József Kollár

Acetazolamide as a vasodilatory stimulus in cerebrovascular diseases and in conditions affecting the cerebral vasculature

Pathologic processes affecting the brain vessels may damage cerebral vasodilatory capacity. Early detection of cerebral dysfunction plays an important role in the prevention of cerebrovascular diseases. In recent decades acetazolamide (AZ) has frequently been used for this purpose. In the present work the mechanism of action and the previous studies are reviewed. The authors conclude that AZ tests are useful in cerebrovascular research. Further investigations are recommended to prove how impaired reserve capacity and reactivity influence the stroke risk in patients and whether these tests may indicate therapeutic interventions.

MRI findings in central nervous system systemic lupus erythematosus are associated with immunoserological parameters and hypertension.

Abstract.Involvement of the brain is one of the most important complications of systemic lupus erythematosus (SLE).To investigate the correlation between abnormal cranial MRI findings and age, duration of SLE, neuropsychiatric (NP) manifestations, hypertensive status, and the presence of antiphospholipid antibodies (PA) in patients with SLE we evaluated the MRI results of 81 SLE patients in nine NP clinical subgroups.Immunoserological status was described by the presence of lupus anticoagulant (LA), and anticardiolipin antibodies (aCL). The MRI findings were categorized as normal [41], cerebral atrophy [15], small subcortical hyperintensity [7], and infarct larger than 10mm [18]. Mean age differed among the clinical subgroups (ANOVA, p = 0.002), whereas there was no age difference among the subgroups based on MRI and immunoserological results. Patients with hypertension (33/81) were a mean of 6 years older at the time of examination (p = 0.033) and had stroke more frequently, than normotensive ones (p = 0.0015). MRI abnormalities were more frequent in patients with LA positivity (p < 0.01) than in those without these antibodies, and in the hypertensive than in the normotensive subgroup (p = 0.00041). The presence of PA was associated with abnormal MRI even after controlling for the effect of age and hypertensive status (p = 0.011).In our study the MRI findings in central nervous system SLE were independent of the age of patients and the age at the diagnosis of SLE, and were not influenced by the duration of SLE; however, they were associated with immunoserological parameters and hypertension.

Image Quality of the Temporal Bone Window Examined by Transcranial Doppler Sonography and Correlation with Postmortem Computed Tomography Measurements

Background and Purpose: The major limitation of native transcranial colour-coded duplex sonography (TCCS) in older stroke patients is the relatively frequent occurrence of an insufficient temporal window. Our goal was to investigate the relationship between the in vivo Doppler ultrasound image quality of the temporal bone, and computed tomography (CT)-determined thickness, density, and homogeneity of cadaver temporal bone. Methods: Thirty-three moribund neurological patients who eventually died were examined by TCCS using the transtemporal approach. The sonographer categorized the quality of the TCCS image (excellent, intermediate, and poor). During autopsy, a rectangular sample of the temporal squama was removed, which corresponded to the area of the in vivo acoustic window. The thickness of the whole temporal bone, cortical, and cancellous (= diploe) bone as well as the density and homogeneity were determined by high-resolution CT. Results: Thirty-seven temporal bones were obtained. The quality of the acoustic window was classified as excellent in 13, intermediate in 6 and poor in 18 cases. A significant correlation between the complete bone thickness, as well as between the absolute thickness of the diploe and the quality of the acoustic window was found: the thinner the bone/diploe, the better the colour Doppler signal. The thickness of the cortical plates and the homogeneity of the bones were identical in the three image quality categories. Conclusion: The transtemporal TCCS image quality depends mainly on the thickness of the cancellous component of the temporal bone.

