Prevalence and correlates of post-traumatic stress disorder after ischaemic stroke.

Although most often considered a consequence of traumatic event, post-traumatic stress disorder (PTSD) also occurs after illness. The aim of this study was to establish prevalence of PTSD in patients with ischaemic stroke (IS) and its correlation to lesion location, degree of disability, age, gender and marital status. The study included 85 patients with IS. PTSD was diagnosed using a modified version of the PTSD Checklist Specific for a stressor (PCL-S). Depression and anxiety were assessed using Hospital Anxiety and Depression Scale (HADS). We defined stroke localisation as right cerebral hemisphere, left cerebral hemisphere, brainstem and cerebellum. Stroke severity was measured using the modified Rankin scale (mRS). Demographic information including age, gender and marital status was collected from medical history. Of the 85 patients with IS, 11 (12.9%) fulfilled PCL-S criteria for PTSD. We found a positive correlation between PTSD and higher degree of disability, P < 0.001. Patients with PTSD had lesions more frequently localised in the right cerebral hemisphere and the brainstem. We found no statistically significant correlation of PTSD with age, gender and marital status. Our results show that a significant number of IS patients develop PTSD after IS. Determining correlates of post-stroke PTSD can help to identify those at higher risk for its development. If proven by additional large sample studies, more patients can benefit from screening for the PTSD symptoms.

Distribution of Stroke Risk Factors in Eastern Croatia.

The aim of this study was to determine the distribution of risk factors according to age, gender, subtypes and recurrence of stroke in eastern Croatia. The study included 250 acute stroke patients admitted to University Department of Neurology, Osijek University Hospital Centre in 2011. Patients were grouped according to age, gender, subtypes and recurrence of stroke. The study showed significant differences in the distribution of cigarette smoking, diabetes, cardiomyopathy and hyperuricemia according to patient age. According to gender, male patients had a significantly higher prevalence of smoking and alcohol abuse, whereas in female patients the prevalence of arterial hypertension, atrial fibrillation and hyperuricemia was significantly higher. Regarding stroke subtypes, significant differences were noticed in the prevalence of arterial hypertension, atrial fibrillation, cardiomyopathy and cerebral blood vessel stenosis. Atrial fibrillation was significantly more common in first-ever than in recurrent stroke. Study results identified the groups of patients requiring special attention regarding particular risk factors in eastern Croatia and emphasized the need of developing regional strategies of screening, prevention and holistic care for stroke patients.

Transcranial sonography and the pocket smell test in the differential diagnosis between parkinson's disease and essential tremor.

The aim of this study was to determine the specificity and sensitivity of transcranial sonography (TCS) and the Pocket Smell Test (PST) in differing Parkinson's disease from essential tremor. The results were compared with the dopamin transporter scan (DaTSCAN) findings. Based on the DaTSCAN finding we formed a group of patients with essential tremor (51 patients) and a group with the Parkinson's disease (59 patients). The control group consisted of 26 healthy one. To evaluate the olfactory dysfunction the PST was used, whereas by TCS the substantia nigra hyperechogenicity was marked. The sensitivity and specificity of each diagnostic method was statistically calculated. In confirming Parkinson's disease the specificity of TCS was 88.2 % and the sensitivity 94.9 %. The specificity of PST was 80.4 % whereas the sensitivity was 74.6 %. TCS and PST should be performed to evaluate which patients need to be examined by DaTSCAN.

Incidence of Stroke and Transient Ischemic Attack in Croatia: A Population Based Study.

