When modern diagnostics is challenged by a historical disease: A case report.

RATIONALE: Syphilis is a bacterial, systemic infectious disease caused by Treponema pallidum spirochetes, which spread rapidly through the body affecting various organs. The term neurosyphilis (NS) refers to a CNS infection that can occur at any stage of the disease. The lack of a gold standard for the diagnosis of NS greatly hinders diagnosis, which must be based mainly on clinical assessment. PATIENT CONCERNS: A 58-year-old man reported dizziness and headache for a week and right-sided hearing impairment, with suspected transient cerebral ischemic attack. A month later he experience transient speech disturbance and suspected cerebral ischemic stroke. DIAGNOSIS: MRI showed fresh ischemic lesions with a diameter up to 10 mm in the deep brain structures on the left side and foci of subacute ischemia also in the deep structures and the brain stem. Cerebrospinal fluid examination showed positive Pandy's reaction, doubtful Noone-Apelt reaction, increased protein level and decreased glucose level. The reactive result of the USR test performed (VDRL) finally allowed the diagnosis of symptomatic CNS syphilis. INTERVENTIONS: Empiric treatment for bacterial meningitis was administered. The patient was transferred to the Department of Infectious Diseases for further treatment. OUTCOMES: The diagnosis has been confirmed at the Department of Infectious Diseases after repeating CSF analysis including VDRL and FTA-ABS. LESSON: Symptoms of NS are nonspecific, hence the diagnostic process is not straightforward. Despite the availability of modern diagnostic techniques, establishing a final diagnosis was challenging, but the patient ultimately received appropriate treatment. It is important to remember that syphilis is not only a disease known from history lessons but is still present in modern times and its incidence is increasing.

Evolution of Hypodensity on Non-Contrast CT in Correlation with Collaterals in Anterior Circulation Stroke with Successful Endovascular Reperfusion.

INTRODUCTION: The aim of the study was to assess the impact of collaterals on the evolution of hypodensity on non-contrast CT (NCCT) in anterior circulation stroke with reperfusion by mechanical thrombectomy (MT). METHODS: We retrospectively included stroke patients with middle cerebral artery occlusion who were reperfused by MT in early and late time window. Artificial intelligence (AI)-based software was used to calculate of hypodensity volumes at baseline NCCT (V1) and at follow-up NCCT 24 h after MT (V2), along with the difference between the two volumes (V2-V1) and the follow-up (V2)/baseline (V1) volume ratio (V2/V1). The same software was used to classify collateral status by using a 4-point scale where the score of zero indicated no collaterals and the score of three represented contrast filling of all collaterals. The volumetric values were correlated with the collateral scores. RESULTS: Collateral scores had significant negative correlation with V1 (p = 0.035), V2, V2- V1 and V2/V1 (p < 0.001). In cases with collateral score = 3, V2 was significantly smaller or absent compared to V1; in those with collateral score 2, V2 was slightly larger than V1, and in those with scores 1 and 0 V2 was significantly larger than V1. These relationships were observed in both early and late time windows. CONCLUSIONS: The collateral status determined the evolution of the baseline hypodensity on NCCT in patients with anterior circulation stroke who had MT reperfusion. Damage can be stable or reversible in patients with good collaterals while in those with poor collaterals tissues that initially appear normal will frequently appear as necrotic after 24 h. With good collaterals, it is stable or can be reversible while with poor collaterals, normal looking tissue frequently appears as necrotic in follow-up exam. Hence, acute hypodensity represents different states of the ischemic brain parenchyma.

Cerebral amyloid angiopathy-related inflammation (CAARI): case report.

Cerebral amyloid angiopathy-related inflammation is a new disease entity whose proper diagnosis may be difficult due to the fact that the early phase and radiological image resemble other conditions such as intracerebral haemorrhage or proliferative disorder. Also, the brain biopsy, which is an important part of the evaluation to confirm the diagnosis and rule out mimics, cannot be performed in each patient. In this paper we present the case of a 58yearold man who was correctly diagnosed with cerebral amyloid angiopathy-related inflammation (CAARI) based on the results of the histopathological examination of the brain tissue, which was possible mainly owing to the inclusion of the expansive process as the underlying cause in the initial differentiation. Further progression of the disease, despite applying treatment of increasing intensity in response to progressive deterioration of the patient's condition, revealed the multiplicity of clinical courses that a new and not easily pinpointed entity can take.

