Arterial spin labeling in neonatal magnetic resonance imaging - first experience and new observations.

PURPOSE: Arterial spin labeling (ASL) is a noninvasive non-contrast technique of perfusion imaging that uses endogenous water from the blood as the perfusion tracer, with very scant data on its use in neonates. The authors present the added value of ASL in the examined babies in their own material and discuss it in the light of the existing literature. MATERIAL AND METHODS: During the first 10 months after the purchase of a new magnetic resonance imaging (MRI) scanner, 123 neonates were examined using it in an MR-compatible incubator, 117 of them had brain MRI, and in 104 ASL was incorporated in the routine protocol, which resulted in prolongation of the study time by approximately 4 minutes. 3D ASL sequence uses Pulsed Continuous Arterial Spin Labeling (PCASL; aka pseudo continuous) technique. RESULTS: The quality of the cerebral blood flow (CBF) maps was good in all cases but 2 because all the babies were sedated. Apart from the knowledge about normal perfusion patterns in the preterm and term neonatal brains, the use of ASL sequence provided important additional information in 11 cases (10.8%): increased CBF correlating with electroencephalographic seizure localization in otherwise normal MRI (n = 1), increased CBF in the cortex without clinical information about seizures and with posthaemorrhagic changes (n = 1), increased CBF in the brain stem and decreased in the upper parts of the brain (n = 2), probably reflecting the homeostatic mechanism which allows preferential perfusion of the vital structures of the brain stem, hypoperfusion (n = 1) or hypoperfusion with peripheral hyperperfusion (n = 1) in the area of stroke, hypoperfusion of the posterior areas of the brain in the presence of subarachnoid or epidural haemorrhage (n = 3), significantly increased CBF in the presumed nidus of arteriovenous malformation causing haemorrhage (n = 1), and lack of perfusion in the supratentorial compartment in a case of suspected brain death (n = 1). CONCLUSIONS: Our short experience but relatively large volume of material encourages the use of ASL in routine neonatal MRI as a useful and non-time-consuming tool providing additional important clinical information in a significant percentage of cases.

Significance of aneurysm wall enhancement on high-resolution vessel wall magnetic resonance imaging in clinical management of patients with intracranial aneurysms.

INTRODUCTION: The prevalence of intracranial aneurysms is estimated to be around 3% in the general population. Although these are often incidental findings, they potentially carry the risk of rupture, with all of the devastating consequences of SAH. STATE OF THE ART: Several risk factors of aneurysm rupture have been identified, including aneurysm size, irregular shape, and location. Although it is widely accepted that the risk of rupture increases with size, small aneurysms remain the cause of a significant percentage of aneurysmal SAH. Up to 30% of patients with acute aneurysmal SAH have multiple aneurysms. Determining the site of rupture in these patients can be challenging, given that the results of imaging studies and clinical symptoms are sometimes inconclusive. It would be extremely useful to identify new imaging biomarkers of aneurysm instability which could have an impact on patient management and qualification for treatment. High-resolution vessel wall magnetic resonance imaging (HR-VW MRI) opens up new possibilities for improved characterisation of intracranial vasculature. One of the most promising clinical applications of this new imaging tool is the evaluation of intracranial aneurysms. CLINICAL IMPLICATIONS: Aneurysm wall enhancement (AWE) on HR-VW MRI is believed to be a marker for wall inflammation and, potentially, for aneurysm instability. In this article, we summarise the published literature on AWE with special emphasis on its use in determining the site of rupture in the setting of acute SAH in patients with multiple aneurysms, as well as its role in identifying unruptured aneurysms which are at the greatest risk of rupture. FUTURE DIRECTIONS: More and larger studies are needed to definitively establish the role of AWE on HR-VW MRI in the diagnostic workup of patients with intracranial aneurysms.

Diagnostic value of non-enhanced computed tomography in identifying location of ruptured cerebral aneurysm in patients with aneurysmal subarachnoid haemorrhage.