Screening for depressive symptoms in the acute phase of stroke

Depressive symptoms can often be observed after stroke. We prospectively evaluated patients at a stroke unit in order to determine the occurrence and severity of depressive symptoms in the acute phase of stroke in 82 patients 7 +/- 2 days after admission to the stroke unit. Severity of stroke was evaluated by the Scandinavian and Orgogozo scales and the Barthel index. Severity of depressive symptoms was measured by the 13-item Beck scale. Mean age of the patients was 65.8 years. No gender difference was observed in the severity of stroke or depressive symptoms. DSM-IV criteria of adjustment disorder with depressed mood were fulfilled by 27% of the patients. In this group, stroke was significantly more severe by the Barthel, Orgogozo, and Scandinavian scales (p < 0.001). Whereas Beck score was at least 10 in 19.5%, severe depressive symptoms (Beck score > or = 15) occurred in less than 5% of patients with acute stroke. Those who could not walk by themselves or who were aphasic had significantly higher mean Beck scores (6.3 +/- 5.1 vs 2.4 +/- 3.1, p < 0.001, and 7.0 +/- 5.8 vs 3.4 +/- 3.9, p = 0.002). Significant correlation was found between the severity of stroke and that of the depressive symptoms (r = -0.56, -0.58, and -0.54 for the Scandinavian, Orgogozo, and Barthel scales, p < 0.001).

Screening of vascular cognitive impairment on a Hungarian cohort

Cerebrovascular disease is a major public health problem in Eastern European countries. A Hungarian post‐stroke population was examined to estimate the rate of dementia, the risk factors for cognitive impairment, and the applicability of a recently established Canadian diagnostic checklist in this cohort. Chronic cerebrovascular outpatients were screened for cognitive impairment with a combined checklist: the Diagnostic Checklist for Vascular Dementia established by the Consortium of Canadian Centres for Clinical Cognitive Research using the Mini Mental State Examination instead of the detailed neuropsychological part of the Checklist. Of the 247 consecutive patients at a cerebrovascular outpatient unit, 176 had cerebrovascular disorder diagnosed either by computed tomography (CT; n = 126) or by the clinical signs. Of these, 15% were cognitively impaired and 5% fulfilled the criteria of dementia. The mean age of the patients with cognitive impairment was significantly higher than that of patients with normal cognition (68.2 ± 10.2 and 60.5 ± 10.5 years, P < 0.001). The Barthel index was significantly lower in the cognitively affected group than in non‐affected patients (92.4 ± 16.0 and 97.1 ± 8.7, P = 0.027). Diabetes and more than two subcortical infarcts on CT or magnetic resonance imaging were more frequent in patients with cognitive loss (P = 0.043 and P = 0.013, respectively). Cognitive performance was also influenced by the level of education. Higher age, diabetes, motor deficits, and multiple subcortical infarcts are risk factors for cognitive impairment after stroke. The combined checklist appears to be a practical screening test for cognitive impairment in patients with chronic cerebrovascular diseases.

Cortical Spreading Edema in Persistent Visual Migraine Aura

We present imaging evidence of the spreading of cortical edema with reversibly restricted water diffusion from the left occipital to the temporoparietal cortex in persistent visual migraine aura in a 58‐year‐old man. The right‐sided visual field defect lasting for 15 days was associated with discoupling of glucose metabolism and blood flow and the decreased apparent diffusion coefficient also suggested cytotoxic edema. At 8 weeks no signs were present, and magnetic resonance imaging became normal; therefore, long‐lasting restricted cortical water diffusion, even if coupled with hypometabolism and edema, can be reversible in persistent visual migraine aura.

Detection of Carotid Artery Stenosis by In Vivo Duplex Ultrasound: Correlation With Planimetric Measurements of the Corresponding Postmortem Specimens

Background and Purpose— The correct detection and quantification of carotid artery disease are of decisive impact on patient prognosis and adequate treatment. In this study, we evaluated the ability of ultrasonography to detect and to grade carotid artery stenosis through a comparison of the in vivo ultrasound findings with the planimetric analysis of the corresponding postmortem specimens. Methods— Shortly before their death, 59 critically ill neurological patients (mean age, 70 years) were prospectively examined by extracranial and intracranial Doppler sonography and color-coded duplex ultrasound. Carotid stenosis was classified by hemodynamic and morphological ultrasound criteria. Carotid specimens were removed in toto during autopsy. Under standardized conditions, specimens were redistended, sectioned, and histologically processed. Computerized planimetric measurements of the arteries were carried out and compared with the ultrasound findings. Correlation of the ultrasound and postmortem planimetric findings was available in 93 carotid bifurcations. Results— Through both techniques, 46 carotid arteries were found to be normal. Steno-occlusive carotid lesions ranged from 8.5% to 100% lumen reduction. Overall, r =0.96 and adjusted R2=0.90. For the steno-occlusive carotid lesions, r =0.91. Conclusions— Extracranial and intracranial Doppler and color-coded duplex ultrasound permits reliable detection and quantification of carotid artery stenoses and occlusions even under difficult examination conditions in critically ill patients.