The aim of this population based neuroepidemiological study was to establish the real incidence rates of acute cerebrovascular disease (CVD): stroke and transient ischemic attack (TIA) in the Republic of Croatia. Multicentric study included 89 501 persons of all ages in four regional centres in Croatia: Zagreb, Osijek + Slavonski Brod, Rijeka and Split. The following incidence rates of stroke, expressed at population of 100 000, have been established: Zagreb 290.52, Osijek + Slavonski Brod 302.14, Rijeka 219.65, Split 195.82. Incidence rate of stroke for the Republic of Croatia is 251.39. The following incidence rates of TIA, expressed at population of 100,000, have been established: Zagreb 87.15, Osijek + Slavonski Brod 156.53, Rijeka 90.11, Split 59.10. Incidence rate of TIA for the Republic of Croatia is 100.55. In the continental part of Croatia (Zagreb, Osijek + Slavonski Brod) incidence rate of stroke is higher by 45%, while incidence rate of TIA is higher by 82% than in the coastal part of Croatia, probably due to different lifestyle and environmental factors. The study has shown relatively high incidence rates of acute CVD (stroke and TIA) in the Republic of Croatia, which proves that CVD are a great public health problem.

Relationship between Age and Thickness of Carotid Arteries in a Population without Risk Factors for Atherosclerosis.

The intima-media thickness (IMT) of carotid arteries is a marker of subclinical atherosclerosis associated with risk factors for atherosclerosis and a predictor of vascular disease. The aim of the research was to determine the correlation of IMT and age, and above normal IMT values in healthy adults in Slavonia (eastern Croatia). The study included 275 subjects of both sexes, aged between 20 and 79, who had no clinical manifestations of vascular disease or presence of major risk factors for atherosclerosis (hypertension, hypercholesterolemia, diabetes mellitus, cigarette smoking). Ultrasonic measurement of IMT in the B-mode was performed on far walls of the carotid arteries on both sides at three locations (common and internal carotid artery, carotid bifurcation). At all three sites of measurement a high correlation between the IMT values and age was found in both sexes, including the maximum for IMT of carotid bifurcation (men r=0.92, women 0.91). Upper normal values (75th percentile) IMT of common carotid arteries were determined for the ten year age groups. It is the same for both men and women in age groups both 20-29 and 30-39 (0.41, 0.46 mm). On the other hand, in age groups 40-49, 50-59, 60-69 and 70-79 upper normal values for men are 0.57, 0.62, 0.77 and 0.96 mm, and for women 0.50, 0.57, 0.71 and 0.81 mm. Our study in healthy adults in Slavonia (eastern Croatia) established a clear con- nection between carotid IMT and age, which implies a need for taking the age as an essential factor into account when conducting researches that involve the IMT.

General recommendations for the management of aneurysmal subarachnoid hemorrhage.

Subarachnoid hemorrhage is a neurologic emergency and a detrimental cerebrovascular event with a high rate of death and complications. Recommendations have been developed and based on literature search, evaluation of the results of large international clinical trials, collective experience of the authors, and endorsed by the Croatian Society of Neurovascular Disorders, Croatian Society of Neurology including Section for Neurocritical Care, Croatian Neurosurgical Society, Croatian Society for Difficult Airway Management and Croatian Medical Association. The aim of these guidelines is to provide current and comprehensive recommendations and to assist physicians in making appropriate decisions in the management of subarachnoid hemorrhage. Evidence based information on the epidemiology, risk factors and prognosis, as well as recommendations on diagnostic work up, monitoring and management are provided, with regard to treatment possibilities in Croatia.

Recommendations for the management of medical complications in patients following aneurysmal subarachnoid hemorrhage.

These are evidence based guidelines for the management of medical complications in patients following aneurysmal subarachnoid hemorrhage, developed and endorsed by the Croatian Society of Neurovascular Disorders, Croatian Society of Neurology including Section for Neurocritical Care, Croatian Neurosurgical Society, Croatian Society for Difficult Airway Management and Croatian Medical Association. They consist of recommendations for best monitoring, medical treatment and interventions based on the literature, evaluation of the results of large international clinical trials, and collective experience of the authors.

Aphasia in patients with ischemic stroke.

