Zofia Kazibutowska

Inflammatory markers in patients with internal carotid artery stenosis.

Introduction Available reports underline the significance of the inflammatory process in the development, progression and destabilisation of atherosclerotic plaques in the internal carotid artery (ICA). The aim of this study was to evaluate the relationship between the degree of ICA stenosis, ultrasound plaque morphology and serum concentration of selected inflammatory markers. Material and methods Sixty-five patients with ICA stenosis > 50% (39 symptomatic) and 30 healthy volunteers were enrolled in the study. Clinical, neurological examination and laboratory evaluation (leucocyte count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), fibrinogen, tumour necrosis factor-α (TNF-α), interleukins (1β, 6 and 10), anti-cytomegalovirus IgG antibody titre) were performed. Stenosis grade ≥ 70%, ulcerations on the plaque surface and a hypoechoic (or predominantly hypoechoic) structure of the plaque, obtained by colour-coded duplex examination, were accepted as the characteristics of unstable stenoses. Results Unstable ultrasound features of ICA stenosis were found significantly more often in symptomatic than in asymptomatic patients (71.79% vs. 30.71% for stenosis degree ≥ 70%, p = 0.001 and 61.23% vs. 38.46% for unstable plaque morphology, p = 0.01). Patients with ICA stenosis had significantly higher serum concentrations of interleukin-6, fibrinogen, ESR and higher CRP values than the individuals from the control group (p = 0.001, p = 0.009, p = 0.036, p = 0.009 respectively). Patients with unstable plaques structure had significantly higher concentrations of TNF-α, interleukin-6, fibrinogen, higher number of leukocytes, monocytes and higher CRP values than patients with stable plaques (p = 0.008, p = 0.049, p = 0.012, p = 0.0002, p = 0.006, p = 0.0003 respectively). No significant differences in above-mentioned parameters between the groups with stenosis < 70% and ≥ 70% were found. Conclusions There is a relationship between the activity of the selected inflammatory markers in serum and atherosclerotic unstable internal carotid artery stenosis. There is no relationship between serum concentration of inflammatory markers and degree of carotid artery stenosis.

Efficacy and safety assessment of alteplase in the treatment of stroke — gender differences

Abstract Background: Evidence for gender disparity in response to pharmacological thrombolysis for acute stroke treatment is inconclusive. Objective: To compare the effectiveness and safety of alteplase used in the treatment of male and female stroke patients. Material and methods: One thousand and seventy-seven patients who recently had their first-ever clinically apparent stroke (group I: 113 patients treated with intravenous alteplase and group II: 964 not treated with alteplase) were qualified. Groups I and II were divided into subgroups based on gender and were analysed based on: the age when they had a stroke, presence of key stroke risk factors (quantitatively: ≤ or >3), neurological state according to NIHSS in the first day of stroke, mortality rate, and the modified Rankin scale (mRS) at day 90 after the stroke. In group I, other determinants were additionally assessed: recent lesions as appeared on CT scans of the head in the first day of stroke and 24 hours after recombinant tissue plasminogen activator (rtPA), neurological state according to NIHSS in the second day of stroke, and the incidence of iatrogenic bleeding. Results: The age of the onset of stroke was older in women both in group I and group II. Apart from lipid disorders, no statistically significant differences in the distribution of other risk factors for stroke between groups I and II were found. The neurological state (according to the NIHSS scale) on the first day of the disease was significantly more severe in women both in group I and group II. In group II, the level of functioning according to the mRS scale at day 90 day after the onset of the disease was significantly more severe in women; there was no significant difference in group I. Among patients from group I, a significantly greater improvement, according to the NIHSS scale, was found in women 24 hours after rtPA administration in comparison with men. The presence of focal ischemia, responsible for the occurrence of stroke, on the CTs of the head performed 24 hours after rtPA administration, was also significantly more often found in women (in group I). No statistically significant differences in the incidence of complications after rtPA between women and men in group I were observed. In multivariate methods, we did not find any impact of factors other than gender on the outcome after stroke. Conclusions: The use of alteplase in women during the treatment of stroke is associated with a greater and faster improvement in their neurological state in comparison with men. Treating stroke with alteplase in women improves long-term prognosis regarding self-efficacy in everyday functioning. Finally, there are no gender-related differences regarding the safety of intravenous thrombolytic therapy.