BACKGROUND: In patients with SAH and multiple aneurysms, the ruptured lesion must be identified to prevent recurrent bleeding. AIM OF THE STUDY: To assess the diagnostic value of non-enhanced computed tomography (NECT) in identifying the rupture site in patients with subarachnoid haemorrhage (SAH) and multiple aneurysms. MATERIAL AND METHODS: We included patients with SAH revealed by NECT and multiple aneurysms detected on computed tomography angiography (CTA) in whom a ruptured aneurysm was identified during neurosurgery. Two radiologists predicted the location of the ruptured aneurysm based on the distribution of the SAH and location of intracerebral haematoma (ICH) by NECT. RESULTS: Eighty-three patients with a mean age of 55.7 ± 14.4 years were included. Ruptured aneurysms were significantly larger (mean size 7.7 ± 4.7 mm) than unruptured aneurysms (mean size 5.9 ± 4.5 mm; p = 0.014). Interobserver agreement was 0.86 (p < 0.001). Overall sensitivity and specificity of radiological prediction were 78.3% (95% CI, 68.6%-87.1%) and 96.4% (95% CI, 94.3%-97.8%) respectively. Overall PPV and NPV were 78.3% (95% CI, 67.6%-86.3%) and 96.8% (95% CI, 94.8%-98.1%) respectively. The sensitivity and PPV for aneurysms in the anterior communicating, anterior, and middle cerebral arteries appeared to be significantly higher than in other locations (p = 0.015 and 0.019 respectively). Analysis of independent predictive factors of correct radiological location revealed that ICH predisposes to a correct radiological diagnosis with an odds ratio of 8.57 (95% CI, 1.07-68.99; p = 0.03). CONCLUSIONS: NECT has a high diagnostic value in identifying the source of bleeding in patients with multiple aneurysms for anterior circulation aneurysms, especially with coexisting ICH. For other locations, NECT is not reliable enough to base treatment decisions upon.

Comparison of Two Apnea Test Methods, Oxygen Insufflation and Continuous Positive Airway Pressure During Diagnosis of Brain Death: Final Report.

INTRODUCTION: Deterioration of the pulmonary function after the apnea test (AT) conducted with the classic oxygen insufflation AT (I-AT) is often observed during the brain death (BD) diagnosis procedure. In the present study, two AT methods were compared before a method is recommended for the currently revised Polish BD criteria. METHODS: Classic I-AT and continuous positive airway pressure AT (CPAP-AT) were performed in 60 intensive care unit patients. I-AT was performed at the end of two series of clinical tests, and approximately 1-1.5 h later, after BD was confirmed, a different method, CPAP-AT with 100% FiO2 and CPAP value of 10 cm H2O provided by a ventilator in CPAP mode was performed. The patients in I-AT and CPAP-AT groups were further divided into two subgroups: non-hypoxemic (NH) with good lung function before AT (PaO2/FiO2 index ≥ 200 mmHg) and hypoxemic (H) with poor lung function (PaO2/FiO2 index < 200 mmHg). PaO2 and PaCO2 were recorded prior to I-AT and CPAP-AT at time-point one (T1), 5 min after each test at time-point two (T2), and after 10 min prior to the end of tests at time-point three (T3). The I-AT NH subgroup consisted of 50 patients, and CPAP-AT NH subgroup 43 patients. The I-AT H subgroup consisted of 10 patients, and the CPAP-AT H subgroup 17 patients. RESULTS: In the I-AT NH subgroup, a gradual decrease in PaO2/FiO2 was observed throughout the AT but not in the CPAP-AT NH subgroup. The PaO2/FiO2 ratio during the AT in the CPAP-AT H group was stable with a slight tendency to increase but not in the I-AT H group. During the first 5 min of the AT, the mean increase in CO2 was approximately 5 mmHg/min. Most patients in all groups met the AT criteria after 5 min of the test. CONCLUSIONS: The results from the study show that I-AT may compromise pulmonary function in some cases and is one of the reasons for the recommendation of a safer option, CPAP-AT, in the currently revised Polish BD criteria. During AT, the mean CO2 increase rate was 5 mmHg/min, which, in most patients, would allow the test to be completed after just 5 min.

Accuracy of Computed Tomographic Perfusion in Diagnosis of Brain Death: A Prospective Cohort Study.

