The multifactorial origin of posterior reversible encephalopathy syndrome in cyclophosphamide-treated lupus patients.

The cyclophosphamide as a predisposing factor for Posterior Reversible Encephalopathy Syndrome (PRES) and therapeutic option for systemic lupus erythematosus (SLE) is still confusing. The first and only case of PRES, probably induced by cyclophosphamide, in Croatia followed by the findings of 36 SLE patients diagnosed with PRES after treatment with cyclophosphamide worldwide are described. An 18-year-old Caucasian female patient with a 1-year history of SLE was admitted to the hospital due to lupus nephritis and acute arthritis. After the second dose of cyclophosphamide was administered, according to the Euro-lupus protocol, the patient presented with a grand mal status epilepticus. The differential diagnosis of neurolupus, cerebrovascular insult, and infection were excluded. The MRI findings showed brain changes in corresponding to PRES. The treatment consisted of antihypertensives, antiepileptics, antiedema therapy, mechanical ventilation, and avoiding further cyclophosphamide use. A Naranjo Adverse Drug Reaction Probability Scale total score of five and a probable reaction related to drug therapy (cyclophosphamide, PRES) was confirmed. In this systematic review, along with cyclophosphamide use, the main predisposing factors involved in PRES occurrence in SLE patients were active SLE and renal involvement. Due to the high number of simultaneously involved predisposing factors (max. six) and their overlapping effect, it is still not possible to clearly establish the role of every factor on PRES onset. The use of cyclophosphamide, as a contributing factor for PRES onset, should be carefully assessed, based on clinicians' experience and knowledge, in the setting of active SLE.

Simultaneous appearance of cerebral venous thrombosis and subdural hematomas as rare cause of headache in puerperium following epidural analgesia: a case report.

The aim of this study is to report the first case of simultaneous appearance of cerebral venous thrombosis (CVT) and bilateral subdural hematomas (SDHs) following epidural analgesia for labor and delivery and to point out the difficulty of establishing such a diagnosis in the presence of postpartum headache. A 26-year old primigravida with a history of epilepsy received epidural analgesia for delivery. Three days after the uneventful spontaneous vaginal delivery she complained about the headache. Patient responded very well to the pain medication and oral hydration, and the headache was relieved. Ten days after the delivery, the headache reoccurred, and an epidural blood patch was performed that successfully relieved her symptom. Stronger progressive headache with nausea reappeared two days later and the parturient was readmitted to hospital. Urgent neuroimaging examinations detected CVT of right the transverse sinus, ipsilateral cortical veins, and partially occluded superior sagittal sinus, as well as bilateral subacute/chronic SDHs. The treatment of the patient with low molecular weight heparin and antiaggregation therapy was effective. In this case, the diagnosis was delayed because of atypical clinical presentation and potentially confounding events (epidural analgesia and assumption that it was a case of PDPH). It is important to carefully observe patients in such conditions and promptly conduct suitable diagnostic tests. Otherwise, unrecognized intracranial complications and delay of appropriate therapy could be life-threatening.

Intravenous thrombolysis for acute ischemic stroke--our experiences.

Intravenous (i.v.) thrombolysis with recombinant tissue plasminogen activator (rt-PA) is the only available pharmacological therapy to improve the outcome of acute ischemic stroke. We compared 71 patients presenting with ischaemic stroke and given intravenous rt-PA (0.9 mg/kg total dose) within 3 h with 71 patients who present to the hospital more than 3 hours after stroke symptom onset. The primary endpoint was the modified Rankin scale (mRS) at 90 days, dichotomised for favourable and unfavourable (score 2-6). Outcome measures were symptomatic intracerebral haemorrhage within 36 h (haemorrhage associated with National Institutes of Health Stroke Scale [NIHSS] > or = 4 points deterioration), and mortality at 3 months. More patients had favourable outcome with the rt-PA-treated group than with the control group (64.79% vs. 22.54%; p = 0.0001). The greater proportion of patients left with minimal or no deficit 90 days after rt-PA treatment, as compared with the control group. In the treated group symptomatic intracranial hemorrhage occurred in 1 patient who recovered to a level of functional independence, and asymptomatic intracranial hemorrhage was observed in 2 patients. Our experience of an acute stroke thrombolysis service shows that we are able to provide this treatment safely and in accordance with established treatment guidelines. We recommend thrombolytic treatment in acute ischemic stroke for selected population.