Seizure frequency and bioelectric brain activity in epileptic patients in stable and unstable atmospheric pressure and temperature in different seasons of the year – a preliminary report

BACKGROUND AND PURPOSE An epileptic seizure is a sum of exogenous and endogenous factors affecting an epileptic focus. The aim of the study was to examine the influence of changes in atmospheric pressure and temperature on the increase in the frequency of seizures and changes in EEG in epileptic patients. MATERIAL AND METHODS The study included 30 epileptic patients (aged 19-54) reporting the influence of changes in weather conditions on the increase in the frequency of seizures for at least 2 years. EEG was performed twice each season at the time of stable and unstable weather conditions. RESULTS In stable and unstable weather conditions, epileptic changes in EEG were most often found in winter (in 43.3% and 63.3% of patients, respectively). Unstable weather conditions increased the proportion of patients with epileptic changes in EEG also in the other seasons. Unstable weather conditions caused an increase in the frequency of seizures in 40% of patients in spring, 43.3% in autumn, 40% in winter and in approximately 7% in summer. CONCLUSIONS In spring, autumn and winter, unstable weather conditions cause an increase in the frequency of seizures in almost half of the epileptic patients but only in 7% in summer. The increase in frequency of seizures in unstable weather conditions did not correspond in all patients with increase of changes in EEG. The higher proportion of epileptic patients with changes in EEG in unstable weather conditions in all seasons suggests an impact of these conditions on subclinical seizure discharges in this period.

Elevated factor VIII level and stroke in patients without traditional risk factors associated with cardiovascular diseases

Introduction Hemostasis is affected by interactions between physiological processes, including those connected with the coagulation system, whose essence is converting fibrinogen into fibrin. The role of factor VIII (FVIII) consists in activating factor X, which directly participates in the generation of thrombin, which is able to produce stable fibrin, which in turn forms blood clots. There are divergent opinions regarding the significance of high levels of FVIII in stroke pathogenesis. Aim The aim of our study was to evaluate FVIII activity in individuals with cryptogenic stroke in order to determine a potential relationship between it and cerebral ischemia. Material and methods Nine patients suffering with stroke were used in this study: six women and three men aged 49–63 years. In all of the patients, the presence of known and potential risk factors for stroke had been excluded during previous diagnostic procedures. These patients accounted for 1.2% of the 719 people who suffered a stroke and were hospitalized in 2011 at the Stroke Unit. FVIII activity was examined in each of the nine qualified subjects within 1–2 months of the occurrence of stroke (the first test) and repeated (the second test) in five patients with abnormal results obtained from the first examination. Results Increased activity of FVIII was found in 5 out of 9 patients. In patients with abnormal results, elevated FVIII was found in follow-up examinations in the 8th–10th month following stroke. Hemodynamic abnormalities in carotid or cerebral artery (presence of thrombus) were found in 3 of the 5 patients with increased FVIII levels. In the first 24 hours following stroke the neurological state of patients with abnormal FVIII was worse than individuals with normal FVIII activity. The patients with abnormal FVIII levels were found to be more disabled in the examination of self-dependence on the 90th day after stroke. Conclusion When searching for the causes of stroke, it is worth examining the coagulation system, including FVIII concentration, the abnormality of which may play a significant part in brain ischemia. More research is needed to determine the relationship between abnormal FVIII activity and stroke.INTRODUCTION Hemostasis is affected by interactions between physiological processes, including those connected with the coagulation system, whose essence is converting fibrinogen into fibrin. The role of factor VIII (FVIII) consists in activating factor X, which directly participates in the generation of thrombin, which is able to produce stable fibrin, which in turn forms blood clots. There are divergent opinions regarding the significance of high levels of FVIII in stroke pathogenesis. AIM The aim of our study was to evaluate FVIII activity in individuals with cryptogenic stroke in order to determine a potential relationship between it and cerebral ischemia. MATERIAL AND METHODS NINE PATIENTS SUFFERING WITH STROKE WERE USED IN THIS STUDY: six women and three men aged 49-63 years. In all of the patients, the presence of known and potential risk factors for stroke had been excluded during previous diagnostic procedures. These patients accounted for 1.2% of the 719 people who suffered a stroke and were hospitalized in 2011 at the Stroke Unit. FVIII activity was examined in each of the nine qualified subjects within 1-2 months of the occurrence of stroke (the first test) and repeated (the second test) in five patients with abnormal results obtained from the first examination. RESULTS Increased activity of FVIII was found in 5 out of 9 patients. In patients with abnormal results, elevated FVIII was found in follow-up examinations in the 8th-10th month following stroke. Hemodynamic abnormalities in carotid or cerebral artery (presence of thrombus) were found in 3 of the 5 patients with increased FVIII levels. In the first 24 hours following stroke the neurological state of patients with abnormal FVIII was worse than individuals with normal FVIII activity. The patients with abnormal FVIII levels were found to be more disabled in the examination of self-dependence on the 90th day after stroke. CONCLUSION When searching for the causes of stroke, it is worth examining the coagulation system, including FVIII concentration, the abnormality of which may play a significant part in brain ischemia. More research is needed to determine the relationship between abnormal FVIII activity and stroke.