Beneficial effects of pre-stroke statins use in cardioembolic stroke patients with atrial fibrillation: a hospital-based retrospective analysis.

INTRODUCTION: Statins are widely used in stroke patients. The AHA/ASA guidelines recommend aggressive statin therapy in atherosclerotic stroke patients. Their beneficial effects are due to both their hypolipemic and pleiotropic properties. The aim of this study was to establish potential benefits from statin use in ischemic stroke patients with the diagnosis of atrial fibrillation (AF). MATERIAL AND METHODS: Ischemic stroke patients with AF were enrolled in the study. Group I, the statin group (n = 181), consisted of patients who had been treated with statins before stroke. Group II, the non-statin group (n = 153), consisted of patients who had not received such treatment in the last year. In-hospital mortality and neurological deficit on admission and at discharge were analyzed using the National Institutes of Health Stroke Scale (NIHSS) score. RESULTS: Patients from the non-statin group had greater initial and discharge NIHSS scores (10 vs. 11.9, probability value p < 0.05; 7.6 vs. 9.5, p < 0.05 respectively). The improvement in NIHSS score was greater in the statin group (73.5% vs. 59.5%, p < 0.01). In-hospital mortality was more frequent in the non-statin group (9.9% vs. 18.3%, p < 0.05). CONCLUSIONS: Despite the predominant use of statins in atherothrombotic stroke patients, we demonstrated the beneficial effects of statins in cardioembolic stroke patients. Detailed cardiovascular screening for statin therapy should be carried out in all AF patients with regard to primary and secondary stroke prevention.

A Novel NOTCH3 Gene Mutation in a Polish CADASIL Family.

Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) is a genetically determined disease of the cerebral vessels, characterized by recurrent ischemic strokes, dementia, and degeneration of the cerebral white matter. The condition is caused by a mutation in the NOTCH3 gene, whose product plays a great role in the development and physiology of the cardiovascular system. Magnetic resonance imaging reveals multiple hyperintensive lesions of the white matter in the T2-weighted images also in asymptomatic carriers of CADASIL and can be detected even 10-15 years prior to clinical signs. Diagnosis is confirmed by genetic testing. We present 2 patients (mother and daughter) carrying the same mutation p.Cys212Gly in 1 allele of the NOTCH-3 gene, which has not yet been recorded in the Human Gene Mutation Database for that gene and therefore described as a new one. The clinical manifestation of the disease differs between patients -the 63-year-old mother has been suffering from severe migraine headaches since her early youth and the first vascular event occurred when she was about 50 years old, she is now presenting with impaired cognitive functions, left facial palsy, bilateral pyramidal syndrome more prominent on the left side, and four-wheel support assisted walking. The neurological deficits that her 42-year-old daughter is afflicted with are discreet. Observation to date indicates a definitely less severe clinical course of the disease. This indicates that members of the same family carrying the same mutation may produce different clinical course of the disease.

Early Emergency Medical Service Calls for Stroke: Was the Long-Term Education Program Based on the Experience of West Pomerania Successful?

BACKGROUND: Our objectives are to investigate whether the percentage of early emergency calls for stroke had increased and to assess current factors determining the time of deciding to seek medical help in the event of early stroke symptoms. MATERIALS AND METHODS: We analyzed data concerning the decision to call for medical help in relation to observed stroke symptoms. Group I comprised 287 people who made the decision to call emergency medical service (EMS) in the first 10 minutes after observing stroke symptoms. Group II included 275 people who called EMS after that time. Data from the current database (2013-2014) were compared with relevant data from the period 2003-2005. RESULTS: In 2013-2014, awareness of stroke signs was 2.5 times greater than in 2003-2005. Among the groups of early and delayed EMS calls during 2003-2005 and 2013-2014, there were no significant differences in the number of people who suspected stroke. Advanced patient age, young caller age, hemiparesis, facial weakness, and the severity of neurological deficit were independent factors that correlated strongly with an early EMS call, whereas feelings of numbness and dizziness correlated significantly with delayed EMS calls. CONCLUSIONS: In the West Pomeranian community, general knowledge of stroke is not a significant factor when making appropriate decisions at the onset of stroke symptoms. The education campaign regarding the initial symptoms of stroke and the possible fatal consequences appears to have been ineffective.

