Ivan Marjanovic

Clinical and epidemiological features of Guillain‐Barré syndrome in the Western Balkans

The aim of this study was to define features of Guillain‐Barré syndrome in a large cohort of patients from three Western Balkans countries. Data from adult Guillain‐Barré syndrome (GBS) cases from 2009 to 2013 were retrospectively obtained from all tertiary health care centers. During the 5‐year period, 327 new cases of GBS were identified with a male to female ratio of 1.7 : 1. The most common GBS variants were demyelinating (65%) and axonal (12%). At nadir 45% of patients were chair‐bound, confined to bed, or required assisted ventilation, while 5% died. The crude incidence of GBS in Serbia and Montenegro was 0.93 per 100,000 population, and age‐adjusted incidence according to the world standard population was 0.86 per 100,000. Incidence was particularly high in 50‐ to 80‐year‐old men. Statistically significant seasonal variations of GBS were not observed. This study of patients with GBS in the Western Balkans allows us to prepare the health system better and to improve the management of patients. This study also opens opportunities for international collaboration and for taking part in the multinational studies on GBS.

Dependent and paranoid personality patterns in myotonic dystrophy type 1

To analyze frequency and type of personality pattern in patients with myotonic dystrophy type 1 (DM1), to correlate these findings with clinical data, and to assess its possible influence on quality of life (QoL).

An aortoduodenal fistula as a complication of immunoglobulin G4-related disease.

Most primary aortoduodenal fistulas occur in the presence of an aortic aneurysm, which can be part of immunoglobulin G4 (IgG4)-related sclerosing disease. We present a case who underwent endovascular grafting of an aortoduodenal fistula associated with a high serum IgG4 level. A 56-year-old male underwent urgent endovascular reconstruction of an aortoduodenal fistula. The patient received antibiotics and other supportive therapy, and the postoperative course was uneventful, however, elevated levels of serum IgG, IgG4 and C-reactive protein were noted, which normalized after the introduction of steroid therapy. Control computed tomography angiography showed no endoleaks. The primary aortoduodenal fistula may have been associated with IgG4-related sclerosing disease as a possible complication of IgG4-related inflammatory aortic aneurysm. Endovascular grafting of a primary aortoduodenal fistula is an effective and minimally invasive alternative to standard surgical repair.

Is nail fold capillaroscopy useful in normotensive and primary open angle glaucoma? A pilot study.

Purpose: Vascular dysregulation is deemed a significant risk factor in glaucoma occurrence and progression. Capillaroscopy of the blood vessels on the finger nail-fold is a method that can provide information regarding the state of the vascular system at the capillary level. The aim of this pilot study was to determine whether there are significant differences in the morphological characteristics of the peripheral blood vessels in normotensive glaucoma and primary open angle glaucoma. Matherials and Methods: An ophthalmological and capillaroscopic examination was conducted on 30 normotensive glaucoma patients and 30 primary open angle glaucoma patients. The capillaroscopic characteristics described were as follows: capillary row density, capillary diameter, number of spirally formed capillaries, permeability of the loop, and loop resistance. Results: Statistically, significantly more intensively spiraled capillaries were found in normotensive glaucoma patients (χ2 test, p < 0.05). Conclusions: Results confirm the thesis that vascular factors play a significant role in the pathogenesis of the glaucoma, especially in cases where the level of intraocular pressure cannot be deemed responsible for the present damage of the optical nerve. Despite the newer, technologically more developed methods for diagnostics and monitoring glaucoma, it is often not easy to establish the right diagnosis and determine further the course of the illness, since the role the intraocular pressure (IOP) plays compared to the role of vascular factors is unknown; hence, capillaroscopy as a complementary diagnostic procedure can be of help.

Extrathymic malignancies in a defined cohort of patients with myasthenia gravis

INTRODUCTION Myasthenia gravis (MG) may be associated with extrathymic malignancies, especially in patients with thymoma. AIM To determine the frequency and type of extrathymic malignancies in MG patients from the Belgrade area, and to identify potential risk factors associated with tumors. PATIENTS AND METHOD The study comprised 390 patients with MG. Different sociodemographic and clinical variables potentially associated with extrathymic neoplasms were analyzed. RESULTS Extrathymic malignancies were present in 42 (10.8%) MG patients - 22 (52.4%) males and 20 (47.6%) females. The most frequently detected were breast (40%) and lung (40%) neoplasms. The tumors appeared with similar frequency before (45.2%) and after the onset of MG (42.9%). Significant predictors for the development of extrathymic malignancies were current age (p = 0.001) and immunoglobulin (IVIg) therapy (p = 0.021). On the other hand, current age (p=0.001), longer MG duration (p = 0.001) and generalized form of MG (p = 0.002) were significant predictors of malignancy occurring after the MG onset. CONCLUSION Our study revealed that older MG patients, as well as those with longer duration of the disease, and those who received IVIg therapy had a higher oncogenic risk for the development of extrathymic malignancies.