Aphasia in ischemic stroke patients is associated with increased mortality, decreased rates of functional recovery, and reduced work capability. The aim was to study the prevalence and characteristics of aphasia in ischemic stroke patients. This prospective, cohort study included 177 patients (94 male and 83 female) hospitalized for ischemic stroke at University Department of Neurology in Osijek in 2010. All patients were examined by a neurologist and speech therapist to specify the subtype of stroke and speech disturbance. The study showed 75 (42.4%) study patients to have aphasia (48.2% of females and 37.2% of males). The most frequent clinical type was expressive-receptive aphasia. Aphasic patients were statistically significantly older (75 vs. 70 years) and showed female predominance (53% vs. 42%). Patients with aphasia also had a threefold share of large vessel stroke (51% vs. 17%) and approximately twofold share of cardioembolic stroke (41% vs. 22%). The share of left hemisphere stroke was nearly twofold in aphasic (61%) compared to non-aphasic (31%) patients. The study showed a high prevalence of aphasia in patients with ischemic stroke, which increased with age, was more pronounced in females and most frequently found in patients suffering from large vessel stroke and cardioembolic stroke.

Quality of life in post-stroke patients: self-evaluation of physical and mental health during six months.

The purpose of this prospective study was to determine the quality of life and resocialization of post-stroke patients in the Osijek-Baranya County during six months. The study included 161 patients (82 men and 79 women) having sustained their first ever acute stroke and being treated at University Department of Neurology, Osijek University Hospital Center in Osijek. The Health Survey SF-36 questionnaire was used for self-evaluation of the patients' physical and mental health. Initial assessment was carried out in the acute phase of the disease and follow-up assessments were carried out 30, 90 and 180 days post-stroke in patient homes. The mean value of physical health measured by SF was 46.1 on initial measurement, 37.8 on second, 44.3 on third and 53.0 on fourth measurement. The mean value of mental health was 48.0 on initial measurement, 36.6 on second, 44.0 on third and 48.5 on fourth measurement. The median of total physical health and mental health on all measurements was higher in men than in women. Comparison of the quality of life areas and the items measured by SF-36 questionnaire according to sex and measurements showed statistically significant differences on all four measurements in women for all items except for social function (p = 0.669). In men, statistically significant differences between the measurements were only recorded for the item of physical activity (p = 0.013). Stroke significantly impairs the quality of life of affected people. The study showed that the poorest results were recorded 30 days of the onset of symptoms, while recovery was achieved in six months. Patients affected by stroke who stayed with their families considered their physical and mental health better than before stroke.

Effect of elevated catecholamine levels on cerebral hemodynamics in patients with chronic post-traumatic stress disorder.

The aim of the study was to assess the correlation between the levels of catecholamines and cerebral hemodynamics in patients with chronic post-traumatic stress disorder (PTSD). The study included 50 patients with chronic PTSD hospitalized for psychiatric treatment for the first time, and 50 healthy control subjects. All study subjects were in the 30-50 age group. In PTSD group, determination of vanllylmandelic acid (VMA), an epinephrine and norepinephrine metabolite, in 24-h urine and transcranial Doppler (TCD) sonography of the circle of Willis vasculature were performed on the first day of hospital stay. The same diagnostic procedures were repeated upon the completion of 21-day medicamentous psychiatric treatment. Initial analysis revealed concurrently elevated 24-h VMA in 29 (58.00%) patients and increased values of the mean blood flow velocity (MBFV) in the circle of Willis vasculature in 34 (68.00%) patients, indicating a high correlation of the respective parameters (p = 0.3290). Second analysis performed after 21-day psychiatric treatment showed concurrently elevated 24-h VMA in eight (16.00%) patients and increased MBFV in the circle of Willis vasculature in nine (18.00%) patients, also pointing to a high correlation of the parameters observed (p = 0.7906). In the control group, only two (4.00%) subjects had elevated MBFV in the circle of Willis vessels, whereas the level of 24-h VMA was normal in all control subjects. Study results pointed to a significant association between elevated levels of stress hormones and increased MBFV in the circle of Willis vasculature caused by cerebral vasospasm. Medicamentous psychiatric treatment for PTSD administered for three weeks significantly reduced the proportion of PTSD patients with elevated levels of the catecholamine metabolite and cerebral vasospasm. Study results showed a high correlation between diurnal VMA level and elevated MBFV in the circle of Willis vessels, clearly demonstrating the effect of prolonged elevation of catecholamine levels on cerebral hemodynamics.

Quality of life of patients after stroke in county Osijek-Baranya.