Protective properties of HDL cholesterol and atherosclerotic plaque calcifications in advanced atherosclerosis in ischaemic stroke patients.

Introduction: Atherosclerotic changes in carotid arteries play an important role in the pathogenesis of ischaemic stroke. To a high extent there is evident asymmetry within the development of these changes, affecting just one artery. The aim of the study was to determine the impact of the cardiovascular risk factors on the presence of haemodynamically significant atherosclerotic changes or occlusion only in one compared to both of the carotid arteries in patients with ischaemic stroke. Material and methods: Patients diagnosed with ischaemic stroke were retrospectively assessed towards stenosis of ≥70% or occlusion in at least one of the internal or common carotid arteries. There were 104 patients enrolled in the study. Group I consisted of individuals with haemodynamically significant (≥70%) stenosis or occlusion in one carotid artery (n = 48). Group II consisted of patients with bilateral significant (≥70%) stenosis or occlusion in carotid arteries (n = 56). Results: There were no changes found in the presence of non- -modifiable stroke risk factors between the groups. In group I higher HDL level (45.7 vs 38.9 mg/dL, p = 0.038) and significantly more frequent calcifications in the atherosclerotic plaques of carotid arteries were found (p = 0.03). There were no differences in other tested factors between groups. Conclusions: The protective properties of HDL cholesterol and the slow formation of more stable, calcified plaques play an important role only in the development of unilateral advanced atherosclerosis in carotid arteries. The role of HDL cholesterol in stroke pathomechanism needs further studies.

Atrial fibrillation and stroke - Coexistence and attitude to preventive therapy on the basis of Szczecin and Szczecin region patients.

Atrial fibrillation (AF) is an independent factor increasing the risk of an ischemic stroke (IS) fivefold. The objective of the study was to evaluate the frequency of coexistence of non-valvular AF and IS during the acute stroke and to analyze the attitude of AF patients to treatment. The study included 3712 successive patients presenting either an IS or a transient ischemic attack. The analysis revealed a significant increase in the rate of patients with AF and IS in the years 2010-2013 (31.9%) compared with 2002-2005 (20.2%). A rise in the proportion of AF and IS patients was recorded over the course of consecutive years in group II. The proportion of newly detected AF cases during hospital stay differed significantly between the groups (16.9% vs. 31.9%). Group I and II patients differed essentially with regards to hypertension incidence and female rates. Antiplatelet medications or OACs were taken by a significantly greater number of AF patients in group II. Low number of therapeutic levels of INR was recorded in both groups. IS and AF coexist more frequently than indicated by previous assessments and demographic data from other countries. Increase in the number of IS and AF patients may result from higher detectability of AF and older age of patients affected with stroke, women in particular. Despite a well grounded knowledge about the benefits of OACs use in the prophylaxis of thrombotic-embolic events in AF patients, they are rarely used. A surprisingly low proportion of patients taking OACs reaches a therapeutic INR level.

Anti-oxLDL antibodies are clinically insignificant for stroke patients.

