Spontaneous spinal epidural haematoma: management and main risk factors in era of anticoagulant / antiplatelet treatment.

AIM OF THE STUDY: Spontaneous spinal epidural haematomas (SSEH) are rare nosological units wherein acute collections of blood develop in the spinal canal. SSEH are usually manifested by sudden severe back pain accompanied by the development of neurological symptoms. In this study, we retrospectively describe management and the main risk factors of SSEH in a series of 14 cases. MATERIAL AND METHODS: Between 2010 and 2019, we examined 14 patients (age range 17-89 years, 10 women) diagnosed with SSEH. Eight cases were patients using anticoagulant therapies (six warfarin, one dabigatran, one apixaban) and two others were using ASA of 100 mg/day. The exact localisation and extent of changes was determined from acute magnetic resonance imaging. Three people using warfarin had INR values higher than 3.0 at the time of their diagnosis. RESULTS: Ten patients (71%) were taking oral anticoagulants or antiplatelet agents. In seven patients, SSEH were localised in the lower cervical/thoracic spine. Ten patients (71%) had arterial hypertension. Six patients underwent acute surgery due to rapidly developing spinal cord compression. Eight patients (57%) with slight or mild neurological symptoms were successfully managed without surgery. CONCLUSIONS: SSEH should be suspected in any patient receiving anticoagulant/antiplatelet agents who complains of sudden, severe back pain accompanied by neurological symptoms. SSEH is mostly localised in the lower cervical/thoracic spine. Arterial hypertension appears to be a risk factor of SSEH. Early decompression is an important therapeutic approach; in cases with minor neurological deficits, conservative treatment may be chosen.

Encephalitis with Prolonged but Reversible Splenial Lesion.

INTRODUCTION: The splenium of the corpus callosum has a specific structure of blood supply with a tendency towards blood-brain barrier breakdown, intramyelinic edema, and damage due to hypoxia or toxins. Signs and symptoms of reversible syndrome of the splenium of the corpus callosum typically include disorientation, confusion, impaired consciousness, and epileptic seizures. CASE REPORT: A previously healthy 32-year-old man suffered from weakness, headache, and fever. Subsequently, he developed apathy, ataxia, and inability to walk, and therefore was admitted to the hospital. Cerebrospinal fluid showed protein elevation (0.9 g/l) and pleocytosis (232/1 ul). A brain MRI showed hyperintense lesions in the middle of the corpus callosum. The patient was treated with antibiotics, and subsequently, in combination with steroids. Two months later, the hyperintense lesions in the splenium and the basal ganglia had disappeared. Almost seven months since his hospitalization in the Department of Neurology, the patient has returned to his previous employment. He now does not exhibit any mental changes, an optic edema and urological problems have improved. In addition, he is now actively engaged in sports. CONCLUSION: We have described a case of a 32-year-old man with confusion, ataxia, and inability to stand and walk. The man developed a febrile meningeal syndrome and a hyperintense lesion of the splenium, which lasted for two months. Neurological changes, optic nerve edema, and urinary retention have resolved over the course of seven months. We think that the prolonged but transient lesion of the splenium may have been caused by encephalitis of viral origin.

Association of Giant Cell Arteritis with Papillary Thyroid Carcinoma.

Previous studies suggest that there may be an association between cancer and autoimmune diseases. We describe the case of a 59-year-old patient who did not have any significant diseases in the last year. She had new onset of fever of unknown aetiology, headache, fatigue and night sweats. We used laboratory methods to rule out infectious diseases. Significant laboratory findings reported increased signs of inflammation and anti-nuclear antibody (ANA) positivity. Positron emission tomography/computed tomography (PET/CT) imaging showed the origin of the patient's difficulties, arteritis, with increased metabolic activity in the aortic wall and other arteries. Doppler ultrasonography of the arteries did not show pathology in the temporal arteries but found accelerated blood flow in the superior mesenteric artery (AMS). Another finding from PET/CT was a tumour in the thyroid gland, later verified histologically as papillary thyroid carcinoma (PTC). We investigated the link between rheumatological disease and papillary carcinoma, applying similar therapy, corticosteroids and immunosuppressants.

Guillan-Barré Syndrome after First Vaccination Dose against COVID-19: Case Report.

A number of neurological complications have been reported after the administration of flu vaccine, including Guillain-Barré syndrome (GBS), especially after vaccination against swine flu. Only facial nerve neuropathy has thus far been reported after vaccination against COVID-19. More recently, there was a case of an elderly woman with GBS. In our report, we describe a case of a 42-year-old, previously almost healthy male who developed sensory symptoms 14 days after the first dose of Pfizer vaccine. One week later, the patient developed right facial nerve palsy and lower limb weakness and was no longer able to walk. Albuminocytological dissociation was detected in the cerebrospinal fluid, and there were inflammatory radicular changes in MRI scans of the lumbosacral spine. EMG indicated significant demyelinating polyradiculoneuritis and no antibodies against gangliosides were demonstrated. A 5-day course of immunoglobulins at a dose of 2 g/kg lead to a significant improvement and the patient was soon able to walk. In conclusion, we report a case of Guillan-Barré syndrome after COVID-19 vaccine in a young patient with a rapid diagnosis and prompt administration of immunoglobulins.

Acute Compartment Syndrome.