The impact of intraocular pressure reduction on retrobulbar hemodynamic parameters in patients with open-angle glaucoma

Purpose To assess the retrobulbar hemodynamic parameters in the ophthalmic artery (OA), central retinal artery (CRA), and short posterior ciliary arteries (PCA) after decreasing elevated intraocular pressure (IOP) in patients with open-angle glaucoma (OAG) by using color Doppler imaging. Methods A total of 46 eyes from 46 patients with OAG, with elevated IOP, were consecutively included in this prospective study. Peak-systolic velocity, end-diastolic velocity, and Pourcelot resistivity index were assessed in the OA, CRA, and PCA. The IOP was measured with Goldmann applanation tonometer (GAT) and the dynamic contour tonometer (DCT), 3 times respectively. Ocular pulse amplitude (OPA) appeared during the DCT measurement. Results After decreasing the elevated IOP, measured with both GAT and DCT, the retrobulbar parameters showed no differences as compared with baseline measurements. After Bonferroni correction (p≤0.0042, alpha/12), statistical significance appeared in retrobulbar hemodynamics only in DCT (29.3±6.4 vs 15.5±4.2 mmHg), GAT (33.0±8.3 vs 15.8±7.0 mmHg), and OPA measurements (4.1±1.3 vs 2.7±1.4 mmHg), in comparison to baseline. There was no correlation between the changes in IOP measured with either DCT or GAT and the changes in the retrobulbar hemodynamic parameters (p>0.05 for all). Conclusions The results of our study suggested a lack of correlation between the changes in IOP, measured with either DCT or GAT, and the changes in the retrobulbar hemodynamic parameters. The results of our study might suggest that the blood flow disturbances found in glaucoma patients are independent of the IOP.

Early inflammatory response following elective abdominal aortic aneurysm repair: A comparison between endovascular procedure and conventional, open surgery

BACKGROUND/AIM Abdominal aorta aneurysm (AAA) represents a pathological enlargment of infrarenal portion of aorta for over 50% of its lumen. The only treatment of AAA is a surgical reconstruction of the affected segment. Until the late XX century, surgical reconstruction implied explicit, open repair (OR) of AAA, which was accompanied by a significant morbidity and mortality of the treated patients. Development of endovascular repair of (EVAR) AAA, especially in the last decade, offered another possibility of surgical reconstruction of AAA. The preliminary results of world studies show that complications of such a procedure, as well as morbidity and mortality of patients, are significantly lower than with OR of AAA. The aim of this paper was to present results of comparative clinical prospective study of early inflammatory response after reconstruction of AAA be tween endovascular and open, conventional surgical technique. METHODS A comparative clinical prospective study included 39 patients, electively operated on for AAA within the period of December 2008 - February 2010, divided into two groups. The group I counted 21 (54%) of the patients, 58-87 years old (mean 74.3 years), who had been submited to EVAR by the use of excluder stent graft. The group II consisted of 18 (46%) of the patients, 49-82 (mean 66.8) years, operated on using OR technique. All of the treated patients in both groups had AAA larger than 50 mm. The study did not include patients who have been treated as urgent cases, due to the rupture or with simptomatic AAA. Clinical, biochemical and inflamatory parameters in early postoperative period were analyzed, in direct postoperative course (number of leucocytes, thrombocytes, serum circulating levels of cytokine--interleukine (IL)-2, IL-4, IL-6 and IL-10). Parameters were monitored on the zero, first, second, third and seventh postoperative days. The study was approved by the Ethics Commitee of the Military Medical Academy. RESULTS The study showed a statistically significantly shorter time of treatment in the EVAR group (average 90 min) compared to the OR group (average 136 min). Also, there was a statistically significantly less blood loss in the patients operated on by the use of EVAR surgery (average 60 mL) as compared to the patients treated with OR techinique (average 495 mL), as well as a shorter postoperative hospitalization of patients in the EVAR group (average 4 days) compared to the OR group (average 8 days). The OR group was detected with a statistically significant increase of leucocytes and statistically significant fall of the number of thrombocytes in comparison with the EVAR group in all the investigated terms. A significant concentration rise of IL-2 in the OR group and concentration rise of IL-6 in the EVAR group was shown 24 hours after the procedure, whereas on the second postoperative day there was detected a significant fall of IL-6 in the EVAR group. IL-4 concentration in the OR group was significantly higher as of the third postoperative day in comparison to the EVAR group. There was no significant difference in IL-10 concentration between the groups. CONCLUSION The EVAR techinique is a safer and less invasive and less traumatic procedure for patients than the OR of AAA. Following the EVAR, there are less inflammatory reactions in the early postoperative period as compared to the OR and therefore less possibility of the development of systemic inflammatory respons syndrome in patients treated.