BACKGROUND This study was designed to determine diagnostic accuracy of computed tomographic perfusion (CTP) compared to computed tomographic angiography (CTA) for the diagnosis of brain death (BD). MATERIAL AND METHODS Whole-brain CTP was performed in patients diagnosed with BD and in patients with devastating brain injury with preserved brainstem reflexes. CTA was derived from CTP datasets. Cerebral blood flow (CBF) and volume (CBV) were calculated in all brain regions. CTP findings were interpreted as confirming diagnosis of BD (positive) when CBF and CBV in all ROIs were below 10 mL/100 g/min and 1.0 mL/100 g, respectively. CTA findings were interpreted using a 4-point system. RESULTS Fifty brain-dead patients and 5 controls were included. In brain-dead patients, CTP results revealed CBF 0.00-9.98 mL/100 g/min and CBV 0.00-0.99 mL/100 g, and were thus interpreted as positive in all patients. CTA results suggested 7 negative cases, providing 86% sensitivity. In the non-brain-dead group, CTP results revealed CBF 2.37-37.59 mL/100 g/min and CBV 0.73-2.34 mL/100 g. The difference between values of CBF and CBV in the brain-dead and non-brain-dead groups was statistically significant (p=0.002 for CBF and p=0.001 for CBV). CTP findings in all non-brain-dead patients were interpreted as negative. This resulted in a specificity of 100% (95% CI, 0.31-1.00) for CTP in the diagnosis of BD. In all non-brain-dead patients, CTA revealed preserved intracranial filling and was interpreted as negative. This resulted in a specificity of 100% (95% CI, 0.31-1.00) for CTA in diagnosis of BD. CONCLUSIONS Whole-brain CTP seems to be a highly sensitive and specific method in diagnosis of BD.

Serum Interleukin-23 in Polish Patients with Systemic Lupus Erythematosus: Association with Lupus Nephritis, Obesity, and Peripheral Vascular Disease.

OBJECTIVES: To analyze the correlation between the serum concentration of interleukin- (IL-) 23 and atherosclerotic changes, traditional atherosclerotic risk factors, the autoantibody profile, and involvement of selected organs in systemic lupus erythematosus (SLE) patients. PATIENTS AND METHODS: We studied 94 SLE patients and 27 controls. We analyzed the IL-23 serum concentration, autoantibodies, carotid intima-media thickness and atherosclerotic plaque, the ankle-brachial index, atherosclerotic risk factors, and organ manifestations. RESULTS: Concentrations of IL-23 significantly differed between SLE patients and the controls (p = 0.0015). On the basis of multivariate stepwise analysis, we revealed that high levels of IL-23 were associated with atherosclerotic plaque in common femoral arteries (OR = 12.67; 95% CI: 1.41-113.84), lupus nephritis (OR = 3.69; 95% CI: 1.16-12.22), and obesity (OR = 4.21; 95% CI: 1.40-12.67). Autoantibodies related to IL-23 were anti-phosphatidylethanolamine antibodies (OR = 11.06; 95% CI: 1.24-98.65) and anti-SS-B/La antibodies (OR = 15.43; 95% CI: 1.73-137.25). CONCLUSIONS: IL-23 may be involved in lupus nephritis pathogenesis. Through its association with obesity and selected antiphospholipid antibodies, IL-23 might promote a hypercoagulable state contributing to atherothrombosis development in SLE patients.

Early outcomes and periprocedural complications of transarterial embolization of brain arteriovenous malformations with Onyx®.

BACKGROUND: Brain arteriovenous malformation (BAVM) is a rare pathology diagnosed mostly in young adults. However, due to its hemorrhagic complications, it constitutes an important clinical problem. Treatment modalities available include endovascular, surgery and radiosurgery. The aim of the study was to assess the efficacy and safety of endovascular treatment of BAVM with Onyx® by reporting one-center experience. MATERIAL AND METHODS: Between 2006 and 2013, 54 patients with BAVM were embolized with Onyx. The group consisted of 24 males and 30 females, aged 10 to 65 years (mean 42.6±15.4). Clinical manifestations of BAVMs were: hemorrhage in 27 (50.0%), headaches in 12 (22.2%), seizures in 7 (13.0%) and focal neurologic deficits in 2 (3.7%) patients. Six (11.1%) patients were asymptomatic. A majority of BAVMs were of II and III grade in Spetzler-Martin scale (19 and 22 cases respectively). RESULTS: A total number of 108 endovascular procedures were performed (mean 2.00±0.98 sessions/patient). Complete obliteration of malformation was achieved in 25 (46.3%) patients, mostly with grade II and III BAVMs. In 29 (53.7%) patients, embolization led to a decrease in size of BAVM that made it feasible for other treatment modality. Morbidity and mortality rates were 5.6% and 1.8% respectively. The rate of hemorrhagic complications was 9.3%. CONCLUSION: Embolization of BAVM with Onyx® is an effective and safe method of treatment. However, regarding type and consequences of complications, the technique needs further improvement.

