagnosed rare co-morbidity of neurobrucellosis (confirmed after ELISA-test in serum samples and CSF analysis of pleocytosis/increase in protein/decrease in glucose level) in the setting of cerebral venous thrombosis developed in left sigmoid/left transverse sinus (confirmed after MRV of brain). Favorable outcome was achieved by applying protracted polymicrobial antibiotic therapy and heparin. Discussion: It may be challenging to diagnose neurobrucellosis, especially in patients with atypical presentation and abortive clinical forms. The co-morbidity of neurobrucellosis and cerebral venous sinus thrombosis is uncommon. However, it provides a possibility of brucella-colonization in cerebral venous sinuses as a potential hidden link between them. Conclusion: Patients with severe and persistent headache, as well as other neurological symptoms/signs should be considered for neurobrucellosis in endemic, but also in brucella non-endemic regions due to migrations. According to literature survey, this co-occurrence of neurobrucellosis and cerebral venous sinus thrombosis is third one reported from Europe.

Intravenous thrombolytic therapy for acute ischemic stroke in Tuzla Canton, Bosnia and Herzegovina.

It is well known that thrombolysis with intravenous recombinant tissue plasminogen activator (rt-PA) is the first evidence-based treatment for acute ischemic stroke. In the European Union (EU), rt-PA was approved in 2002 and has been used widely since then. Bosnia and Herzegovina is one of the few European countries not yet part of the EU, and approval for rt-PA in acute ischemic stroke was granted in 2007 under the same conditions as in other European countries. We presented our results with the use of intravenous thrombolytic therapy in patients with acute ischemic stroke in Tuzla Canton, Bosnia and Herzegovina. Between April 2008 and December 2011, intravenous rt-PA was administered to 72 patients with acute ischemic stroke, which represents 3·5% of patients with acute ischemic stroke admitted to the Department of Neurology Tuzla in that period (2067 patients). Baseline characteristics of the patients treated with thrombolytic therapy are provided in Table 1. Figure 1 illustrates the three-month outcome of our patients treated with thrombolytic therapy in comparison with the results of the neighboring countries: Sestre milosrdnice University Hospital Zagreb, Croatia (1) and Institute of Neurology Belgrade, Serbia (2). We wish to emphasize that these are only the results from our department, not at the national level. Bosnia and Herzegovina is one of the few countries in Europe that does not have an official National Stroke register, primarily because of the political situation. Therefore, our participation in multicenter studies is limited. With this article we want to demonstrate that we are working in line with the established protocols and show that our results are approximate to the results of other countries, despite the aforementioned shortcomings. These are small steps for world’s neurology but big ones for neurology in Bosnia and Herzegovina.

Short‐term outcome of intracerebral hemorrhage: a hospital‐based study in Tuzla, Bosnia and Herzegovina

Dear Editor, International Journal of Stroke readers will probably be surprised by the fact that Bosnia and Herzegovina is one of rare countries in Europe that does not have an official Stroke register, mainly because of a complex political system. Our country is divided in two entities of which one entity is separated in 10 cantons, besides Brčko District. Our clinic is located in Tuzla, the largest city of Tuzla Canton, that has 500 000 inhabitants. All patients with stroke in Tuzla region were hospitalized at our department. We did a few studies in domain of cerebrovascular diseases, but all the data were based on hospital records due to the aforementioned situation. Despite this situation, we are making efforts to keep up with the trends in domain of cerebrovascular diseases, and we managed to form a Stroke unit on our clinic and to start applying thrombolytic therapy for the last four-years. The main goal for this article is to show results in one of our studies about intracerebral hemorrhage, which is done in the Department of Neurology Tuzla, for the period June 1, 2007 to March 31, 2008. It was one of the first studies of this kind in our country and it contained analysis of clinical and neuroradiological characteristics of intracerebral hemorrhage (ICH) and its influence on short-term outcome. Based on 75 patients, we came up with following results: 40 patients (53·4%) were male, the mean age for all patients was 64·3 13·7 years, and men were older than women (P = 0·031). The disturbance of consciousness on admission significantly influenced the sixmonth outcome (P < 0·0001). Patients with multiple hematomas had higher mortality rate (41%); however, localization of hematomas did not have any significant influence on the six-month mortality. Surviving of patients highly depended of volume of hematomas (P < 0·0001). Less than half of patients (39%) who survived six-months after stroke were functionally depended (Rankin scale >2, Barthel Index <90). Predictors of poor six-month prognosis were brain edema (P = 0·002), intraventricural bleeding (P = 0·004), and Glasgow Coma Scale <8 (P < 0·0001) (Table 1). It can be concluded that there are certain clinical and neuroradiological predictors for short-term prognosis in intracerebral hemorrhage. Intracerebral hemorrhage has high mortality rate (52%), and most of the survivors are functionally independent six-months after stroke (61%). Our results do not differ from studies with similar design (1–3). Perhaps, we could provide better results, but due to the aforementioned shortcomings, we are limited to participation in larger multicenter studies.

Stroke and disorders of consciousness.

Objectives. To determine the severity of stroke and mortality in relation to the type of disturbance of consciousness and outcome of patients with disorders of consciousness. Patients and Methods. We retrospectively analyzed 201 patients. Assessment of disorders of consciousness is performed by Glasgow Coma Scale (Teasdale and Jennet, 1974) and the Diagnostic and Statistical Manual of Mental Disorders (Anonymous, 2000). The severity of stroke was determined by National Institutes of Health Stroke Scale (Lyden et al., 2011). Results. Fifty-four patients had disorders of consciousness (26.9%). Patients with disorders of consciousness on admission (P < 0.001) and discharge (P = 0.003) had a more severe stroke than patients without disturbances of consciousness. Mortality was significantly higher in patients with disorders of consciousness (P = 0.0001), and there was no difference in mortality in relation to the type of disturbance of consciousness. There is no statistically significant effect of specific predictors of survival in patients with disorders of consciousness. Conclusion. Patients with disorders of consciousness have a more severe stroke and higher mortality. There is no difference in mortality and severity of stroke between patients with quantitative and qualitative disorders of consciousness. There is no statistically significant effect of specific predictors of survival in patients with disorders of consciousness.

25 Alternations of level of consciousness in acute stroke

hospitalization. Ten patients could function independently and perform daily activities, with minor or more serious motor problems, while one patient needed help during movement. Upon release from the hospital, all patients took routine laboratory tests, including among other things liver enzyme values and creatine kinase. All tests showed normal values, and thus there was no need to terminate the Atorvastatin(Atorvox) therapy. Conclusions: Analysis of recorded cases during the urgent ICV treatment, regardless of the etiology (ischemic or hemorrhagic) showed that early Atorvastatin administration, practically immediately upon insult, in a maximum one-off daily dose of 80 mg is safe from the aspect of increase in liver enzyme values. Thus, there were no cases of hepatotoxicity related to myolysis cases recorded in literature, and creatine kinase was observed. The observed group was relatively small and the observance period too short, and thus the total assumed effect, given the farmacological effects, could not be fully evaluated.