Omer Ć. Ibrahimagić

Brain Edema After Ischaemic Stroke

Objectives: To determine the incidence of brain edema after ischaemic stroke and its impact on the outcome of patients in the acute phase of ischaemic stroke. Patients and Methods: We retrospectively analyzed 114 patients. Ischaemic stroke and brain edema are verified by computed tomography. The severity of stroke was determined by National Institutes of Health Stroke Scale. Laboratory findings were made during the first four days of hospitalization, and complications were verified by clinical examination and additional tests. Results: In 9 (7.9%) patients developed brain edema. Pneumonia was the most common complication (12.3%). Brain edema had a higher incidence in women, patients with hypertension and elevated serum creatinine values, and patients who are suffering from diabetes. There was no significant correlation between brain edema and survival in patients after acute ischaemic stroke. Patients with brain edema had a significantly higher degree of neurological deficit as at admission, and at discharge (p = 0.04, p = 0.004). Conclusion: The cerebral edema is common after acute ischaemic stroke and no effect on survival in the acute phase. The existence of brain edema in acute ischaemic stroke significantly influence the degree of neurological deficit.

HYPERHOMOCYSTEINEMIA AND ITS TREATMENT IN PATIENTS WITH PARKINSON’S DISEASE

Introduction: Homocysteine is process-product of methionine demethylation. It has proatherogenic, prothrombotic, prooxidative, proapoptotic, osteoporotic, neurotoxic, neuroinflamatory, and neurodegenerative effects. Hyperhomocysteinemia correlates with C667T MTHFR mutation, decrease of folic acid and vitamin B, as well as prolonged use of certain medications. Materials and Methods: We measured levels of homocysteine in thirty patients (15::15) with “de novo” Parkinson’s disease, with average age 64.17 ± 13.19 (28-82) years (Department of Neurology, University Clinical Center Tuzla). Normal level of homocysteine for women was 3.36-20.44 micromole/l and 5.9-16 micromole/l for men. We followed the effects of medicament approach (folic acid) every six months for next five years. Results: 20% of patients with “de novo” Parkinson’s disease exhibited hyperhomocysteinemia. An average level of homocysteine was 13.85 ± 5.82 micromole/l. Differences due to age and homocysteine levels, regardless of sex, were not concluded. For the next five years intake of folic acid (periodically, 1-2 months, 5 mg per day, orally) was effective to normalized levels of homocysteine in all. Conclusion: Hyperhomocysteinemia is present in every fifth patient with “de novo” Parkinson’s disease. Folic acid is medication of choice in treatment of hyperhomocysteinemia coexisting with Parkinson’s disease.

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.

Psychological Stress and Changes of Hypothalamic-Pituitary-Adrenal Axis in Patients with De Novo Parkinson's Disease

Introduction: Psychological stress and changes in hypothalamic-pituitary-adrenal (HPA) axis in period after diagnosis of “de novo” Parkinson disease (PD) could be a big problem for patients. Materials and Methods: We measured psychological stress and changes in hypothalamic-pituitary-adrenal axis (HPA) in thirty patients (15:15) with “de novo” Parkinson’s disease, average age 64.17 ± 13.19 (28-82) years (Department of Neurology, University Clinical Center Tuzla). We used Impact of events scale (with 15 questions) to evaluate psychological stress. Normal level of morning cortisol was 201-681 nmol/l, and morning adrenocorticotropic hormone (ACTH) up to 50 pg/ml. Results: Almost 55% patients suffered from mild or serious psychological stress according to IES testing (Horowitz et al.). Non-iatrogenic changes in HPA axis were noticed at 30% patients. The differences between female and male patients regarding to the age (p=0.561), value of cortisol (p=0.745), value of ACTH (p=0.886) and IES testing (p=0.318) were not noticed. The value of cortisol was the predictor of value of ACTH (r=0.427). Conclusion: Psychological stress and changes in hypothalamic-pituitary-adrenal axis are present in patients with “de novo” PD. There is significant relation between values of cortisol and ACTH. Psychological stress is frequent problem for “de novo” PD patients.

PREDICTORS FOR POST- STROKE DELIRIUM OUTCOME.

