Correlation of Inflammatory Parameters with the Development of Cerebral Vasospasm, Takotsubo Cardiomyopathy, and Functional Outcome after Spontaneous Subarachnoid Hemorrhage.

Background: The present work aimed to determine whether a relationship exists between inflammatory parameters and the development of vasospasm (VS) and Takotsubo cardiomyopathy (TTC), as well as clinical outcome, in patients suffering from spontaneous subarachnoid hemorrhage (SAH). Methods: In this study, the authors processed the prospectively collected laboratory and clinical data of spontaneous SAH patients admitted to the neurointensive care unit between March 2015 and October 2023. The highest values of neutrophils (NEUpeak), monocytes (MONOpeak), neutrophil-to-lymphocyte ratio (NLRpeak), and CRP (CRPpeak) during the initial 7 days were correlated with the occurrence of VS and TTC, and with the outcome measures at day 30 after onset. Results: Data were collected from 175 SAH patients. Based on ROC analysis, for the development of VS, MONOpeak was the most accurate indicator (AUC: 0.619, optimal cut-off: 1.45 G/L). TTC with severe left ventricular dysfunction (ejection fraction < 40%) was indicated most sensitively by NEUpeak (ROC: 0.763, optimal cut-off: 12.34 G/L). Both for GOS and Barthel Index at day 30, CRPpeak was the best predictor for the outcome (GOS: ROC: 0.846, optimal cut-off: 78.33 mg/L and Barthel Index: ROC: 0.819, optimal cut-off: 78.33 mg/L). Conclusions: Laboratory parameters referring to inflammation during the initial 7 days after SAH correlate with the development of VS and TTC, and thus may predict functional outcome.

Assessment of malformations, variations and diameters of vessels forming the circle of Willis - An autopsy study in a non-cerebrovascular cohort.

Background a purpose: The collateral capacity of the circle of Willis (CoW) may play an important role in the development of ischemic strokes. The occurrence of classical polygon shows wide geographical variations and morphological data on diameters of the Willisian collaterals are scarce. We aimed to assess CoW variations and vessel diameters in a Central European cohort. Subjects and methods: CoWs were removed during routine autopsy. The morphological pattern of the circles was recorded. The prepared circles were then put between two glass plates and tightly compressed. The length of the vessels and half of the circumference were measured under a light microscope enabling measurement with an approximation of 0.1 mm. Vessel diameters were calculated from vessel circumference. Results: A total of 110 circles were analysed. Incomplete circles (missing one or two segments of CoW) were found in 25 cases (22.7%). Any forms of anatomical variations were detected in 14 cases (12.7%). When applying the <1 mm diameter threshold for analysis, 36 anterior communicating arteries (32.7%), 53 right posterior communicating arteries (48.2%), 73 left posterior communicating arteries (66.4%) and 18 posterior communicating arteries (16.3%) on both the sides were considered hypoplastic. Conclusions: In patients without stroke in their history, complete CoW may be present in >60% of the cases. Our diameter data may serve as reference values for the Central-European population.

Takotsubo cardiomyopathy in patients suffering from acute non-traumatic subarachnoid hemorrhage-A single center follow-up study.

BACKGROUND: Takotsubo cardiomyopathy (TTC) is an important complication of subarachnoid hemorrhage (SAH), that may delay surgical or endovascular treatment and may influence patient outcome. This prospective follow-up study intended to collect data on the prevalence, severity, influencing factors and long-term outcome of TTC in patients suffering from non-traumatic SAH. METHODS: Consecutive patients admitted with the diagnosis of non-traumatic SAH were included. Intitial assessment consisted of cranial CT, Hunt-Hess, Fisher and WFNS scoring, 12-lead ECG, transthoracic echocardiography (TTE), transcranial duplex sonography and collecting laboratory parameters (CK, CK-MB, cardiac troponin T, NT-proBNP and urine metanephrine and normetanephrine). Diagnosis of TTC was based on modified Mayo criteria. TTC patients were dichotomized to mild and severe forms. Follow-up of TTE, Glasgow Outcome Scale assessment, Barthel's and Karnofsky scoring occurred on days 30 and 180. RESULTS: One hundred thirty six patients were included. The incidence of TTC in the entire cohort was 28.7%; of them, 20.6% and 8.1% were mild and severe, respectively. TTC was more frequent in females (30/39; 77%) than in males (9/39; 23%) and was more severe. The occurrence of TTC was related to mFisher scores and WFNS scores. Although the severity of TTC was related to mFisher score, Hunt-Hess score, WFNS score and GCS, multivariate analysis showed the strongest relationship with mFisher scores. Ejection fraction differences between groups were present on day 30, but disappeared by day 180, whereas wall motion score index was still higher in the severe TTC group at day 180. By the end of the follow-up period (180 days), 70 (74.5%) patients survived in the non-TTC, 22 (81.5%) in the mild TTC and 3 (27%) in the severe TTC group (n = 11) (p = 0.002). At day 180, GOS, Barthel, and Karnofsky outcome scores were higher in patients in the control (non-TTC) and the mild TTC groups than in the severe TTC group. CONCLUSIONS: Takotsubo cardiomyopathy is a frequent finding in patients with SAH, and severe TTC may be present in 8% of SAH cases. The severity of TTC may be an independent predictor of mortality and outcome at 6 months after disease onset. Therefore, a regular follow-up of ECG and TTE abnormalities is warranted in patients with subrachnoid hemorrhage for early detection of TTC. TRIAL REGISTRATION: The study was registered at the Clinical Trials Register under the registration number of NCT02659878 (date of registration: January 21, 2016).

