Variation of a Persistent Primitive Hypoglossal Artery (PPHA) as Incidental Finding in the Diagnostic Clarification of Cerebral Vasculopathy Associated with Intracranial Vasculitis.

We present a very rare variation of a persistent primitive hypoglossal artery (PPHA) arising from the internal carotid artery, detected during a diagnostic angiography. A 50-year-old female patient was admitted with an atypical intracranial hematoma in the left frontal lobe. Catheter angiography revealed intracranial vasculopathy with segmental stenoses, a small aneurysm of the right internal carotid artery bifurcation and a "string of beads" appearance of the left carotid artery, consistent with fibromuscular disease. On the left side, a vertebral artery ending in the posterior inferior cerebellar artery (PICA) was detected, whereas on the right side the vertebral artery was aplastic. During selective angiography of the right common carotid artery, a persistent hypoglossal artery was seen supplying the basilar artery. The literature of persistent embryonal carotid-vertebrobasilar anastomosis and their anatomical variations is discussed with respect to clinical importance for ischemia, interventional procedures, and surgery.

Impact and Effectiveness of Dual Aspiration Technique in Stent-Assisted Mechanical Thrombectomy: Recent Improvements in Acute Stroke Management.

BACKGROUND AND PURPOSE: To evaluate feasibility and impact of dual aspiration technique (DAT) within stent-assisted mechanical thrombectomy on procedural parameters and clinical outcome. MATERIALS AND METHODS: Within 16 months, 76 consecutive patients (mean age 70.7 year; range 33-89) underwent stent-assisted mechanical thrombectomy. Of 52 enrolled patients (68.4 %) with occlusion of the anterior circulation, 22 patients (42.3 %) underwent DAT; 30 patients (57.7 %) were treated in conventional monoaspiration technique (MAT). Epidemiological data, clinical and imaging characteristics (mRS, NIHSS, ASPECTS) as well as procedural details were analyzed (TICI, number of retrieval, procedure time). Clinical outcome was determined with mRS at discharge and after 90 days. RESULTS: In the context of DAT additional carotid artery stenting was required in 45.5 % (10/22) in underlying tandem lesion (vs. 0/30 MAT). No differences were found in NIHSS at admission (MAT: 20.5, range 15-29; DAT: 18.6; range 11-25), mRS at admission (MAT: 4.6 vs. DAT: 4.57) or ASPECT score (MAT: 8.3, ±1.5; DAT: 8.4, ±1.5; P > 0.05). TICI ≥ 2b/3 was conducted in 90 % (MAT) and 100 % (DAT), respectively. The procedure time was longer in the MAT group (65 min, ±25.9, range 18-126) compared to the DAT group (49.7 min, ±15, range 32-101; P = 0.016). The clinical outcome increased from admission to discharge and in follow-up after 90 days (mRS ≥ 2: MAT: 53.3 %, DAT: 54.5 %; P > 0.05). CONCLUSIONS: The dual aspiration technique with an additional intermediate guide catheter placed closed to the stent retriever leads to decreased procedure time in the anterior circulation. Even in cases with higher thrombus load and treated in DAT, clinical outcome improved.

Treating with an implant: BMS or DES?

As the minimal invasive procedures for the treatment of peripheral arterial disease grow at exponential rates, interventional radiologists and vascular surgeons are more often faced with the difficult decision of which devices are the most appropriate to bring the desired results. Under the light of the newest studies and always having in mind the concept of "leaving no metal behind", when focusing on the lesions within the superficial femoral artery and popliteal arteries, we try to answer the question: treating with an implant, bare metal stents or drug eluting stents?

Assessing neuropsychological impairment using Reitan and Wolfson's screening battery.