The town of Cabar, Croatia, familiar pseudocluster for multiple sclerosis--descriptive epidemiological study.

Previous descriptive surveys in the town of Cabar, Croatia carried out by our own epidemiological research group, have established that this area is at high risk for MS. To confirm the above assumption and to update MS frequency in this area we conducted a community-based intensive prevalence and incidence study. On December 31st 2001, the average prevalence was 205.7 per 100,000 with prevailing age-specific prevalence in the group of patients between 30 and 49 years of age. The average incidence (1948-2004) was 5.52/100.000 population per year (95% CI = 3.27-8.72), average mortality in the year was 2.76/100 000 inhabitants (95% CI = 1.26-5.24). Sexual index stood at 1:11, starting time was 10:04 +/- 28.53 in the year, and the average duration of the disease to the prevalence 11:11 +/- 27.26 years.

The town of Cabar, Croatia, a high risk area for multiple sclerosis--analytic epidemiology of dietary factors.

Multiple sclerosis (MS) is demyelization disease of central nervous system of unidentified causes. Analytic epidemiological research of 19 patients, clinically approved cases of MS and 25 controls, autochthonic inhabitants of town of Cabar, Croatia, the high-risk zone for the disease, was made. The research plan included case-control investigation--the "door to door" questionnaire--about nutrition habits. An odds ratio (OR) was calculated for all the factors which were more frequently found in the patients than in the controls, and vice versa. The variables that were connected with significant risk for MS in the town of Cabar included: alcohol consumption (p = 0.05), animal fats/dried meat products consumption (p = 0.007), nitrate salting (p = 0.03), strong spices (p = 0.007), mixed bread (p = 0.002), oat and oat products consumption (p = 0.0075). No connection was found with regular consumption of vegetables and fruit (p = 0.009), blue fresh fish (p = 0.028), other fresh fish (p = 0.03), freshwater fish (p = 0.002), canned fish (p = 0.004), dormouse meat (p = 0.007), air-dried meat products (p = 0.004) and using the water from water supply (p = 0.011). In the town of Cabar nutritional customs, primarily food rich in animal fats, alcohol-abuse, and oat consumption could have an influence on MS pathogenesis in genetically inclined individuals.

Effect of intraventricularly administered low-dose recombinant tissue plasminogen activator on interleukin 1-beta and transforming growth factor beta concentrations in cerebrospinal fluid of patients with primary intracerebral hemorrhage associated with intraventricular hemorrhage: A retrospective study.

It is increasingly recognized that modulation of brain inflammation may uncover new potential therapeutic strategies for stroke. Recent studies have shifted focus from immunological implications in ischemic stroke to a more devastating form; the hemorrhagic stroke.The aim of this study was to investigate the neuroinflammatory response in cerebrospinal fluid in patients with primary intracerebral hemorrhage (ICH) associated with intraventricular hemorrhage (IVH) in the presence of low-dose recombinant tissue plasminogen activator (rt-PA).This retrospective study included 88 adults with primary ICH associated with IVH. Patients were divided into 2 groups: rt-PA group and non-rt-PA group, which received normal standard of care for this diagnosis. The rt-PA group was treated via catheter-based clot lysis using low-dose rt-PA injected through the external ventricular drain (EVD) system, and the non-rt-PA group was treated with saline applied to EVD system in equivalent volume. Cerebrospinal fluid samples from rt-PA were obtained from the EVD system at 4 time points: once before the drug administration, and then on day 1, 3, and 7. No attempt at randomization was made. The decision to inject rt-PA was based on the preference of the primary attending neurologist and the ability to obtain consent. Temporal interleukin-1 beta and transforming growth factor beta concentration changes were analyzed and compared between the 2 groups.The concentration of interleukin-1 beta was significantly lower in the rt-PA group than in the non-rt-PA group on day 7. In addition, the concentration of transforming growth factor beta was significantly higher in the rt-PA group than in the non-rt-PA group on day 1. There was a significant difference in interleukin-1 beta concentration between days 0 and 1 in comparison to day 3 in the rt-PA group, and between day 0 in comparison to day 3 and 7 in the non-rt-PA group. We also observed a significant difference in transforming growth factor beta concentration between days 0 and 1 and between days 3 and 7.The different pattern of pro- and anti-inflammatory cytokines in patients with ICH associated with IVH suggest distinct characteristics of secondary brain injury depending on the treatment modality.

