The Role of Early Serum Biomarkers and Clinical Rating Scales in the Prediction of Delayed Cerebral Ischaemia and Short-Term Outcome after Aneurysmal Subarachnoid Haemorrhage: Single Centre Experience.

Considering the variety of complications that arise after aneurysmal subarachnoid haemorrhage (aSAH) and the complex pathomechanism of delayed cerebral ischaemia (DCI), the task of predicting the outcome assumes a profound complexity. Therefore, there is a need to develop early predictive and decision-making models. This study explores the effect of serum biomarkers and clinical scales on patients' outcomes and their interrelationship with DCI and systemic complications in aSAH. This was a retrospective analysis including aSAH patients admitted to the Wroclaw University Hospital (Wroclaw, Poland) from 2011 to 2020. A good outcome was defined as a modified Rankin Scale (mRS) score of 0-2. The prediction of the development of DCI and poor outcome was conducted using logistic regression as a standard model (SM) and random forest as a machine learning method (ML). A cohort of 174 aSAH patients were included in the analysis. DCI was diagnosed in 79 (45%) patients. Significant differences between patients with poor vs. good outcome were determined from their levels of albumin (31 ± 7 vs. 35 ± 5 (g/L); p < 0.001), D-dimer (3.0 ± 4.5 vs. 1.5 ± 2.8 (ng/mL); p < 0.001), procalcitonin (0.2 ± 0.4 vs. 0.1 ± 0.1 (ng/mL); p < 0.001), and glucose (169 ± 69 vs. 137 ± 48 (nmol/L); p < 0.001). SM for DCI prediction included the Apache II scale (odds ratio [OD] 1.05; 95% confidence interval [CI] 1.00-1.09) and albumin level (OD 0.88; CI 0.82-0.95). ML demonstrated that low albumin level, high Apache II scale, increased D-dimer and procalcitonin levels had the highest predictive values for DCI. The integration of clinical parameters and scales with a panel of biomarkers may effectively facilitate the stratification of aSAH patients, identifying those at high risk of secondary complications and poor outcome.

Changes in autonomic nervous system during cerebral desaturation episodes in aneurysmal subarachnoid hemorrhage.

INTRODUCTION: Little evidence is available on the effect of regional cerebral desaturation (rCD) episodes that occur in the first days after aneurysm subarachnoid haemorrhage (aSAH) on the autonomic nervous system activity and on cardiovascular hemodynamics. In this study, we aimed to determine the impact of rCD episodes, developed within 5 days of aSAH, on the autonomic nervous system based on the assessment of baroreflex sensitivity (BRS) and on cardiac output (CO) and cardiac index (CI), and on cerebral autoregulation (CA). MATERIALS AND METHODS: Of 96 patients with aSAH, 36 patients (aged 57 (48-69)) met the inclusion criteria and were included in the study. Regional cerebral oxygen saturation and rCD episodes were evaluated using near-infrared spectroscopy. CA was quantified by the correlation coefficient (TOxa). Cardiac output (CO) and cardiac index (CI) were monitored using the FloTrack®/EV1000. Baroreflex sensitivity (BRS) was assessed using the cross-correlation method. Scores of 1 to 3 in Glasgow Outcome Scale were classified as a poor outcome. RESULTS: During episodes of rCD, BRS decreased significantly compared to baseline (p = 0.027) in patients who had a total duration of rCD episodes of more than 10 hours. During rCD episodes, CA improved slightly in comparison to baseline (p = 0.027). The threshold associated with poor outcome was: rSO2 < 62% (p = 0.002). CONCLUSIONS: BRS decreased in patients who had a total duration rCD episodes of more than 10 hours within the 5 days of aSAH. These results might partly explain the relationship between lower BRS and worse prognosis.

The quality of life after transnasal microsurgical and endoscopic resection of nonfunctioning pituitary adenoma.

BACKGROUND: A pituitary tumor can be reached by a transsphenoidal approach with the use of a microscope or an endoscope. The impact of the surgical technique on the patient's quality of life (QOL) is of great interest to us. Currently, the development of both surgical techniques, especially the endoscopic one, is very rapid. Treatment outcomes are extremely important, especially in terms of patients' QOL after pituitary tumor resection, irrespective of the technical aspects. OBJECTIVES: To compare the quality of life between patients who had undergone either transsphenoidal microscopic (MTS) or endoscopic (ETS) non-functioning pituitary adenoma resection. MATERIAL AND METHODS: The study population consisted of 32 consecutive patients (21 for the endoscopic and 11 for the microscopic method) who had undergone pituitary adenoma resection. Their QOL was evaluated using the World Health Organization's Quality of Life assessment tool (WHOQOL-BREF), the Sino-Nasal Outcome Test (SNOT-22) and the Visual Functioning Questionnaire (VFQ-25). Questionnaires were collected before and after surgery during the patients' hospital stay and 3 months after the surgery. RESULTS: The patients in the 2 groups did not differ significantly in terms of age, sex, tumor size, length of hospital stay, or QOL before the surgery. Vision-related QOL (VR-QOL) significantly improved in patients undergoing endoscopic surgery (p < 0.001). There were no statistically significant differences in QOL between the study groups at any stage of the trial (p > 0.05). Significantly more patients had improved QOL after endoscopic surgery according to the WHOQOL-BREF (p = 0.005) and the VFQ-25 (p = 0.002). CONCLUSIONS: The novel observation in this study is the significant improvement of VR-QOL in patients after endoscopic non-functioning pituitary adenoma resection in comparison to patients having microscopic resection. The microscopic method does not exacerbate rhinological symptoms more than the endoscopic one. Endoscopic surgery seems to be more beneficial for patients with pituitary adenoma, which deteriorates VR-QOL.