Massive Upper Gastrointestinal Bleeding from a Splenic Artery Pseudoaneurysm Caused by a Penetrating Gastric Ulcer: Case Report and Review of Literature.

BACKGROUND: Splenic artery aneurysm and pseudoaneurysm are rare pathologies. True aneurysms are usually asymptomatic. Aneurysm rupture occurring in 2-3% of cases results in bleeding into the lesser sack, peritoneal space or adjacent organs typically presenting as abdominal pain and hemodynamic instability. In contrast, pseudoaneurysms are nearly always symptomatic carrying a high risk of rupture of 37-47% and mortality rate of 90% if untreated. Therefore, prompt diagnosis and treatment are essential in the management of patients with splenic artery pseudoaneurysm. Typical causes include pancreatitis and trauma. Rarely, the rupture of a pseudoaneurysm presents as upper gastrointestinal (UGI) bleeding. Among causes, peptic ulcer is the casuistic one. CASE REPORT: This report describes a very rare case of recurrent UGI bleeding from a splenic artery pseudoaneurysm caused by a penetrating gastric ulcer. After negative results of endoscopy and ultrasound, the diagnosis was established in CT angiography. The successful treatment consisted of surgical ligation of the bleeding vessel and suture of the ulcer with preservation of the spleen and pancreas, which is rarely tried in such situations. CONCLUSIONS: The most important factor in identifying a ruptured splenic artery pseudoaneurysm as a source of GI bleeding is considering the diagnosis. UGI hemorrhage from splenic artery pseudoaneurysm can have a relapsing course providing false negative results of endoscopy and ultrasound if performed between episodes of active bleeding. In such cases, immediate CT angiography is useful in establishing diagnosis and in application of proper therapy before possible recurrence.

Pulmonary benign metastasizing leiomyoma from the uterine leiomyoma: a case report.

BACKGROUND: Benign metastasizing leiomyoma (BML) is a rare condition described as multiple well-differentiated leiomyomas at sites distant from the uterus. Apart from lungs it has also been reported in lymph nodes, heart, brain, bone, skin, eye and spinal cord. We present a case of pulmonary benign metastasizing leiomyoma in a female patient admitted to our hospital with suspicion of left adnexal tumor. CASE REPORT: A 45-year-old woman was referred to our hospital with suspicion of left adnexal tumor. The control transvaginal ultrasound examination performed at admission to the Gynecological Department excluded adnexal neoplasm. However, a large amount of fluid within the Douglas pouch raised the oncological concern. The patient underwent myomectomy in 2005. In the same year she was diagnosed with multiple lung nodules and underwent pulmonary wedge resection with the diagnosis of pulmonary benign metastasizing leiomyoma being stated. The decision of reevaluation of the specimen, control CT and puncture of the Douglas pouch fluid was made. Computed tomography performed at the Department of Diagnostic Imaging and Interventional Radiology of the Pomeranian Medical University Hospital revealed multiple, bilateral nodules. The microscopic examination of the samples confirmed the initial diagnosis of benign metastasizing leiomyoma with no evidence of neoplastic cells within the fluid. CONCLUSIONS: Pulmonary benign metastasizing leiomyoma is a rare entity. However, it should be always taken into consideration in women with a previous or coincident history of uterine leiomyoma, especially when no evidence of other malignancy is present.

Computed tomographic angiography criteria in the diagnosis of brain death-comparison of sensitivity and interobserver reliability of different evaluation scales.

INTRODUCTION: The standardized diagnostic criteria for computed tomographic angiography (CTA) in diagnosis of brain death (BD) are not yet established. The aim of the study was to compare the sensitivity and interobserver agreement of the three previously used scales of CTA for the diagnosis of BD. METHODS: Eighty-two clinically brain-dead patients underwent CTA with a delay of 40 s after contrast injection. Catheter angiography was used as the reference standard. CTA results were assessed by two radiologists, and the diagnosis of BD was established according to 10-, 7-, and 4-point scales. RESULTS: Catheter angiography confirmed the diagnosis of BD in all cases. Opacification of certain cerebral vessels as indicator of BD was highly sensitive: cortical segments of the middle cerebral artery (96.3 %), the internal cerebral vein (98.8 %), and the great cerebral vein (98.8 %). Other vessels were less sensitive: the pericallosal artery (74.4 %), cortical segments of the posterior cerebral artery (79.3 %), and the basilar artery (82.9 %). The sensitivities of the 10-, 7-, and 4-point scales were 67.1, 74.4, and 96.3 %, respectively (p<0.001). Percentage interobserver agreement in diagnosis of BD reached 93 % for the 10-point scale, 89 % for the 7-point scale, and 95 % for the 4-point scale (p=0.37). CONCLUSIONS: In the application of CTA to the diagnosis of BD, reducing the assessment of vascular opacification scale from a 10- to a 4-point scale significantly increases the sensitivity and maintains high interobserver reliability.