Hyperbaric oxygen treatment: the influence on the hippocampal superoxide dismutase and Na+,K+-ATPase activities in global cerebral ischemia-exposed rats.

The influence of hyperbaric oxygen (HBO) treatment on the activities of superoxide dismutase (SOD) and Na(+),K(+)-ATPase was determined during different time periods of reperfusion in rats exposed to global cerebral ischemia. Ischemic animals were either sacrificed or exposed to the first HBO treatment 2, 24, 48 or 168 h after ischemic insult (for SOD activities measurement) or immediately, 0.5, 1, 2, 6, 24, 48, 72 or 168 h after ischemic procedure (for Na(+),K(+)-ATPase activities measurement). Hyperbaric oxygenation procedure was repeated for seven consecutive days. The results of presented experiments demonstrated the statistically significant increase in the hippocampal SOD activity 24 and 48 h after global cerebral ischemia followed by a decrease in the enzymatic activity 168 h after ischemic insult. In the ischemic rats treated with HBO the level of hippocampal SOD activity was significantly higher after 168 h of reperfusion in comparison to the ischemic, non HBO-treated animals. In addition, it was found that global cerebral ischemia induced a statistically significant decrease of the hippocampal Na(+),K(+)-ATPase activity starting from 1 to 168 h of reperfusion. Maximal enzymatic inhibition was obtained 24 h after the ischemic damage. Decline in Na(+),K(+)-ATPase activity was prevented in the animals exposed to HBO treatment within the first 24 h of reperfusion. Our results suggest that global cerebral ischemia induces significant alterations in the hippocampal SOD and Na(+),K(+)-ATPase activities during different periods of reperfusion. Enhanced SOD activity and preserved Na(+),K(+)-ATPase activity within particular periods of reperfusion, could be indicators of a possible beneficial role of HBO treatment in severe brain ischemia.

Epidemiology of primary central nervous system tumors in the Coast and Gorski Kotar County, Croatia, 1977-2000.

AIM AND BACKGROUND: To establish the incidence of primary tumors of the central nervous system (CNS) in the resident population of the Coast and Gorski Kotar County, Croatia, in the period 1977-2000. METHODS: A retrospective descriptive epidemiological study. Tumors were classified according to the World Health Organization's scheme. A total of 911 cases was identified. Information about patient gender and age at diagnosis, tumor location and histologic type was obtained from case histories, autopsy protocols and pathology reports. Age- and sex-adjusted incidence were determined by a direct standardization method. RESULTS: Histologic confirmation was obtained in 84.5% of cases. The most frequent tumors were glioblastoma in men (30.2%) and meningioma in women (29.5%). The average annual crude and world-standardized incidence was 11.2 (95% CI, 10.1-12.3) and 8.2/100,000/year (95% CI, 7.4-9.0), respectively. The highest specific age incidence was detected in the seventh decade of life, 24.7/100,000/year (95% CI, 21.4-28.8). The tumors occurred equally in each sex. The lowest incidence was detected on the islands, 7.4/100,000/year (95% CI, 5.9-9.2) and the highest along the coast, 12.7/100,000/year (95% CI, 11.4-14.0). The survey showed the highest incidence of these neoplasms in the coastal municipality of Senj, 14.7/100,000/year (95% CI, 10.3-20.5). CONCLUSION: The descriptive epidemiological incidence of primary CNS tumors in the Coast and Gorski Kotar County, Croatia, especially those of neuroepithelial and meningeal origin, correspond to the data reported in similar studies elsewhere in the world. The incidence of these neoplasms in the area investigated is uneven. Limitations in study design preclude definitive conclusions about the causes of these differences.

Ultrasound-guided percutaneous dilatational tracheostomy with laryngeal mask airway control in a morbidly obese patient.