Correlation between calcium, water contents and ultrasonographic appearance of atherosclerotic lesions of carotid artery lesions.

BACKGROUND: We tested the hypothesis whether there is a correlation between the echogenicity and calcium and water contents of carotid plaques. PATIENTS AND METHODS: Ninety carotid befurcations from 45 deceased patients were removed during autopsy. Thirty-four plaques were categorized as homogenous echolucent (HEL), homogenous echogenic (HEG) and heterogenous (HE) plaques based on premortem B-mode image. Water content was expressed in % of wet weight. Ca was determined by proton-induced X-ray emission and expressed in ppm. Relative optical density of the B-mode images was analyzed offline using a computer program. RESULTS: HEL plaques had lower Ca content (medians and IQRs: 6,145 [4,465-6,536 ppm]) compared to HEG (74,100 [15,300-1,44,500-ppm]), P ≤ 0.001). HE plaques showed an intermediate calcium content (7,310 [4,840-9,920 ppm]) that was statistically not different from echolucent plaques. Water content of HEG plaques was statistically not different from HEL and HE (HEG:53.5 [35.5-64%], HEL: 73.5 [69.7-78.5%], HE: 70.6 [67.4-73.9%]). HEG plaques had the highest relative optical densities (196 [188-217%]). HEL and HE had similar relative optical densities (HEL: 176 [164-187%], HE: 164 [144-188%], respectively). A significant positive correlation was found between the Ca content and relative optical density of plaques. CONCLUSIONS: Echogenicity of carotid plaques increases along with their calcium content. Water content may be an important factor in differentiation of different plaques.

Assessment of two prophylactic fluid strategies in aneurysmal subarachnoid hemorrhage: A randomized trial.

OBJECTIVE: To compare the effect of two prophylactic euvolemic fluid strategy regimens on the incidence of cerebral vasospasm and clinical outcomes in patients with aneurysmal subarachnoid hemorrhage (SAH). METHODS: Ninety-six patients with a basal intravenous intake of 15 mL/kg/day of Ringer's lactate solution were included, and an additional 15 to 50 mL/kg/day Ringer's lactate (RL-group) or hydroxyethyl starch 130/0.4 solution (HES-group) was administered to maintain the targeted mean arterial pressure. The primary end point was the occurrence of cerebral vasospasm during the first 14 days. The secondary end points were case fatality, Barthel's index, and Glasgow Outcome Scores (GOS) at 30 days after SAH. RESULTS: Cerebral vasospasm developed in 42 patients (43.7%), and nine of these events were severe. The vasospasm rate among the RL- and HES-based groups was 25/48 and 17/48, respectively. For the secondary endpoint, four patients (4%) died by the end of follow-up (two in each group). Unfavorable outcome cases were not different in the RL and HES groups (9 vs. 14, respectively). There was no difference between the Barthel's scores at 30 days between the two groups. CONCLUSIONS: Using starches in a prophylactic treatment strategy in aneurysmal SAH in not supported by the study.The trial was registered at Clinicaltrials.gov under the number NCT02064075.

Administration of preemptive analgesia by diclofenac to prevent acute postcraniotomy headache.

PURPOSE: Postcraniotomy headache (PCH) is a frequent perioperative complication in neuroanesthesia. The aim of the present work was to assess the incidence of PCH and to test the efficacy and safety of preoperatively administered diclofenac. METHODS: Patients undergoing craniotomies for intracranial tumor resections were enrolled. In the case group 100 mg diclofenac p.o. one hour prior to surgery was used as a preemptive analgesic along with infiltration of the surgical site with a combination of lidocaine and epinephrine. In controls only surgical site infiltration was used. VAS scores were assessed preoperatively, on the day of surgery (DoS), on the 1st and 5th postoperative days. RESULTS: We have found that PCH of any severity is between 50-90% during the first five days after surgery. The number of cases characterized as "no pain" significantly decreased in the early postoperative period, but remained in both groups still higher on the 5th postoperative day than observed preoperatively. In both groups, the number of headaches characterized as mild pain remained relatively stable and substantial increases in case numbers were observed in moderate and severe headaches, showing a declining tendency over time in the postoperative period. A significant effect of diclofenac pretreatment was observed compared to controls on DoS (chi2: 10.429, p<0.015), on the 1st (chi2: 8.75, p<0.032) and 5th postoperative days (chi2: 14.3, p<0.002). CONCLUSIONS: The relatively low incidence of severe PCH on day five in the diclofenac group may indicate that preoperatively administered diclofenac effectively reduces postcraniotomy headache. A randomized study is encouraged to test this hypothesis.