The purpose of this prospective study was to determine quality of life of patients after stroke in Osijek-Baranya County. The research included 161 patients (82 men and 79 women) who had their first acute stroke and were treated at Department of Neurology, Osijek University Hospital Center The Barthel Index (BI) was used to assess functional deficiency and SS-QOL (Stroke-Specific Quality of Life) questionnaire was used for self-evaluation of patients' physical and mental health. The first assessment was carried out in the acute phase of the disease, and control assessments 30, 90 and 180 days after the stroke. Mean Barthel Index score was higher at every successive measurement (55, 80, 95, 95). All BI items were statistically significant (Friedman, p < 0.001) apart from dressing and bowel control. BI score indicated greater dependence in women in all assessments except for those taken 90 days after onset of symptoms (chi2-test, p = 0.111). Mean values of SS-QOL for physical health were: 105.2, 98.3, 105.7, 117.5 and for mental health: 64.24, 57.9, 64.3, 68.1. Statistically significant difference was present in men, both for physical health (Friedman p = 0.009) and total SS-QOL (Friedman p = 0.014), while in women there was no statistically significant difference between the measurements (Friedman p = 0.719). The research showed that stroke has significant influence on basic and specific daily life activities and interferes with the quality of life of stroke patients. Women have lower level of independence. Patients who live with their families make better evaluation of their physical and mental health.

The effect of stress hormones on cerebral hemodynamics in patients with chronic posttraumatic stress disorder.

The aim of the study was to assess the possible correlation between catecholamine and cortisol levels and changes in cerebral hemodynamics in patients with chronic posttraumatic stress disorder (PTSD). The study included 50 patients with chronic PTSD first ever hospitalized for psychiatric treatment and 50 healthy control subjects. All study subjects were aged 30-50. In PTSD patients, 24-h urine levels of the epinephrine and norepinephrine metabolites vanillylmandelic acid (VMA) and cortisol were determined and transcranial Doppler ultrasonography was performed on day 1 of hospital stay and repeated after 21-day psychiatric medicamentous treatment. On initial testing, increased level of 24-h VMA, decreased cortisol level and elevated mean blood flow velocity (MBFV) in the circle of Willis vessels were recorded in 25 (50.00%) patients. Repeat findings obtained after 21-day psychopharmaceutical therapy showed increased 24-h VMA, decreased cortisol and elevated MBFV in the circle of Willis vessels in seven (14.00%) patients (initial vs. repeat testing, P = 0.0002). Such parameters were not recorded in any of the control subjects (initial PTSD patient testing vs. control group, P = 0.0000). Study results pointed to a significant correlation between increased catecholamine levels, decreased cortisol level and elevated MBFV in the circle of Willis vessels caused by cerebral vasospasm. Psychiatric medicamentous therapy administered for three weeks significantly reduced the proportion of patients with concurrently altered cerebral hemodynamics, increased levels of catecholamine metabolites and decreased level of cortisol.

[Prevalence of acute cerebrovascular disease in Bizovac, Osijek-Baranya county: a door-to-door survey in eastern Croatia]. / Prevalencija akutne cerebrovaskularne bolesti na podrucju opcine Bizovac u Osjecko-Baranjskoj zupaniji: rezultati populacijske studije vrata-do-vrata.

BACKGROUND AND PURPOSE: A door-to-door survey was carried out in Bizovac area, Osijek-Baranya County in east Croatia. A cluster sample of 1899 inhabitants were screened to determine the prevalence of acute cerebrovascular disease (CVD): transient ischemic attacks (TIA) and stroke in this population. METHODS: We used a modified version of the World Health Organization screening instrument. A door-to-door survey of stroke was conducted in five Osijek suburbs, east Croatia. The data obtained were compared with data in personal records of the study subjects. RESULTS: On March 31, 2005, the prevalence of acute CVD was 3370/100.000 (stroke 1948/100,000 and TIA 1422/100,000), of CVD in males 3047/100,000 (stroke 1959/100,000 and TIA 1088/100,000); of CVD in females 3673/100,000 (stroke 1939/100,000 and TIA 1735/100,000); and the prevalence of acute CVD progressively increased with age: in 45-54 age group 1290/00,000 (stroke 942/100,000, TIA 348/100,000); in 55-64 age group 7895/100,000 (stroke 5623/100,000, TIA 2272/100,000); in 65-74 age group 11386/100,000 (stroke 7393/100,000, TIA 3993/100,000); and in 75-84 age group 14035/100,000 (stroke 10001/100,000, TIA 4034/100,000) as the highest figure. CONCLUSION: The study revealed a very high prevalence of acute CVD in the study area and confirmed CVD as one of the leading medical and public health issues in Bizovac area, Osijek-Baranya County, east Croatia.