The aim was to verify the applicability of Reitan and Wolfson's proposed neuropsychological screening battery for adults (2006, 2008) in the Czech population. The sample consisted of 70 participants aged 19-65 years, all of whom were examined using a screening method as well as the full Halstead-Reitan neuropsychological battery (HRNB). The correlation, logistic regression, ROC curve analysis, sensitivity and specificity, and positive and negative predictive values were all calculated. The Pearson correlation between the screening scale of neuropsychological deficit and the General Neuropsychological Deficit Scale (GNDS) from HRNB was 0.78 (p < .001). When optimal cut-off scores of 8 were utilized (in accordance with Horwitz, Lynch, McCaffrey, & Fisher in Screening for neuropsychological impairment using Reitan and Wolfsons preliminary neuropsychological test battery. Archives of Clinical Neuropsychology, 23, 393-398, 2008, but different from Reitan, & Wolfson in The use of serial testing in evaluating the need for comprehensive neuropsychological testing of adults. Applied Neuropsychology, 15, 21-32, 2008), 78.6% of individuals were correctly classified having neuropsychological impairment or no impairment according to the GNDS. Our results confirm that this neuropsychological screening battery has good psychometric properties in the Czech population.

Solitaire® stent for endovascular coil retrieval.

Coil migration during embolization is an emergency, requiring individual solutions. A 71-year-old female patient was referred to our hospital suffering from subarachnoid hemorrhage due to a ruptured giant aneurysm of the ophthalmic segment of the right internal carotid artery (ICA). During the endovascular procedure, a coil migrated in the ICA. Coil dislocation could be treated by either retrieval or fixation. On intention to treat we retrieved the coil with the self-expanding Solitaire(®) AB stent (Ev3, Irvine, CA, USA). The Solitaire(®) stent is established to perform mechanical thrombectomy for treatment of acute stroke. This report demonstrates the Solitaire(®) stent's potential for safe and effective retrieval of dislocated coils. Other retrieval systems will be discussed.

Differences in onset of disease and severity of psychopathology between toxoplasmosis-related and toxoplasmosis-unrelated schizophrenia.

OBJECTIVE: Toxoplasmosis is a lifelong parasitic disease that appears to be associated to schizophrenia. However, no distinguishing attributes in Toxoplasma-infected schizophrenia patients have been described as yet. METHOD: We searched for differences in symptom profile, cognitive performance and treatment response between 194 Toxoplasma-free and 57 (22.7%) Toxoplasma-infected schizophrenia patients treated in Prague Psychiatric Centre between 2000 and 2010. RESULTS: Infected and non-infected patients differed in severity of symptoms (P = 0.032) measured with the Positive and Negative Symptom Scale (PANSS). Infected patients scored higher in positive subscale of PANSS, but not in the general and negative subscales. Infected men scored higher also in Total PANSS score, and negative, reality distortion, disorganisation and cognitive scores. Higher PANSS scores of positive, negative and disorganised psychopathology were associated with the lower titres of anti-Toxoplasma antibodies suggesting that psychopathology deteriorates with duration of parasitic infection. Infected patients remained about 33 days longer in hospital during their last admission than uninfected ones (P = 0.003). Schizophrenia started approximately 1 year earlier in infected men and about 3 years later in infected women, no such difference was observed in uninfected subjects. CONCLUSION: Latent toxoplasmosis in schizophrenia may lead to more severe positive psychopathology and perhaps less favourable course of schizophrenia.

[The significance of biological intracranial meningioma behaviour for their long-term management]. / Význam biologického chování nitrolebních meningiomu pro jejich dlouhodobý management.