Assessment of cerebral embolism and vascular reserve parameters in patients with carotid artery stenosis

AIM Carotid artery stenosis can result in the brain tissue injury related to the intracranial aterial flow disturbances as well as microembolic complications. The choice of the proper therapy in patients with carotid artery stenosis, especially asymptomatic, remains still a significant clinical problem. The study aim was an assessment of the cerebral embolism and brain vascular reserve parameters in patients with carotid artery stenosis regarding the occurrence of the clinical symptoms, the degree of stenosis as well as plaque morphology. METHODS The study included 60 patients, with internal carotid artery stenosis. The degree of stenosis, the atherosclerotic plaque surface and morphology were assessed by the means of Duplex Doppler ultrasound. Cerebrovascular reactivity (vasomotor reactivity reserve test and Breath Holding Index) and monitoring of the microembolic signals (MES) were assessed with transcranial Doppler ultrasound examination (TCD). RESULTS The vasoreactivity parameters were significantly lower in the group of patients with stenosis ≥70% and in patients with ulcerations on the plaque surface. Microembolic signals were recorded significantly more often in symptomatic patients; in patients with stenosis ≥70%; in patients with ulcerations on the plaque surface and those with hypoechogenic plaque structure. CONCLUSIONS Microembolic signals in patients with symptomatic carotid stenosis are one of the ultrasound features of unstable carotid stenosis. Worse reactivity parameters of the cerebral arteries are associated with the presence of a large degree of carotid artery stenosis.

Efficacy and safety of mitoxantrone use in primary and secondary progressive multiple sclerosis - study site experience based on the therapy of 104 patients.

ABSTRACT Mitoxantrone (MX) is used in patients with primary and secondary progressive as well as relapsing–remitting type of multiple sclerosis (PPMS, SPMS, RRMS). The objective of our project was to evaluate the efficacy and safety of MX use in patients with PPMS and SPMS. Methods: The retrospective study included 104 patients (mean age 54.2 ± 9.0), with PPMS (13.46%) and SPMS (86.54%) treated with MX. During single cycle of the MX therapy a dose of 12 mg/m2 of body surface area was administered and next cycles every three months up to a total dose of 140 mg/m2 were realized. Results: The course of the therapy was completed by 95 patients (91.34%) including 73 patients who received a scheduled whole dose. The average cumulative dose per patient was 75.2 mg/m2. Thirty-two patients reported nausea after MX administration, 20 revealed increase in the incidence of infection and 19 patients hair loss. Twenty-two patients discontinued therapy (seven patients because of the progress of disability). Independent risk factors for deterioration were: age and the form of PPMS (RR 1.56 [95% CI: 1.17–2.07] and RR 2.8 [95% CI: 1.08–7.21], respectively). Five patients revealed a asymptomatic decrease in EF value <50% or 10% in relation to the previous test. Conclusions: MX therapy enables us to stabilize the disease without causing any significant side effects in most patients with progressive disease as compared to patients with primary progressive disease with a comparable safety profile. Larger benefits of MX therapy are associated with the patients with secondary progressive disease.