OBJECTIVES: The question about anti-oxidized low-density lipoprotein antibodies (anti-oxLDL Abs) involvement in the pathogenesis of atherosclerosis-related ischemic stroke is still open. The aim of this study was to determine how anti-oxLDL Abs are involved in the pathogenesis of atherosclerosis-related ischemic stroke and identify the main risk factors for stroke, such as arterial hypertension, diabetes mellitus type 2, dyslipidemia, and atherosclerotic changes in the common and internal carotid arteries. MATERIAL AND METHODS: A total of 40 stroke patients and 25 age- and sex-matched healthy individuals were included in the study. For each subject, IgG anti-oxLDL Abs expression in peripheral blood was assessed and analyzed in relation to clinical data, carotid Doppler ultrasonography results, and results of peripheral blood laboratory tests, including inflammatory parameters and lipid profile. RESULTS: The blood level of assessed antibodies was significantly higher in stroke patients than in control group. It did not relate to stroke severity and stroke outcome. The relationship between anti-oxLDL Abs and carotid plaques hyperechogenicity was observed. The antibodies concentration was significantly higher in patients with diabetes mellitus type 2 and also positively correlated with C-reactive protein blood level. However, multiple regression method did not confirm their independent influence. DISCUSSION: Patients with atherogenic ischemic stroke may have significantly higher anti-oxLDL Abs concentrations. This should be interpreted as an attempt to limit the consequences of oxLDL production; however, this phenomenon does not seem to protect patients against cerebrovascular events.

Circulated CD4+CD28- lymphocytes rate and their cytotoxicity and morphological parameters of internal carotid artery atheromatous plaques in patients with atherosclerosis-related ischemic stroke.

BACKGROUND: The question about the role of CD4+CD28- lymphocytes in the pathogenesis of atherosclerosis-related ischemic stroke is still open. MATERIAL AND METHODS: The study included patients, who underwent endarterectomy of internal carotid arteries. The group consisted of patients after stroke and ones without previous stroke. The histopathologic examination of obtained plaques has been performed. The percentage of CD4+CD28- lymphocytes in peripheral blood and their cytotoxicity has been assessed for each patient. RESULTS: The global percentage of CD4+CD28- lymphocytes in blood was higher in the group of patients with plaques where connective tissue fibers consisted significantly of collagen fibers. The cytotoxicity of analysed cells related to less plaques calcification and presence of cholesterol crystals in the plaque. A multifactor regression of dependent variable presented the last relationship above as a only strong. CONCLUSIONS: CD4+CD28- cytotoxic lymphocytes seem to be involved in carotid atherosclerotic plaques development. Intraplaque cholesterol deposits may contribute to this process.

Carotid atheromatous plaques' instability. Practical implication of morphologic assessment.

The only method giving the possibility of a thorough assessment of plaques instability, is a histologic examination. Three plaques categories were distinguished: unstable, potentially unstable and stable. The distribution of particular types of plaques was similar in symptomatic and asymptomatic patients. Over three quarters of lesions which could correspond to stable plaques in a macroscopic assessment, microscopically fulfilled the criteria for unstable or potentially unstable ones (the number of confirmed stable lesions vs the number of unconfirmed ones, 13 vs. 51 respectively, p < 0.0001). In a microscopic assessment made for all the plaques altogether, 52 plaques (58.4%) were considered unstable; 18 (20.2%) fulfilled the criteria for potentially unstable ones. The remaining 19 plaques (21.4%) were classified as plaques of stable structure. Unstable plaques constituted a significant majority (unstable vs potentially unstable and unstable vs. stable, p = 0.0006 and p = 0.0008 respectively). Due to the fact that majority of carotid atheromatous plaques appear to be unstable or potentially unstable because of the inflammation and related mechanisms, the role of the inflammatory-immunologic component of atherosclerosis should be used in prophylaxis of stroke and the new therapeutic concepts worked out.

The character of haemostatic disorders and level of protein S-100 in acute ischaemic stroke can affect survival in the first week of follow-up: a pilot study.