INTRODUCTION: From the histological point of view, most meningiomas are benign tumours. Nevertheless, their recurrence is quite frequent, and identifying the risk factors for recurrent disease is of utmost importance. MATERIAL AND METHODS: Prospective study, patients operated on in the period 2/2008-9/2009. Inclusion criteria for enrolment into the study: age 18-70 years, good health status, and previously untreated solitary intracranial meningioma. Evaluation of clinical, surgical, MRI findings and vascular endothelial growth factor serum levels (prior to procedure, 3 months after, 12 months after, 24 months after procedure and at the time of the last follow-up in 11/2011) was performed. Immunohistochemical analysis of histological samples was carried out. Further treatment (wait and see, redo surgery, treatment with radiation using the Leksell Gamma Knife, external radiotherapy) was recorded in case of a positive follow-up MRI finding (recurrent disease, progression of residual tumour). RESULTS: A total of 50 consecutive patients (34 women and 16 men) were included into the study. Average age at the time of surgery was 59.2 years (range 27-75 years). Radical resection with no residual tumour left was achieved in 35 cases. Histological analysis showed grade I meningioma in 45 cases and grade II (atypical) meningioma in 5 cases. Correlation between E-cadherin expression and recurrent meningioma was proved by immunohistochemical examinations; in the remaining investigations, however, such a correlation was not found. No correlation was detected between the serum vascular endothelial growth factor level and the expression of vascular endothelial growth factor in immunohistochemical investigation. A correlation was found between the expression of vascular endothelial growth factor in immunohistochemical investigation and peritumoural oedema. The tumour recurred in 5 cases. CONCLUSIONS: On the basis of our results as well as literature findings we can conclude that all the patients after meningioma surgery need to be carefully followed for the rest of their life by repeated MRI invetigations.

Attentional networks in euthymic patients with unipolar depression.

BACKGROUND: The capacity to focus and concentrate or to direct attention supports many aspects of cognitive functioning including short-term memory and higher-level cognitive functions. The purpose was to assess attentional networks in euthymic patients with unipolar depression using the Attentional Network Test (ANT). MATERIALS AND METHODS: We investigated performance of attention by virtue of ANT during remission from unipolar depressive disorder and tested a hypothesis that there are no differences between outpatient group (euthymic patients, N=32) and matched controls in attentional variables, the relationship of attentional networks and everyday cognitive failures. RESULTS: No differences between the groups in attentional networks were found and no relationship between attentional networks and cognitive failures was found. LIMITATIONS: One assessment during remission could be insufficient to recognize long-term pattern of cognitive functions. CONCLUSIONS: These data show non-impaired attentional networks possibly explained by sufficient level of remission and ameliorated influence of high education on cognition.

Aripiprazole as an adjunct to clozapine therapy in adolescents with early-onset schizophrenia: a retrospective chart review.

INTRODUCTION: Combination of antipsychotic substances is a therapeutic option increasingly applied in patients with schizophrenia, who do not respond to antipsychotic monotherapy. Recently, various reports on combination of clozapine with aripiprazole in adults have been published. As there is not yet data on adolescent patients, we aimed to study the above-mentioned augmentation strategy in this population. METHODS: We included 15 patients with schizophrenia from a child and adolescent psychiatric department (8 male; mean age 19.3 [SD+/-1.2, range 17.2-21.2] years). Patients had been under clozapine treatment, followed by aripiprazole augmentation. Retrospectively, patients' medical records were reviewed, using a rating scale in analogy to the Clinical Global Impressions (CGI) scale. RESULTS: Mean observation time was 11.1 [SD+/-9.7] months. Mean CGI-Severity scores improved significantly (p=0.003, d=0.76) from 5.3 (baseline) to 4.5 (endpoint; last observation carried forward (LOCF)). CGI-Improvement scores decreased from 3.7 (after 1 month) to 3.3 (endpoint; LOCF) (p=0.212, d=0.45). CONCLUSIONS: In adolescents with schizophrenia, aripiprazole augmentation of clozapine treatment might be an effective therapeutic strategy. Prospective studies for this age group are required to obtain more specific clinical data on clinical effectiveness.

Ruptured cerebral aneurysm patients treated by clipping or coiling: comparison of long-term neuropsychological and personality outcomes.