Cerebral microembolism in patients with segmental left ventricular wall motion abnormalities

BACKGROUND AND PURPOSE The significance of segmental heart wall motion abnormalities for stroke is unknown. The aims of the study included (1) comparison of the frequency and type of embolic signals in the middle cerebral artery in patients with segmental left ventricular wall hypokinesis due to coronary heart disease with and without stroke, and (2) determination of the relationship between inflammatory parameters, fibrinogen level, dyslipidemia and microembolic signals in the middle cerebral artery in patients with segmental heart hypokinesis. MATERIAL AND METHODS The study included 68 patients with segmental heart hypokinesis (33 without stroke [group I] and 35 with stroke [group II]), as well as 37 healthy volunteers and a reference group of 30 patients. Echocardiography and carotid/transcranial Doppler with detection of microembolic signals were performed. Patients from group I and II had erythrocyte sedimentation rate, leucocyte count, triglycerides, total cholesterol, HDL, and LDL examined. RESULTS Embolic signals were detected in patients with segmental heart hypokinesis significantly more frequently than in the control and reference groups. The high number of embolic signals, signals of high intensity, hypokinesis of the distal part of the intraventricular septum, increased cholesterol levels, LDL and triglycerides were all found more frequently in patients from group II than in group I. Embolic signals were detected more frequently in patients with high fibrinogen levels and leukocytosis. CONCLUSIONS Embolic signals in the middle cerebral artery in patients with segmental left ventricular hypokinesis have to be considered as a risk factor of stroke. The following changes are observed in patients with cardiogenic stroke: hypokinetic intraventricular septum, high intensity embolic signals, increased serum fibrinogen levels and leucocyte count. It may indicate the importance of these factors in the aetiology of stroke.

Acute neurological symptoms of Moschcowitz disease—Case report

Thrombotic thrombocytopenic purpura (TTP, Moschcowitz disease) is characterized by thrombotic microangiopathy leading to microvascular occlusion and ischemic dysfunction of various organs including the brain. In the course of the rare disease most patients develop neurological symptoms of varying severity and characteristics. The case presented is that of a 34-year-old female patient with profound thrombocytopenia, anemia and rapidly progressive neurological deterioration into coma with normal result of brain imaging. TTP was recognized on the basis of hematological analysis. The initiated steroid therapy and plasma exchange failed to prevent the turbulent course of disease in the patient, who died exhibiting symptoms of multiple organ failure caused by thrombotic microangiopathy. TTP remains to be a diagnostic challenge, particularly in the case of atypical symptoms or when neuroimaging and laboratory results are inconclusive. Before using the corticosteroids and plasma exchange, TTP had a case fatality rate of approx. 90% (Podolak-Dawidziak, 2013). Nowadays recovery is possible when vigorous treatment is introduced early in the course of this disease.

Stroke Risk Factors, Course and Long-Term Functional Outcome of First-Ever Stroke in Women

RESULTS: The age at which first-ever stroke occurred was higher in women (p = 0.030). Atrial fibrillation occurred more frequently in them (p = 0.0007). Hypertension and coronary disease occurred less commonly in women under 55 (p = 0.038 and 0.035 respectively). In women < 55, lipid disorders (p = 0.004) and diabetes (p = 0.018) were observed more rarely, they were more common in > 55 group (p = 0.042 and 0.023). In women, carotid artery stenoses were less common (p = 0.07), cardiogenic stroke more common (p = 0.001). They were in worse neurological state both on day 1 (p = 0.001) and 90 (p = 0.033) of disease.

Patent foramen ovale and cryptogenic stroke - a statistical or cause-and-effect relationship? A neurological point of view.

Patent foramen ovale and atrial septal aneurysm are considered to be factors conducive to the occurrence of stroke and transient ischaemic attacks. However, there is no clear answer to the question whether patent foramen ovale is an independent risk factor for stroke and what the mechanism of potential cerebral ischaemia in patients with an interatrial septal abnormality is. The paper presents the results of studies regarding the issue, including epidemiological, clinical and neuroimaging data. The subject of secondary prevention in patients with cryptogenic stroke and patent foramen ovale, including the results of research into the effectiveness of pharmacological methods and percutaneous closure of interatrial septal defects, is raised. The available research results do not conclusively suggest a causal relationship between patent foramen ovale and stroke. There is a probable summative effect of atrial septal abnormality and other factors (haemostatic and genetic ones as well as those that are associated with cerebral vessels) leading to cerebral ischaemia. There are no indications for the use of anticoagulant treatment in patients with stroke and presence of patent foramen ovale. In patients at a high risk for stroke, invasive treatment should be considered, which is consistent with the position of the European Stroke Organisation.