Percutaneous dilatational tracheostomy (PDT) is a widely used and accepted method of long-term ventilation of critically ill patients in many intensive care units. However, it has certain contraindications that must be taken into account; for example, difficult anatomy and short, bull neck that are so often seen in morbidly obese persons. We present a case of a morbidly obese female patient in whom ultrasound-guided PDT was performed and in whom the airway was controlled by Laryngeal Mask Airway (LMA) during the procedure. Possible advantages of an ultrasonography-guided method and LMA control in morbidly obese patients also are discussed.

Susac's syndrome during pregnancy - the first Croatian case.

Susac's syndrome (SS) is an infrequent neurological disorder characterized by the clinical triad of encephalopathy, branch retinal artery occlusion and hearing loss due to an autoimmune endotheliopathy associated with anti-endothelial cell antibodies. At the onset of the disease SS rarely appears with the complete clinical triad. The most important diagnostic procedures involved in the diagnosis of SS are brain MRI, audiometric testing and retinal fluorescein angiography. Presence of at least two components of the SS clinical triad accompanied by specific brain MRI findings is highly suggestive of SS. We report a case of a young pregnant woman with a history of encephalopathy, hearing loss and walking impairment. Brain MRI revealed a spectrum of findings previously described in patients with SS. We induced labor at 37 weeks' gestation to start with immunosuppressive treatment and avoid possible fetal toxicity. To the best of our knowledge this is the first report of SS in Croatia.

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.

Report of the Croatian Society for Neurovascular Disorders, Croatian Medical Association. Evidence based guidelines for treatment of primary headaches--2012 update.

These guidelines have been developed to assist the physician in making appropriate choices in work-up and treatment of patients with headaches. The specific aim of the Evidence Based Guidelines for Treatment of Primary Headaches--2012 Update is to provide recommendations for establishing an accurate diagnosis and choose the most appropriate therapy in the group of patients with primary headaches, based on a comprehensive review and meta-analysis of scientific evidence with regard to treatment possibilities in Croatia. These data are based on our previous Evidence Based Guidelines for Treatment of Primary Headaches published in 2005 and other recommendations and guidelines for headache treatment.

Recommendations for diagnosis and management of multiple sclerosis.

Multiple sclerosis (MS) is a chronic demyelinating neurologic disorder that mainly affects young individuals (aged 20 to 50 years). Approximately 85% of patients experience an initial course with relapses and remissions (relapsing-remitting multiple sclerosis). Guidelines for the management of MS should be focused on three main areas: (a) the diagnosis of MS; (b) treatment of relapses; and (c) long-term preventive treatment including clinical follow up, dose adjustment, drug switch, control of therapeutic efficacy, and disease progression. Diagnosis should be established according to clinical and paraclinical criteria. Discussion on therapeutic recommendations is focused on the disease-modifying agents in acute phases and drugs for long-term treatment and symptomatic treatment. Differential diagnoses must be taken into account on making the diagnosis of MS. Therefore, diagnosis of MS should be established on clinical and radiological diagnostic criteria, cerebrospinal fluid analysis and evoked potentials.

Hemodynamic changes in the posterior cerebral circulation triggered by insufficient sympathetic innervation--cause of primary intracerebral hemorrhage?

Primary intracerebral hemorrhage (ICH) is caused by hypertensive disease of small penetrating blood vessels in the basal ganglia, brain stem and cerebellum. Those regions are supplied by arteries of the so-called posterior brain circulation with insufficient sympathetic innervation. We propose the following hypothesis: due to insufficient sympathetic innervation hemodynamic changes occur in the vascular bed of the posterior brain circulation serving as a key factor for arterial rupture. If autoregulation is insufficient to maintain normal cerebral blood flow, in abrupt rise in the blood pressure, the amount of blood is rising causing higher static pressure, and according to Laplace's law higher pressure and larger radius leads to higher wall tension and subsequent rupture of arterial wall previously weakened by prolonged hypertension.

Early onset of carpal tunnel syndrome during pregnancy: case report.

Carpal tunnel syndrome is common during pregnancy and is considered to have a short and benign course. Carpal tunnel syndrome occurs most frequently in third trimester. Patients are usually managed conservatively; symptoms improve after delivery and do not require surgical intervention. We report an interesting case of pregnancy-associated carpal tunnel syndrome in a 23-year-old woman, with detailed electrophysiological studies before and after wrist splinting.