Mushroom poisoning.

In the research we included a total of 207 subjects with the dismissal diagnosis of "mycetismus", who were treated at the Department of Infectious Diseases, General Hospital Osijek, during the 1983-1992 period. 32 of them were children. There were 44.93% of men, 39.61% of women and 15.45% of children. The latent time > 6 hours was determined in 51 (25%) and < 6 hours in 75% of subjects. In 156 of patients with the latent time > 6 hours, "false" poisoning occured, while 51 patients experienced real mushroom toxins poisoning. At the admission to the hospital, in patients with the latent time > 6 hours, a pathological PT (protrombine time) was established only in women, leukocytosis in both women and children, increased concentration of GGT (gamma-glutamin-transferase) in men, increased AST (aspartate-aminotransferase) and ALT (alanin-aminotransferase) only in women, and increased urea in both women and children. After 24 hours, control measuring established high values of AST and ALT extended PT uremia and exalted amount of ammonia in blood in 11 of patients (2 men, 7 women and 2 children). They had severe liver and kidney damage, the most probably caused by Amanita phalloides toxins. The latent time lasted 9 to 13 hours. Of the 11 above mentioned patients, 2 women, aged 74 and 43, and one girl, aged 6, died. No pathological laboratory parameters were established in 40 of subjects with the latent time of 6 and more hours, and the disease manifested through vomiting and diarrhea that lasted for several days. These subjects most probably suffered from mushroom toxins poisoning. Mushroom toxins irritate the mucuous membrane of the gastrointestinal tract, and there are many such poisonous mushrooms. There were no mortalities in this group of subjects.

[Treatment of hypertension in acute neurological diseases]. / Lijecenje povisenog krvnog tlaka u akutnim neuroloskim bolestima.

Continuous brain blood supply in healthy individuals is warranted by brain autoregulation, the borders of which are not completely strict and can be changed as a part of dynamic physiological control. In acute neurological diseases like hypertensive encephalopathy, brain infarction, intracerebral hemorrhage and subarachnoid hemorrhage, a great attention should be paid to cerebral perfusion pressure preservation (which represents a difference between mean arterial pressure and intracranial pressure) when blood pressure is regulated. To preserve neurological function it is necessary to know anatomic and pathophysiological qualities of brain circulation and to approach the treatment of hypertension. In case of ishemic stroke hypertension should be reduced gradually, through several days, having in mind the distance of ischemic penumbra. The ideal antihypertensive for the reduction of hypertension in acute neurological diseases should have the following characteristics precise value and time control of blood pressure, not to have a rebound-phemonenon, not to cause the effect of exceeding with initially severe hypotension, not to have impact on heart muscle and not to worsen intracranial pressure. In everyday clinical work with these patients one should act according to the instructions for management of patients with stroke prepared by the Croatian Society for Neurovascular Disorders of the Croatian Medical Association and the Croatian Society for the Prevention of Stroke.

Mortality of cerebrovascular diseases in Croatia--1958-1997.