Disorders of haemostasis which result in ischaemic stroke usually appear as thromboembolism in peripheral veins and the pulmonary circulation, and to a lesser extent as coagulopathy. The S-100 protein, a marker of stroke, correlates positively with the neurological deficit National Institutes of Health Stroke Scale (NIHSS). We adopted the hypothesis that early death of patients with acute ischaemic stroke can be explained by changes in blood coagulation and fibrinolysis. The study included 84 patients hospitalized with acute ischaemic stroke. Three groups were created: I (death between 1 and 2 days), II (death between 5 and 7 days) and III (with no deaths in hospital). We measured levels of fibrinogen, antithrombin, D-dimers, plasmin-antiplasmin complexes, plasminogen and clotting times (prothrombin time and activated partial thromboplastin time), platelet number, euglobulin clot lysis time (ECLTindex) and S-100 protein, C-reactive protein and white blood cells (WBCs). Group I had lower concentrations of fibrinogen compared to groups II (3.13 vs. 4.18, P<0.01) and III (3.13 vs. 3.77, P<0.02) and higher levels of D-dimers (3643 vs. 2278, P<0.05), higher concentrations of plasmin-antiplasmin complexes (1410 vs. 882, P=0.03) and a lower ECLTindex (152 vs. 219, P<0.02) when compared with group III. Group I also had higher concentrations of protein S-100 (2.09 vs. 0.61, P<0.001), higher NIHSS (18.0 vs. 13.2, P=0.073) and number of WBC (14.1 vs. 11.1, P<0.02) than in group III. The observed abnormalities in haemostasis, either found systemically or locally as cerebral microvascular thrombosis, may be factors potentially associated with death of patients with the shortest survival time.

Clinical characteristics of early and late recurrent ischaemic stroke.

BACKGROUND AND PURPOSE: The aim of the study was to search for differences between clinical characteristics of recurrent ischaemic stroke which occurred within the fifth year after the first event or later, and early recurrence, i.e. within the first year after first-ever ischaemic stroke. We also tried to determine prognostic factors of late recurrent ischaemic episodes. MATERIAL AND METHODS: The patients were divided into two groups: group I comprised 124 individuals with recurrence within the first year, and group II - 98 individuals in whom the recurrent episode appeared within the fifth year or later. RESULTS: A significantly higher percentage of patients in group I demonstrated evident stenosis (70% or more) of internal carotid artery ipsilateral to stroke (p = 0.023). In this group more cardioembolic strokes were found compared to group II, while in the latter, predominantly lacunar strokes appeared (p = 0.046 and 0.0002, respectively). Group II patients significantly more frequently reported acetylsalicylic acid application, including systematic drug use (p = 0.001). No evident differences were found between groups considering other important non-modifiable and modifiable risk factors of stroke. CONCLUSIONS: Small differences between risk factors of ischaemic stroke profiles in patients with early and late recurrent episodes do not allow us to distinguish unequivocally a group of patients with better prognosis regarding the time of recurrent stroke. Use of antiplatelet drugs, either systematic or non-systematic, and lacunar stroke are independent, positive prognostic factors of delay of potential recurrent stroke.

Differences in the course of acute phase of spontaneous intracerebral haemorrhage in the elderly.

BACKGROUND AND PURPOSE: The aim of this study was to examine the correlation between age and clinical course of spontaneous intracerebral haemorrhage (SICH) in its acute phase (within 30 days), including severity of neurological deficit, characteristics and frequency of medical complications as well as 30-day mortality. We also attempted to determine independent predictors of early mortality. MATERIAL AND METHODS: This study comprised 153 patients with SICH admitted within 24 hours after SICH onset who were treated pharmacologically and had complete clinical data. The analysis concerned the correlation between age and neurological deficit on admission and on discharge, assessed with NIHSS score; the types and the frequency of general complications that occurred in the acute phase of SICH; characteristics of head CT images; early mortality; and survival time. Multiple logistic regression analysis was used to determine independent predictors of early mortality. RESULTS: Age of patients correlated with NIHSS score on admission (p = 0.000003) and on discharge (p = 0.02); 35.2% of patients developed medical complications, presumably infectious ones, and the age of patients who developed complications was significantly higher (p = 0.004). Patients who died (21.5%) were significantly older (p = 0.0001). Predictors of death were: age (OR 1.1, 95% CI 1.02-1.19, p = 0.002) and severity of neurological deficit on admission (OR 1.3, 95% CI 1.1-1.6, p < 0.001). CONCLUSIONS: In elderly patients with SICH, the neurological deficit and risk of medical complications are more evident. Greater neurological deficit in these patients may result from coincidence of SICH with earlier brain lesions. Age and greater neurological deficit on admission constitute predictors of early mortality in elderly patients with SICH.

Patients' and bystanders' awareness of stroke and pre-hospital delay after stroke onset: perspectives for thrombolysis in West Pomerania Province, Poland.