CT Angiography in the Diagnosis of Brain Death.

Summary Brain death is defined as the irreversible cessation of functioning of the entire brain, including the brainstem. Brain death is principally established using clinical criteria including coma, absence of brainstem reflexes and loss of central drive to breathe assessed with apnea test. In situations in which clinical testing cannot be performed or when uncertainty exists about the reliability of its parts due to confounding conditions ancillary tests (i.a. imaging studies) may be useful. The objective of ancillary tests in the diagnosis of brain death is to demonstrate the absence of cerebral electrical activity (EEG and evoked potentials) or cerebral circulatory arrest. In clinical practice catheter cerebral angiography, perfusion scintigraphy, transcranial Doppler sonography, CT angiography and MR angiography are used. Other methods, like perfusion CT, xenon CT, MR spectroscopy, diffusion weighted MRI and functional MRI are being studied as potentially useful in the diagnosis of brain death. CT angiography has recently attracted attention as a promising alternative to catheter angiography - a reference test in the diagnosis of brain death. Since 1998 several major studies were published and national guidelines were introduced in several countries (e.g. in France, Austria, Switzerland, the Netherlands and Canada). This paper reviews technique, characteristic findings and criteria for the diagnosis of cerebral circulatory arrest in CT angiography.

Value of C-reactive protein as a risk factor for acute coronary syndrome: a comparison with apolipoprotein concentrations and lipid profile.

OBJECTIVE: To investigate whether assessment of C-reactive protein (CRP) and apolipoproteins, besides the traditional lipid profile, enhances the assessment process for the risk of acute coronary syndrome (ACS). METHODS: The study group consisted of 220 consecutive patients admitted to hospital within the first 6 hours from the onset of chest pain. Patients were diagnosed with unstable angina (n = 96), non-ST-elevation myocardial infarction (NSTEMI; n = 57), or ST-elevation myocardial infarction (STEMI; n = 67). ACS patients were compared with 116 healthy volunteers in a case-control study. The serum was assayed on admission for CRP, apolipoproteins ApoAI and ApoB100, and lipid parameters. RESULTS: The highest concentrations of CRP were found in NSTEMI and STEMI, with a median value four-fold higher in ACS patients than in controls (P < 0.0001). Only CRP significantly increased the probability of ACS development (adjusted odds ratio for a 1 mg/L increase 1.90; 95% confidence interval [CI] 1.34-2.89) and explained 90% of the variation for ACS development. Similarly, we demonstrated the highest diagnostic accuracy for CRP among all investigated markers (area under the curve 0.80; 95% CI 0.75-0.85). CONCLUSIONS: Our study indicates that CRP superiorly to apolipoproteins and lipid profile facilitates the risk stratification for ACS occurrence.

Coexistence of splenic hemangioma and vascular malformation of the lower extremity in a child: a case report.

We report a rare finding of the coexistence of splenic hemangioma and progressive vascular malformation of the left lower extremity in a child. The lesion on the left calf was described as a vascular malformation in computed tomography and magnetic resonance. At the age of one year, the abdominal Doppler ultrasound was normal. The examination was repeated at the age of six years due to recurrent pain in the left hypochondrium and revealed giant multiple splenic hemangiomas. The girl underwent splenectomy at the age of 14 years. Histological findings demonstrated multiple cavernous hemangiomas. We present our case report regarding the diagnosis of spleen hemangioma and indications for surgical management in children.

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.

Anti-Phosphatidylethanolamine and Anti-Phosphatidylserine Antibodies-Association with Renal Involvement, Atherosclerosis, Cardiovascular Manifestations, Raynaud Phenomenon and Disease Activity in Polish Patients with Systemic Lupus Erythematosus.