Background: There have been only a small number of studies that have evaluated the outcome of post-stroke delirium. Objectives: To evaluate the effects of gender, age, stroke localization, delirium severity, previous illnesses, associated medical complications on delirium outcome as well as, to determine effects of delirium on cognitive functioning one year after stroke. Patients and Methods: Comprehensive neuropsychological assessments were performed within the first week of stroke onset, at hospital discharge, and followed-up for 3, 6 and 12 months after stroke. We used diagnostic tools such as Glazgow Coma Scale, Delirium Rating Scale, National Institutes of Health Stroke Scale and Mini-Mental State. Results: Patients who developed post-stroke delirium had significantly more complications (p = 0.0005). Direct logistic regression was performed to assess the impact of several factors on the likelihood that patients will die. The strongest predictor of outcome was age, mean age ≥ 65 years with a odds ratio (OR) 4.9. Cox’s regression survival was conducted to assess the impact of multiple factors on survival. The accompanying medical complications were the strongest predictor of respondents poore outcome with Hazard-risk 3.3. Cognitive assessments including Mini Mental State score have showen that post-stroke delirium patients had significant cognitive impairment, three (p = 0.0005), six months (p = 0.0005) and one year (p = 0.0005) after stroke, compared to patients without delirium. Conclusion: Patient gender, age, localization of stroke, severity of delirium, chronic diseases and emerging complications significantly affect the outcome of post- stroke delirium. Delirium significantly reduced cognitive functioning of after stroke patients.

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.

Mortality and Functional Disability of Post-stroke Delirium -

Introduction: Small number of studies have evaluated the mortality and the degree of functional disability of post-stroke delirium, and our aim was to determine that. Patients and Methods: Comprehensive neuropsychological assessments were performed within the first week of stroke onset, at hospital discharge, and followed-up for 3, 6 and 12 months after stroke. We used diagnostic tools such as Glasgow Coma Scale, Delirium Rating Scale, National Institutes of Health Stroke Scale and Mini-Mental State. Results: Delirious patients had a significantly higher mortality (p = 0.0005). As opposed to the type of stroke mortality was higher after ischemic (p = 0.0005). The patients without delirium had significantly better cumulative survival during the first year after stroke (p = 0.0005). Delirious patients aged ≥65 years had a significantly lower cumulative survival during the first year after stroke (p = 0.0005). In relation to the type of stroke delirious patients with ischemic had a significantly lower cumulative survival during the first year after stroke (p = 0.0005). Delirious patients had a greater degree of functional impairment at discharge (p = 0.01), three (p = 0.01), six months (p = 0.01) and one year (p = 0.01) after stroke. Conclusion: Delirious patients have a significantly higher mortality, lower cumulative survival and a greater degree of functional disability in the first year after stroke.

CHANGE OF THE WRITING-HAND: UNUSUAL MANIFESTATION OF HALLERVORDEN-SPATZ DISEASE

Hallervorden-Spatz disease (HSD) is a rare neurodegeneration with accumulation of iron in basal ganglia, dystonia, dysarthria, rigidity, and choreoathetosis. Syndrome may present in childhood and progress relentlessly culminating in early death (classical HSD) or in second or third decade with slow progression (atypical HSD) (Hayflick et al. 2003). Magnetic resonance imaging (MRI) appearance in HSD, revealing bilaterally symmetrical, hyperintense signal changes in the anterior medial globus pallidus, with surrounding hypointensity in the globus pallidus, on T2-weighted scanning. These features are fairly diagnostic of HSD and have been termed the „eye of the tiger“ sign (Dashti & Chitsaz 2014). Unfortunately, exact etiology, predictors, and biochemical markers are not known.

Transcranial Brain Sonography in Parkinson's Disease and Other Parkinsonian Disorders: a Hospital Study from Tuzla, Bosnia and Herzegovina

Introduction: Transcranial sonography (TCS) is a relatively new ultrasound modality which could display echogenicity of human brain tissue through the intact skull. TCS may be useful in differentiation of idiopathic Parkinson’s disease (PD) from other parkinsonian disorders. Therefore, we studied different ultrasound markers by TCS in individuals with Parkinson’s disease. Patients and Methods: We performed TCS in 44 patients with PD and 22 patients with other parkinsonian disorders. Echogenic sizes of the substantia nigra (SN) and the lentiform nuclei (LN), as well as the width of the third ventricle and the frontal horns of the lateral ventricle, were measured. We also analyzed the echogenicity of the brainstem raphe (BR). Results: An unilateral hyperechogenic SN was observed in 31 (70%) patients with PD and only in 2 patients (9%) with other parkinsonian disorders (P<0.0001). Hyperechogenicity of the LN was no observed in patients with PD; however, it was present in 7 (32%) patients with other parkinsonian disorders (P=0.0002). Diameter of third ventricle (8.6+/-2.2 mm vs. 6.9+/-1.7mm, P=0.001), right (18.5+/-2.6 mm vs. 16.5+/-2.3 mm, P=0.003) and left frontal horn of lateral ventricle (19.0+/-3.7 mm vs. 16.2+/-2.6 mm, P=0.0006) was significantly wider in patients with other parkinsonian disorders compared with patients with PD. There was no difference in presence of hypoechogenic or interrupted BR in patients with PD and patients with other parkinsonian disorders (39% vs. 27%, P=0.4). Conclusion: TCS is a promising diagnostic technique and can be very helpful in differentiating between idiopathic Parkinson’s disease and other parkinsonian disorders.