Proton magnetic resonance spectroscopy of the intrinsic tongue muscles in patients with myasthenia gravis with different autoantibodies

OBJECTIVE To assess lipid composition of the intrinsic tongue muscles in patients with myasthenia gravis (MG). METHODS This study included 15 MG patients with antibodies against muscle-specific kinase (MuSK), 15 matched MG patients with antibodies against acetylcholine receptor (AChR) and 15 matched healthy subjects. Middle posterior region of the tongue was analyzed by single voxel point-resolved proton magnetic resonance spectroscopy (MRS) using 1.5T MRI scanner. RESULTS MRS obtained from subject with AChR MG showed a broad resonance arising from methylene groups of lipids (PMN) with no observable shoulder attributed to methyl groups (PML). Full-width at half maximum (FWHM) of PMN+PML peak showed higher value in patients with AChR MG in comparison to healthy subjects and MuSK MG patients (p<0.05). In patients with MuSK MG, the shape and FWHM of PMN+PML peak was similar as in healthy subjects (p>0.05), with tendency toward increased ratio between PMN and resonance from vinyl protons of lipids (PV). In both AChR and MuSK MG, total creatine resonance (creatine+phosphocreatine, CP) was almost absent with significant increase of PMN/CP ratio in comparison to healthy subjects (p<0.05). CONCLUSION MRS is useful in revealing muscle lipid composition in MG. In patients with AChR MG, MRS showed increased lipid content in the tongue muscles due to the lipid migration from intra- to extramyocellular space. Finding in patients with MuSK MG might reflect intramyocellular lipid deposition in the tongue. CP decrease in tongue muscles indicated impairment of oxidative metabolism in both AChR MG and MuSK MG.

Endovascular repair of ruptured abdominal aortic aneurysm

Introduction. Rupture of an abdominal aortic aneurysm (AAA) is a potentially lethal state. Only half of patients with ruptured AAA reach the hospital alive. The alternative for open reconstruction of this condition is endovascular repair (EVAR). We presented a successful endovascular reapir of ruptured AAA in a patient with a number of comorbidities. Case report. A 60-year-old man was admitted to our institution due to diffuse abdominal pain with flatulence and belching. Initial abdominal ultrasonography showed an AAA that was confirmed on multislice computed tomography scan angiography which revealed a large retroperitoneal haematoma. Because of patient’s comorbidites (previous surgery of laryngeal carcinoma and one-third laryngeal stenosis, arterial hypertension and cardiomyopathy with left ventricle ejection fraction of 30%, stenosis of the right internal carotid artery of 80%) it was decided that endovascular repair of ruptured AAA in local anaesthesia and analgosedation would be treatment of choice. Endovascular grafting was achieved with aorto-bi-iliac bifurcated excluder endoprosthesis with complete exclusion of the aneurysmal sac, without further enlargment of haemathoma and no contrast leakage. The postoperative course of the patient was eventless, without complications. On recall examination 3 months after, the state of the patient was well. Conclusion. The alternative for open reconstruction of ruptured AAA in haemodynamically stable patients with suitable anatomy and comorbidities could be emergency EVAR in local anesthesia. This technique could provide greater chances for survival with lower intraoperative and postoperative morbidity and mortality, as shown in the presented patient.

Successful intravenous thrombolysis in a stroke patient with hemiballism.

IntroductionHemiballism (HB) is a relatively rare hyperkinetic disorder commonly caused by an acute stroke. Such patients usually receive symptomatic therapy with limited effect. We report the case of an acute stroke patient with HB who was successfully treated with intravenous recombinant tissue plasminogen activator (rtPA). Case ReportA 67-year-old man with a history of hypertension and ischemic coronary heart disease presented in the emergency room 85 minutes after sudden onset of involuntary coarse flinging movements of the left arm and leg. Neurological investigation revealed oromandibular dyskinesia; left blepharospasm; dyskinetic movements of the head and neck; dysarthria; and forceful, jerky, irregular, flinging, large-amplitude involuntary movements involving his left arm and left leg. Initial brain computed tomography showed only mild confluent periventricular hypodensities in the vicinity of the frontal horns. The calculated National Institutes of Health Stroke Scale score was 1, for dysarthria. The sudden onset of HB, however, suggested an acute stroke and we decided to treat the patient with intravenous rtPA. Thrombolytic therapy with rtPA began 200 minutes after symptom onset, and after the patients increased arterial blood pressure was resolved. Follow-up examination performed 12 hours after therapy revealed only mild dysarthria; mild ataxia of the left arm, and ataxic gait. Delayed brain computed tomography did not indicate recent ischemia, although a fluid attenuated inversion recovery magnetic resonance imaging sequence revealed high signal intensity lesions in the vicinity of the right putamen and left cerebellar hemisphere. After 1 month, a follow-up examination revealed only mild dysarthria and mild ataxia of the left arm. ConclusionsAcute stroke patients with low National Institutes of Health Stroke Scale score, including patients with HB, should be considered as candidates for thrombolytic treatment.