Changes in the level of cardiac troponine and disorders in pulmonary gas exchange as predictors of short- and long-term outcomes of patients with aneurysm subarachnoid haemorrhage.

SUBJECT: Cardiopulmonary abnormalities are common after aneurysmal subarachnoid haemorrhage (aSAH). However, the relationship between short- and long-term outcome is poorly understood. In this paper, we present how cardiac troponine elevations (cTnI) and pulmonary disorders are associated with short- and long-term outcomes assessed by the Glasgow Outcome Scale (GOS) and Extended Glasgow Outcome Scale (GOSE). METHODS: A total of 104 patients diagnosed with aSAH were analysed in the study. The non-parametric U Mann-Whitney test was used to evaluate the difference between good (GOS IV-V, GOSE V-VIII) and poor (GOS I-III, GOSE I-IV) outcomes in relation to cTnI elevation and pulmonary disorders. Outcome was assessed at discharge from the hospital, and then followed up 6 and 12 months later. Pulmonary disorders were determined by the PaO2/FiO2 ratio and radiography. The areas under the ROC curves (AUCs) were used to determine the predictive power of these factors. RESULTS: In the group with good short-term outcomes cTnI elevation on the second day after aSAH was significantly lower (p = .00007) than in patients with poor short-term outcomes. The same trend was observed after 6 months, although there were different results 12 months from the onset (p = .024 and n.s., respectively). A higher peak of cTnI was observed in the group with a pathological X-ray (p = .008) and pathological PaO2/FiO2 ratio (p ≪ .001). cTnI was an accurate predictor of short-term outcomes (AUC = 0.741, p ≪ .001) and the outcome after 6 months (AUC = 0.688, p = .015). CONCLUSION: The results showed that cardiopulmonary abnormalities perform well as predictive factors for short- and long-term outcomes after aSAH.

Assessment of foetal age on the basis of the selected dimensions of the thorax.

BACKGROUND: The correct definition of foetal age is a substantial problem in forensic medicine, gynaecology, obstetrics and anthropology. OBJECTIVES: The goal of the study was the mathematical assessment of the foetal age with the use of thorax selected dimensions. MATERIAL AND METHODS: The material consisted of 110 foetuses aged 4-7 months of foetal life, including 50 females in the CRL range: 80-233 mm. The following methods were incorporated: preparation, anthropological, image digital acquisition, Image J computer system measurements and statistical analysis. For each foetus the following sizes were taken: crump-rump length - CRL (v-tub), total body length - v-pl as well as brachial circumference - BC, thoracic circumference - TC and clavicular length - CLA. RESULTS: Six monofunctional mathematical models were elaborated: Bertalanffy growth curve, three Gompertz function based models and two exponential models to assess examined parameters increase along with t age. Model no. 3 for Gompertz function revealed the biggest consistency with v-pl measurements for every determination ratio R2 = 0.9944 for exponential model R2 = 0.9917. Multiple regression analysis was used to elaborate mathematical formula to assess the foetal age (determination factor R2 = 0.9997) with BC, TC parameters. CONCLUSIONS: Examined parameters BC and TC were found useful in foetal age assessment in the evaluated age range. Elaborated mathematical model can be applied in clinical practice e.g. in foetal age ultrasound determination.

Variability of the trunks and divisions of the brachial plexus in human fetuses.

BACKGROUND: The brachial plexus is an important part of peripheral nervous systems. The studies of variation of the brachial plexus and its parts in the prenatal period are extremely rare. OBJECTIVES: The goal of the study was to assess brachial plexus trunk variability and their divisions in human fetuses. MATERIAL AND METHODS: Examinations were carried out on a total of 220 brachial plexuses derived from 110 fetuses aged 4-7 months, including 50 females (45.45%) in a CRL range of 80-233 mm. The following methods were incorporated into the study: anthropological, dissection, digital image acquisition and statistical methods. Symmetry and sexual dimorphism was observed. RESULTS: Trunk variations were observed in 12 (5.45%) plexus divisions as well as in 74 (33.6%) variants cases. Variants were equally common in both genders and on both sides of the body. Variants of individual trunks were of a similar percentage, usually an observed central trunk formed by nerve roots C7 and C8. Anterior division of the middle trunk (ADMT) was the most variable division, observed in 63 (28.63%) cases. There was no asymmetry and sexual dimorphism. CONCLUSIONS: Trunk variants are rare and anomalies of divisions were observed in one-third of cases, regardless of the side of the body and sex. Brachial plexus variation recognition is important from a clinical point of view.