[Sepsis-associated encephalopathy]. / A szepszishez társuló encephalopathia.

Sepsis-associated encephalopathy is a common but neglected clinical symptom of systemic inflammatory reaction in the early phase. The clinical spectrum of diffuse cerebral dysfunction induced by systemic sepsis--sepsis-associated encephalopathy according to the new terms--varies from transient, reversible encephalopathy, to severe irreversible brain damage. The aim of the present publication is to summarize the pathophysiology, frequent symptoms and possible treatments of the disease based on international and Hungarian articles on this topic. We want to emphasize the importance of monitoring the patient's mental status due to the fact that consciousness' disturbance of different severity is an early warning sign of sepsis, so it has high clinical significance.

Clinical applicability of a mathematical model in assessing the functional ability of the communicating arteries of the circle of Willis.

BACKGROUND: The brain collateral blood supply, which is essential in patients suffering from significant stenoses or occlusions of the extracranial arteries, remains difficult to assess accurately in practice. We compared data obtained from transcranial color-coded duplex sonography (TCCD) combined with carotid compression tests to morphometric autopsy data and to results given by a mathematical model of the cerebral macrocirculation. METHODS AND RESULTS: In 16 moribund patients, anterior and posterior communicating arteries of the circle of Willis were divided into functional and non-functional based on the results of the TCCD combined with carotid compression tests. After death of the patients diameters and lengths of the main intracranial arteries were measured at autopsy and these values were treated with a mathematical model for calculating blood flow and blood pressure in all the segments of the arterial network. The diameters and the blood flows through the communicating arteries were found to be significantly higher in the group of functional arteries than in that of non-functional ones. However, blood flow was also shown to be dependent on other parameters such as the pressure difference between the two ends of the vessel. CONCLUSION: Our data indicate that functional ability of the Willisian collaterals depends on morphological and functional parameters, and is therefore better assessed by a functional method, such as TCCD, than by a solely morphological one, such as cerebral angiography. Mathematically based circulation modeling, when it will be possible, could be a more comprehensive tool for delineating patients at a higher risk for hemodynamic cerebrovascular insufficiency.

Carotid intima-media thickness and cerebrovascular reactivity in long-term type 1 diabetes mellitus.

PURPOSE: Diabetes mellitus (DM) is one of the leading risk factors for cerebrovascular diseases. Both macro- and microvascular damage may occur. The aim of the present work was to assess intima-media thickness as well as cerebral vasoreactivity in patients suffering from type 1 diabetes mellitus (IDDM). METHODS: Intima-media thickness and resting middle cerebral artery blood flow velocity was measured in 33 IDDM patients and 31 healthy controls. After baseline investigations, 30 seconds of breath holding (BH) and 60 seconds of voluntary hyperventilation (HV) were performed by the subjects. Transcranial Doppler measurements were performed in each case after vasodilatory (BH) and vasoconstrictor (HV) stimuli. Cerebrovascular reactivity was expressed as the percentage of change of the middle cerebral mean blood flow velocity after BH or HV. RESULTS: IDDM patients showed a significantly larger intima-media thickness (0.1 +/- 0.02 mm) than healthy controls (0.06 +/- 0.006 mm, p < 0.001). Cerebrovascular reactivity after BH was less intensive in diabetic patients (19.3 +/- 16.1%) than that of the control subjects (38.7 +/- 22.8%, p < 0.01). Similarly, HV induced a less-pronounced decrease of cerebral blood flow velocity in diabetic subjects (-30.1 +/- 13.2%) than in nondiabetics (-37.6 +/- 17.0%, p < 0.05). CONCLUSION: Our results refer to early macro- and microangiopathic involvement of the cerebral vessels, which develop in parallel with angiopathies of the other organs, such as nephropathy and retinopathy. Further prospective studies are needed to clarify the role of these macro- and microangiopathic changes in the development of cerebrovascular complications in patients suffering from DM.

[Assessment of cerebrovascular reactivity using the breath-holding test in hypertensive and normotensive adolescents--preliminary results]. / A cerebrovascularis reaktivitás vizsgálata légzés-visszatartásos teszttel hypertoniás és egészséges serdülókben (elózetes eredmények).

AIM: Authors report on preliminary results of cerebral vasoreactivity-tests performed in frame of the Debrecen Hypertension Study among hypertensive and healthy adolescents. METHODS: Investigators measured blood flow velocities before and after 30 seconds of breath holding using transcranial Doppler sonography. RESULTS: Blood flow velocities at rest were significantly higher in the hypertensive that in the healthy adolescent group. Breath holding induced less intensive cerebral vasoreactivity response in the hypertensive than in the normotensive group. CONCLUSION: It is concluded that altered arteriolar function of the cerebral arterioles can be detected already in this early stage of hypertension.