Acute compartment syndrome occurs most frequently in connection with injuries, terminal or chemical damage of tissues, ischemia, the activity of toxins or in patients with tissue ischemia or muscle necrosis. Clinical findings have found pronounced pain, followed by paresthesias, pallor, and paresis. Decreased pulsation of arteries has also been a frequent finding. In severe forms decompressive fasciotomy has been indicated within the first 12-24 hours after diagnosis. In the following paper, the authors present the case report of a 68-year woman who swallowed 1500 mg of trazodone as an attempt at suicide. After 12 hours her husband found her lying on the carpet with compression of the left arm under the trunk. The patient was treated conservatively and followed clinically, examined by ultrasonography, EMG and finally MRI.

Myelin Oligodendrocyte Glycoprotein Antibody Associated Transverse Myelitis.

Antibodies against myelin oligodendrocyte glycoprotein cause inflammatory lesions of central myelin - in optic nerves, of the brainstem, and spinal cord. There are characteristic changes of CNS white matter, protein-cytological association in cerebrospinal fluid, MOG IgG antibodies, a very important differential diagnosis and a relatively mild course.

Focal nodular hyperplasia: spoke-wheel arterial pattern and other signs on dynamic contrast-enhanced ultrasonography.

OBJECTIVE: To evaluate the prevalence of spoke-wheel pattern and typical symptoms of focal nodular hyperplasia (FNH) by means of dynamic contrast-enhanced ultrasonography (CEUS) in relation to lesion size. METHODS: Twenty-eight patients were included in the trial, in whom, based on the CEUS, we raised suspicion of hypervascularized liver lesion; there were 30 lesions altogether. The final diagnosis of FNH was verified by means of CT, MRI or lesion biopsy. Majority of patients (26) were females, compared to 2 male, with average age of 33.3 years. Average lesion size was 45.6 mm. Besides the ultrasound examination, we used also "blood pool" ultrasound contrast agent of second generation, sulphur hexafluoride (BR1); we evaluated enhancement of the lesion until the late stage-within 5 min from application. RESULTS: In lesions larger than 3 cm (n=20), stellate vascular enhancement was found in 19 cases (95.0%) early in arterial phase. As for lesions smaller than 3 cm (n=10), spoke-wheel pattern was observed only in 3 cases (30%) and lesions smaller than 2 cm practically did not show this phenomenon at all (n=1; 17%). Generally, symptom of spoke-wheel pattern was observed in 22 cases, i.e. in 73.3%. In total, central scar was present in 63.3% (n=19) of cases. In lesions larger than 3 cm, it was present in 85.0% (n=17), in lesions smaller than 3 cm in 20% (n=2). CONCLUSION: Contrast-enhanced ultrasonography can be the final diagnostic method for FNH larger than 3 cm which has typical spoke-wheel vessel structure on CEUS. If this phenomenon is not present and the central scar is not visible, specific diagnosis of FNH cannot be based solely on CEUS findings.

Carotid intima-media thickness and laboratory parameters of atherosclerosis risk in patients with breast cancer.

AIM: To investigate the relation between intima-media thickness (IMT) and laboratory parameters of atherosclerosis risk in patients with breast carcinoma. PATIENTS AND METHODS: IMT and a panel of laboratory parameters associated with the risk of atherosclerosis were studied in 192 patients with histologically-verified breast carcinoma. RESULTS: Patients with metastatic disease had significantly higher fibrinogen, C-reactive protein (CRP), urinary neopterin and mean IMT, and significantly lower serum albumin and hemoglobin concentrations. Significant correlations were observed between CRP, urinary neopterin, mean IMT and other parameters of cardiovascular risk. Age was an independent predictor of the presence of sonographic signs of atherosclerosis using logistic regression, and age, glucose, time from start of chemotherapy, high-density lipoprotein cholesterol, D-dimers were independently associated with IMT in stepwise regression models. CONCLUSION: In addition to the associations between IMT and laboratory or clinical parameters of the risk of atherosclerosis, IMT may also be associated with the time from chemotherapy.

Intima-media thickness, myocardial perfusion and laboratory risk factors of atherosclerosis in patients with breast cancer treated with anthracycline-based chemotherapy.

An increased incidence of complications of atherosclerosis has been noted in cancer survivors. The aim of the present study was to evaluate, in patients with breast carcinoma, the effect of antracycline-based chemotherapy on carotid intima-media thickness (IMT), myocardial perfusion, assessed by single-photon emission tomography (SPECT) and laboratory parameters associated with the risk of atherosclerosis. Thirty-six patients with breast cancer were evaluated before and after anthracycline-based chemotherapy. Retinol, alpha-tocopherol, glycosylated hemoglobin and urinary neopterin were measured by high-performance liquid chromatography. Peripheral blood cell count, D-dimers, fibrinogen, antithrombin, glucose, magnesium, creatinine, uric acid, albumin, C-reactive protein, lipoprotein (a), cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, triglycerides, homocysteine, urinary albumin and N-acetyl-beta-D-glucosaminidase (NAG) were determined with routine methods. No significant differences were observed between patients and 16 controls. Compared to the measurement before the start of therapy, peripheral blood leukocyte and platelet count, hemoglobin, creatinine, HDL cholesterol, retinol, albumin, urinary albumin and NAG decreased, and total cholesterol, LDL cholesterol, triglycerides, neopterin and mean IMT increased significantly after the treatment. Of the 36 patients who had SPECT after treatment, perfusion defects were noted only in two cases, including the patient who had perfusion defects at baseline examination and a patient who did not have a baseline SPECT. In conclusion, a significant increase in carotid IMT, total cholesterol, LDL cholesterol, triglycerides and urinary neopterin and a decrease of peripheral blood leukocyte and platelet counts, hemoglobin, creatinine, HDL cholesterol, retinol, albumin and NAG were observed after the treatment.