The aim of this investigation was to analyze secular trend of mortality from cerebrovascular diseases in Croatia and its regional characteristics. The research comprised all deaths from cerebrovascular diseases in Croatia in persons aged between 35 and 74 years over the period 1958-1997. The investigated period is divided in eight 5-year periods, and for that 5-year periods proportional mortality rates, standardized mortality rates and specific mortality rates, according to the age and gender were calculated. Number of all deaths in the population aged 35-74 in Croatia, by 5-year periods rose from 18,913 to 26,788 (increase of 42%), deaths from cerebrovascular diseases from 2831 to 3959 (increase of 40%). Proportional mortality rate for this disease increased from 9.0% in the first 5-year period to 14.8% in the last 5-year period (increase of 64%). Standardized mortality rates for cerebrovascular diseases increased from 118 to 206 per 100,000 inhabitants (increase of 75%). The specific mortality rates over a 5-year period have shown a trend of increase in all men age groups and stagnation or decrease in women age groups. At the same time the rates standardized by age and sex increased by 62%. Standardized mortality rates for cerebrovascular diseases in continental communities (Osijek, Varazdin) are much higher (twice or even threefold) than those in coastal communities (Split, Rijeka). A data analysis showed that, although mortality trends of cerebrovascular diseases stagnated or even declined in some communities during the recent years, the secular trend for the entire country had a tendency of constant rise over the whole period of research. Therefore, the short-term prognosis predicts further increase of both the number and rates of deaths from cerebrovascular diseases in our country.

Transcranial Doppler ultrasound assessment of intracranial hemodynamics in patients with type 2 diabetes mellitus.

BACKGROUND: Diabetics have a 3-fold risk for cardiovascular diseases compared with non-diabetics. This study was designed to evaluate cerebral hemodynamic changes related to type 2 diabetes mellitus (DM) with transcranial Doppler ultrasonography (TCD). TCD is a highly sensitive and specific method of quick bedside assessment of cerebrovascular circulation hemodynamics. PATIENTS AND METHODS: In a prospective study, we compared a group of 100 patients with the diagnosis of type 2 diabetes mellitus (aged 48 to 67 years) and an age- and sex-matched control group of 100 healthy subjects without diabetes mellitus. We measured flow velocities (Vm) and the Gosling pulsatility index (PI) of the middle cerebral artery (MCA). RESULTS: The rate of TCD abnormalities was significantly higher in diabetic patients than in healthy control subjects (55% vs. 11%, P < 0.05). The PI was significantly higher in diabetic patients than in healthy controls (P < 0.001). Atherosclerotic changes were found in 34.0% and 71.4% of patients suffering from diabetes for <5 and > or =5 years, respectively. CONCLUSION: This study suggests that TCD is a useful marker for the detection of diabetic cerebrovascular changes. The duration and type of diabetes were found to have an impact on the development of pathologic cerebrovascular changes.

[Recommendations for care of patients with cerebral accident. Part One: Organization of care for patients with cerebral accidents, treatment of cerebral accident and neurorehabilitation]. / Preporuke za zbrinjavanje bolesnika s mozdanim udarom. Prvi Dio: Organizacija skrbi za bolesnike s mozdanim udarom, lijecenje mozdanog udara i neurorehabilitacija.

Stroke is the leading cause of disability in modern society. In developed countries stroke is the second or the third cause of death, and in Croatia it is the leading cause of death. Therefore, stroke is not only a great medical, but also economic burden. Figures show that the incidence of stroke in transitional countries is increasing, so the epidemic of stroke could be expected in the forthcoming years. The Croatian Society for Neurovascular Disorders of the Croatian Medical Association and the Croatian Stroke Society wrote the recommendations for stroke management. The first part presents the recommendations for organization of stroke care, stroke treatment and neurorehabilitation, and the second part will present the recommendations for prevention of stroke.

[Recommendations for management of patients with cerebral stroke. Part Two: Primary and secondary prevention of cerebral stroke]. / Preporuke za zbrinjavanje bolesnika s mozdanim udarom. Drugi Dio: Primarna i sekundarna prevencija mozdanog udara.

Despite the enormous progress done in the course of last years in diagnosis, treatment and rehabilitation of stroke patients, prevention is still main strategy in approaching the stroke. After the comprehensive review of the organization of stroke care, treatment and neurorehabilitation of stroke patients, this part shows the recommendations of the Croatian Society for Neurovascular Disorders of the Croatian Medical Association and the Croatian Stroke Society for primary and secondary prevention of stroke.