OBJECTIVE: Thrombolysis is a time-dependent therapy. It is therefore very important how fast stroke patients can reach hospital. The present study was designed to assess which proportion of patients with stroke (from the population of Szczecin, the capital of West Pomerania Province, Poland) reaches hospital within the recommended time from the thrombolytic therapy point of view. The purpose of our study was also to elucidate which factors can influence the time before the ambulance service is called. PATIENTS AND METHODS: The study involved 1,015 patients with stroke admitted to the Emergency Department of the University Hospital, Szczecin. RESULTS: 235 patients (23.1%) were admitted to the hospital within the appropriate period for thrombolytic therapy. Hospital arrival time was significantly earlier in older patients and in patients with severer neurological deficits. We also observed a tendency for faster hospitalization of women, the highly educated, and patients regularly using antiplatelet drugs for cardiovascular disease prevention. CONCLUSIONS: The percentage of stroke patients hospitalized within 2 h after stroke onset should be increased. The most susceptible subpopulations in our country seem to be older patients, the highly educated and patients regularly using antiplatelet drugs for cardiovascular disease prevention.

[Primary diffuse meningeal melanomatosis. Case report]. / Pierwotna czerniakowatosc opon mózgowo-rdzeniowych. Opis przypadku.

Melanoma malignum constitutes only 0.1% of central nervous system neoplasms. It can occur either as a solid tumour or as a diffuse meningeal melanomatosis. A case of the latter form of central nervous system melanoma is presented in a 44-year-old man, suffering from headaches, cerebrospinal fluid protein elevation, optic disc oedema, hydrocephalus, seizures, cranial nerves and multilevel spinal root damage. Above mentioned neurological manifestations gradually increased within 18 months after onset of first symptoms of the disease (headache). The clinical course in our patient suggested diffuse leptomeningeal involvement. Despite the use of detailed diagnostic procedures, the correct diagnosis of primary diffuse meningeal melanomatosis was established at postmortem examination. We present our case because of the casuistic rarity of primary diffuse meningeal melanomatosis coexisting with obstructive hydrocephalus resulting from, among other things, extensive neoplastic infiltration of the vertebral channel, especially the cauda equina.

An approach of patients with ischemic stroke to primary and secondary stroke prevention in Poland.

INTRODUCTION: The stroke mortality rate in the Polish population is significantly higher than the average stroke mortality in Western Europe. It may prove a poor "initial" health condition of the Polish population which is afflicted with many life-threatening diseases which are at the same time the major risk factors for both: first ever and recurrent stroke. The aim of our study was to evaluate what is an attitude of Polish people with first-ever or recurrent stroke to keeping under control the most important risk factors for ischemic stroke. MATERIAL AND METHODS: 1282 consecutive patients with ischemic stroke were examined and categorized as individuals with first ever (group I - 980 patients) and recurrent stroke (group II - 302 patients). The data on the patients' previous history of stroke and vascular modifiable risk factors diagnosed before the onset of stroke: arterial hypertension (AH), type 2 diabetes mellitus (DM), ischemic heart disease (IHD), atrial fibrillation (AF), cigarette smoking and alcohol consumption were determined. The treatment with antiplatelet agents or oral anticoagulants was also taken into account. RESULTS: More than one-third ofpatients, irrespective of group admitted that they had treated AH unsystematically or not treated at all. Based on initial blood pressure, it may be suspected, that also individuals declaring systematic AH treatment, did not do it effectively. It also concerned the type 2 DM - glycemic control remained unsatisfactory within the period preceding first-ever and recurrent stroke. After first stroke, the patients haven't changed their habits considering tobacco smoking and alcohol consumption. The anticoagulants were used relatively seldom in relation to recommendations in both group of patients. CONCLUSIONS: The main risk factors for ischemic stroke are poorly controlled by Polish patients before first ever stroke. After the first cerebrovascular event they usually don't change their habits, which lead to recurrent stroke. In Poland the educational strategies regarding repetitive public information on benefits resulting from stroke prevention and fatal stroke consequences should be centered around the general public and the groupof high-risk patients.