Mathematical models of brachial plexus development during the fetal period: clinical aspects.

BACKGROUND: The brachial plexus is an important anatomical structure. It can be damaged in both the perinatal and postnatal periods as a result of injury. The available literature does not provide much discussion of the development of the brachial plexus in human fetuses. OBJECTIVES: The goal of the study was a mathematical analysis of fetal brachial plexus growth and geometry. MATERIAL AND METHODS: The study examined 220 human brachial plexuses, derived from 110 fetuses (including 50 females - 45.45%) aged 14-32 weeks of fetal life, with a crown-rump length (CRL) ranging from 80 to 233 mm. Anthropological methods, preparation, digital image acquisition, the Image J measurement tool, the Scion Image for Windows program and statistical methods were applied. In each fetus, somatic as well as linear parameters were observed: lengths, diameters and distances between the nerves making up the brachial plexus geometry. RESULTS: In the majority of the linear parameters analyzed, no sexual dimorphism or asymmetry were observed. The following asymmetries and sexual dimorphisms appear to be significant from the clinical point of view: asymmetry in the length of the C7 and Th1 nerve left radix, asymmetry in the diameters of the musculocutaneous nerve on the left and the median and ulnar nerves on the right; as well as an increased distance between nerves roots in female fetuses. The weekly growth of individual parts of the plexus varied, as did the correlation ratios among them. The most rapid growth was observed between the 14th and 18th weeks, and the slowest between the 24th and 28th weeks. Four formulae were used in the mathematical growth model: linear regression, logarithmic function, the von Bertalanffy growth model and the Gompertz curve. CONCLUSIONS: The prenatal development of the brachial plexus is not constant. The applied mathematical functions proved useful in describing its growth rate.

Brachial plexus variations during the fetal period.

The brachial plexus is an important nervous system structure. It can be injured during the perinatal period and by postnatal damage. The goal of this study was to assess human fetal brachial plexus variability. A total of 220 brachial plexuses were surgically prepared from 110 human fetuses aged 14-32 weeks of fetal life (50 females and 60 males) ranging in CRL from 80 to 233 mm. The study incorporated the following methods: dissectional and anthropological, digital image acquisition, digital image processing using Image J and GIMP software, and statistical methods (Statistica 9.0). Symmetry and sexual dimorphism were examined. Anomalies of the brachial plexuses were observed in 117 (53.18 %) cases. No sexual dimorphism was found. It was observed that cord variations occurred more often on the left side. Division variants (33.64 %) occurred most often, but also cords (18.18 %) as well as root nerves and terminal ramifications (15.90 %) were found. Trunk anomalies were rare and occurred in only 5.45 % of plexuses. Three height types of median nerve roots in combination with the nerve were distinguished. In one-third of cases, median nerve root connections were found below the axillary fossa and even half in the proximal part of the humerus. In conclusion, the brachial plexus was characterized for anatomical structural variability. Most often division and cord variations were observed. Anomalies occurred regardless of sex or body side except for cord variants. Brachial plexus variation recognition is significant from the neurosurgical and traumatological point of view.

Anatomical variability of median nerve formation in human foetuses in clinical aspect.

BACKGROUND: The median nerve is an important nerve leaving the brachial plexus. Median nerve damages may result from tunnel syndromes or injuries. The nerve anatomical variants are of great clinical importance in hand surgery. OBJECTIVES: Clinical evaluation of median nerve divergence from brachial plexus morphological variability in foetal period. MATERIAL AND METHODS: The material consisted of 220 brachial plexus sections derived from 110 foetuses aged 14-32 weeks of foetal life (50 females and 60 males, in CRL: 80-233 mm). The survey incorporated the following methods: dissection, anthropological, image digital acquisition, Image J computer transformation system, GIMP programme and statistical methods. Typology assessment was based on 0/1 system. Sexual dimorphism and symmetry were examined. RESULTS: Median nerve left directly lateral cord in 5 cases. In 59 (26.81%) plexuses, anterior division of middle trunk co-created median nerves anomalies. The total of 9 types of anterior division of middle trunk as well as of median nerve were distinguished. Median nerve double root leaving lateral cord was observed in 10 (9.09%) cases, whereas triple lateral root was seen in one case. In 1/3 of the examined plexuses, median nerve roots combined to form the nerve beneath humeral bone head and even in ½ of the bone distal length (type II and III). Type II prevailed more often on the left side. CONCLUSIONS: Median nerve roots as well as the median nerve itself are characteristic for significant morphological variability. Nerve roots low junction into median nerve is clinically favourable as it can prevent nerve damage during injuries.