OBJECTIVE: To evaluate the association between anti-phosphatidylethanolamine (aPE) and anti-phosphatidylserine (aPS) antibodies and cardiovascular risk, organ involvement and disease activity in systemic lupus erythematosus (SLE) patients. METHODS: We studied 93 SLE patients and 30 controls. We analyzed levels of anti-phospholipid antibodies, including aPS and aPE, the profiles of antinuclear, anti-neutrophil cytoplasmic (ANCA) and anti-endothelial antibodies, carotid intima-media thickness (cITM) and atherosclerotic plaque presence, ankle-brachial and high resistance indices, atherosclerotic risk factors, organ manifestations and treatment. RESULTS: Levels of aPS and aPE were significantly higher in SLE patients in comparison with the controls (p = 0.038 and p = 0.044, respectively). aPS was associated with the risk of Raynaud's phenomenon (p = 0.021) development. aPE increased the risk of renal involvement (p = 0.049), cerebral stroke (p = 0.050), high vlues of cIMT (p = 0.041) development as well as occurrence of selected serological markers associated with activity of the disease such as anti-double stranded DNA (p = 0.021). The long duration of regular smoking (p = 0.021) and the high number of cigarettes/day (p = 0.015) were significantly associated with the risk of aPE occurrence. CONCLUSIONS: Patients with aPS and aPE are at risk of vascular involvement. Especially the presence of aPE may significantly increase the risk of thrombotic complications development in SLE patients without classical serological markers of APS. Finally, aPE might be used as a marker of disease activity and risk of renal injury development in this patient group. The classical atherosclerotic markers including lipid indices play an important role in complex analysis of cardiovascular risk in lupus patients and enable to identify patients at the highest risk and implement effective preventive, diagnostic and therapeutic procedures.

Diagnostic efficacy of myeloperoxidase for the detection of acute coronary syndromes.

BACKGROUND: Early diagnosis of acute coronary syndrome (ACS) is frequently a challenging task, while immediate risk stratification remains crucial for the prompt implementation of appropriate therapy in this setting. Employing markers that increase rapidly after the symptom onset may enhance triage and therapeutic decision-making in patients suspected for ACS. Myeloperoxidase (MPO) exerting proinflammatory and pro-oxidative properties is suggested as a reliable early marker for ACS associated with unfavourable clinical outcome. We assessed the diagnostic efficacy of plasma MPO alone or in combination with cardiac troponin I (cTnI) for detecting ACS in patients presenting with chest pain initiating within 6h before the hospital admission. MATERIAL AND METHODS: A study group consisted of 253 patients diagnosed with ACS and 47 subjects having other heart disease or unspecified chest pain. Clinically healthy volunteers (n=124) served as controls. MPO concentration was measured in plasma (Abbott Diagnostics, USA), while serum was assayed for cTnI, creatine-kinase MB, lipids, glucose, creatinine, brain natriuretic peptide type B and C-reactive protein. RESULTS: Both MPO and cTnI values were significantly lower in non-ACS subjects than in patients with ACS. At 97·5th percentile as cut-off, the superiority of MPO over cTnI was observed in patients with unstable angina and non-ACS subjects. Considerably higher MPO concentrations were demonstrated in the troponin-negative ACS patients on admission who became troponin-positive after 6h. Combined evaluation of MPO and cTnI possessed remarkably higher sensitivity than assessment of cTnI alone in all patients with ACS. CONCLUSIONS: Myeloperoxidase substantially facilitates the early diagnosis of ACS.

The Role of Conventionally Fractionated Radiotherapy and Stereotactic Radiotherapy in the Treatment of Carcinoid Tumors and Large-Cell Neuroendocrine Cancer of the Lung.

The occurrence of neuroendocrine tumors among the diagnosed neoplasms is extremely rare and is associated with difficulties in undertaking effective therapy due to the histopathological differentiation of individual subtypes and the scarce clinical data and recommendations found in the literature. The choice of treatment largely depends not only on its type, but also on the location and production of excess hormones by the tumor itself. Common therapeutic approaches include surgical removal of the tumor, the use of chemotherapy, targeted drug therapy, peptide receptor radionuclide therapy, and the use of radiation therapy. This article reviews the current knowledge on the classification and application of radiotherapy in the treatment of lung NETs. Case reports were presented in which treatment with conventional radiotherapy, radical and palliative radiochemotherapy, as well as stereotactic fractionated radiotherapy in the treatment of typical (TC) and atypical (AT) lung carcinoids and large cell neuroendocrine carcinoma (LCNC) were used. We hope that the solutions presented in the literature will allow many radiation oncologists to make the best, often personalized decisions about the therapeutic qualifications of patients.