Assessment of cerebrovascular reserve capacity in asymptomatic and symptomatic hemodynamically significant carotid stenoses and occlusions.

BACKGROUND Cerebrovascular reactivity measurements are believed to be a helpful tool for selecting patients who are at higher risk for hemodynamic strokes. The aim of this study was to compare cerebral vasoreactivity among patients suffering from internal carotid artery stenosis of different severity (asymptomatic stenosis, asymptomatic occlusion, symptomatic stenosis, symptomatic occlusion). METHODS Sixty-two patients with asymptomatic and symptomatic internal carotid artery stenoses and occlusions underwent transcranial Doppler-acetazolamide tests. Absolute velocities of the middle cerebral arteries (MCAV), percent increases of the MCAV at different time points of the test (cerebrovascular reactivity, CVR) and maximal percent increase after administration of acetazolamide (cerebrovascular reserve, CRC) were compared on the affected and non-affected sides. Asymmetry indices (CRC (affected side)/CRC (non-affected side)) were compared between the groups of different severity of obstructive lesion. RESULTS Resting MCAV was similar on both sides in all groups. A significant side-difference of the MCAV values after acetazolamide was observed only in the symptomatic groups. Difference of cerebrovascular reserve capacity between the affected and non-affected side was statistically significant only in the symptomatic groups (CRC symptomatic stenosis 36.6 +/- 20.9% vs. 71.1 +/- 27.9%, CRC symptomatic occlusion: 31.2 +/- 24.6% vs. 64.5 +/- 29.7%). Asymmetry index of the CRC was near to 1 in the asymptomatic stenosis group only, while in all the other groups this index referred to a significant hemispheric asymmetry of the vasoreactivity. CONCLUSIONS Although in general cerebrovascular reserve capacity is compromised in cases of hemodynamically significant carotid lesions, there is a large individual variability within the subgroups. Further randomized studies are needed to clarify whether the clinical efficiency of carotid endarterectomy and extra-intracranial bypass may be improved by selecting the patients using hemodynamic criteria.

Measuring carotid artery stenosis: Comparison of postmortem arteriograms with the planimetric gold standard

AbstractObjectiveFive different calliper methods for assessing the degree of carotid artery stenosis and visual estimation (“eyeballing”) of postmortem carotid arteriograms were compared with the planimetric gold standard of the area reduction at the site of the stenosis.MethodsDuring autopsy 53 carotid specimens were removed in toto from 31 neurological patients. Carotid arteries were ligated and redistended to a physiological degree for standardised three–plane arteriography. Afterwards, the entire specimen was filled with an embedding medium under the same conditions and sectioned. Slices at the site of stenoses were histologically processed. Computerised planimetric analysis of the lumen area reduction was performed and compared with the arteriographic findings. Arteriograms were evaluated by two independent observers by means of linear Common Carotid Artery (CC), the European Carotid Surgery Trial (ECST) and the North American Symptomatic Carotid Endarterectomy Trial (NASCET), and squared measurements (NASCET2, ECST2) after applying the πr2 function. Further, three independent observers performed eyeballing of the degree of stenosis from the postmortem arteriographies.ResultsPlanimetry was carried out in 29 internal carotid artery (ICA) and 17 common carotid artery (CCA) stenoses ranging from 8.5 to 100%. The smallest mean differences of the degree of stenosis in % between planimetry and arteriography were –0.5 and 0.6%. The narrowest 95 %–limits of agreement covered a range of ±24.1 and 26.3% of stenoses, and the highest correlation coefficients were both 0.9 for the CC and ECST2 techniques, respectively. By eyeballing, the degree of stenosis was underestimated by 13.5 to 15.8% on average. The narrowest limits of agreement between two observers for eyeballing covered a range of 35%.ConclusionThree–plane arteriography has only a moderate accuracy and reproducibility in detecting and measuring carotid artery stenosis independent of the technique of measurement used.

Subtentorial subdural empyema: Case report

We present a case of an extensive subtentorial subdural empyema of otorhinological origin. Although 3%-6% of all intracranial suppurations are infratentorial, there is no report on extensive multiloculated subtentorial empyema so far.