Atypical Pupil Reactions in Brain Dead Patients.

BACKGROUND: During routine diagnosis of brain death, changes in pupil diameter in response to the stimulation of peripheral nerves are sometimes observed. For example, pupillary dilation after diagnosed brain death is described in the literature as the ciliospinal reflex. However, pupil constriction creates diagnostic doubts. OBJECTIVE: The pupillometric analysis of pupil response to stimulation of the cervicothoracic spinal cord in patients with diagnosed brain death. METHODS: Instrumental tests to confirm the arrest of cerebral circulation were performed in 30 adult subjects (mean age 53.5 years, range 26-75 years) with diagnosed brain death. In addition, a pupillometer was used to measure the change in pupil diameter in response to neck flexion. INTERVENTION: Flexion of the neck and measuring the response in change of the pupil with the use of the pupillometer. RESULTS: The change in the pupil was observed in the examined group of patients. Difference in pupil size ≥ 0.2 mm was observed in 14 cases (46%). In five cases (17%), pupil constriction was found (from 0.2 to 0.7 mm). Measurement error was +/- 0.1 mm. CONCLUSIONS: Both pupillary constriction and dilatation may occur due to a ciliospinal reflex in patients with brain death. This phenomenon needs further research in order to establish its pathophysiology.

Implementation of Computed Tomography Angiography (CTA) and Computed Tomography Perfusion (CTP) in Polish Guidelines for Determination of Cerebral Circulatory Arrest (CCA) during Brain Death/Death by Neurological Criteria (BD/DNC) Diagnosis Procedure.

BACKGROUND: Brain death/death by neurologic criteria (BD/DNC) guidelines are routinely analyzed, compared and updated in the majority of countries and are later implemented as national criteria. At the same time, extensive works have been conducted in order to unify clinical procedures and to validate and implement new technologies into a panel of ancillary tests. Recently evaluated computed tomography angiography and computed tomography perfusion (CTA/CTP) seem to be superior to traditionally used digital subtraction angiography (DSA), transcranial Doppler (TCD) and cerebral perfusion scintigraphy for diagnosis of cerebral circulatory arrest (CCA). In this narrative review, we would like to demonstrate scientific evidence supporting the implementation of CTA/CTP in Polish guidelines for BD/DNC diagnosis. Research and implementation process: In the first of our base studies concerning the potential usefulness of CTA/CTP for the confirmation of CCA during BD/DNC diagnosis procedures, we showed a sensitivity of 96.3% of CTA in a group of 82 patients. CTA was validated against DSA in this report. In the second study, CTA showed a sensitivity of 86% and CTP showed a sensitivity of 100% in a group of 50 patients. In this study, CTA and CTP were validated against clinical diagnosis of BD/DNC supported by TCD. Additionally, we propose our CCA criteria for CTP test, which are based on ascertainment of cerebral blood flow (CBF) < 10 mL/100 g/min and cerebral blood volume < 1 mL/100 g in regions of interest (ROIs) localized in all brain regions. Based on our research results, CTA/CTP methods were implemented in Polish BD/DNC criteria. To our knowledge, CTP was implemented for the first time in national guidelines. CONCLUSIONS: CTA and CTP-derived CTA might be in future the tests of choice for CCA diagnosis, proper and/or Doppler pretest might significantly increase sensitivity of CTA in CCA diagnosis procedures. Whole brain CTP might be decisive in some cases of inconclusive CTA. Implementation of CTA/CTP in the Polish BD/DNC diagnosis guidelines does not show any major obstacles. We believe that in next edition of "The World Brain Death Project" CTA and CTP will be recommended as ancillary tests of choice for CCA confirmation during BD/DNC diagnosis procedures.

Invitation to participate in a multi-center study for validation of cerebral computed tomography angiography and computed tomography perfusion in the determination of cerebral circulatory arrest during brain death/death by neurological criteria diagnosis procedure in paediatric population below 12 years of age.

We would like to invite paediatric intensive care units (PICU) to join our multi-center trial concerning patient population < 12 y/o and aiming at: • validation of computed tomography angiography (CTA)/computed tomography perfusion (CTP) tests for brain death/death by neurological criteria (BD/DNC) diagnosis procedures, • validation of duplex Doppler insonation of extracranial segments of the internal cerebral arteries and the vertebral arteries for choosing an optimal time for CTA/CTP testing.