BACKGROUND AND PURPOSE: A prospective study was conducted to compare the neuropsychological outcome of surgical versus endovascular treatment in patients with cerebral aneurysms. METHODS: From April 2001 to 2005, 211 patients with ruptured cerebral aneurysms were treated at the senior author's institution. Of these 211 patients, 75 that were able and willing to undergo neuropsychological assessment 1 year after treatment of their aneurysm were enrolled in the study. Thirty-five patients were treated surgically and 40 by endovascular therapy. Standardized neuropsychological and personality tests were employed to assess cognitive and personality functions. One neurosurgical team using the same treatment protocols treated all patients. RESULTS: The two groups of patients did not differ significantly with respect to age, gender, concurrent diseases, Hunt and Hess grade, Fisher grade, frequency of complications, vasospasms and hydrocephalus development. No differences in performance on neuropsychological and cognitive tests (AVLT, TMT and WAIS-III) and personality variables and mood scales (TCI, BDI and SMS) were found one year postoperatively. If a full IQ as defined by WAIS-III and 1SD below the mean is considered as the main measure of cognitive deficits, 5.4% of the sample suffered from cognitive deficits. There were no differences between clipped and coiled patients (t=0.03; p=0.97). CONCLUSIONS: The differences in the neuropsychological assessment of patients treated by either coiling or clipping were small and non-significant. Given the small number of patients in the study, however, we suggest the need for further research with a larger sample size and the use of a randomized design before drawing any firm conclusions.

The influence of low-frequency left prefrontal repetitive transcranial magnetic stimulation on memory for words but not for faces.

Brain imaging studies suggest localization of verbal working memory in the left dorsolateral prefrontal cortex (DLPFC) while face processing and memory is localized in the inferior temporal cortex and other brain areas. The goal of this study was to assess the effect of left DLPFC low-frequency repetitive transcranial magnetic stimulation (rTMS) on verbal recall and face recognition. The study revealed a significant decrease of free recall in word encoding under rTMS (110% of motor threshold, 0.9 Hz) in comparison with sham stimulation (p=0.03), while no significant difference was found with facial memory tests. Our findings support the essential role of the left DLPFC in word but not facial memory and confirm the content specific arrangement of cortical areas involved in semantic memory. As a non-invasive tool, rTMS is useful for cognitive brain mapping and the functional localization of the category specific memory system.

Invasive pulmonary aspergillosis: effects of early resection in a neutropenic rat model.

OBJECTIVE: Invasive pulmonary aspergillosis is frequent in neutropenic patients. Usually localized in the beginning, the disease spreads and mortality is high despite antifungal treatment. The role of early adjuvant surgery is not clear. Surgery may help to confirm fungal disease, may control fungal disease locally and may prevent systemic spreading. This study examines effects of early resection on survival and dissemination in a rat model of localized invasive pulmonary aspergillosis. METHODS: Forty persistently neutropenic male albino rats were challenged with standardized conidial aspergillus inoculum injected into peripheral lung tissue of the right upper lobe under direct vision. Animals were divided into four groups. Twenty animals were treated with amphotericin B at 1 mg/kg per day beginning 48 h after inoculation, 20 animals were left untreated. In each group half the animals underwent early resection of localized invasive aspergillosis by lobectomy. Animals were checked daily and mortality was recorded up to 28 days after which surviving animals were sacrificed. RESULTS: Significantly higher survival was observed in resected animals in the non-Am B groups (survival: 10 +/- 19% without early resection and 50 +/- 32% with early resection; P = 0.044). However, early resection did not lead to improved survival in animals treated with amphotericin B (survival 70 +/- 29% without early resection and 50 +/- 32% with early resection; P = 0.316). CONCLUSIONS: In this rat model of localized invasive pulmonary aspergillosis effects of early resection on survival could be demonstrated only in animals not receiving amphotericin B treatment.

[Aortic dissection in pregnancy in Marfan syndrome--case report and treatment concept]. / Aortendissektion in der Gravidität bei Marfan-Syndrom--Fallbericht und Behandlungskonzept.

PATIENTS AND METHODS: Herein we report the case of a 37 year old pregnant women with Marfan syndrome with dilatation of the aorta ascendens of 42 mm preconceptionAl. The dilatation remained stable until 34 weeks of gestation when a aortic dissection (De Bakey type I) occurRed rapidly. The patient underwent a cesarean section and hysterectomy, followed by surgery of the aorta asc. by means of implantation of a valved graft immediately. CONCLUSIONS: The criteria of a dilatation of the aorta ascendens < 40 mm does not identify reliably those patients who are at risk of dissection during pregnancy. A interdisciplinary approach together with obstetricians, cardiologists and cardiac surgeons is mandatory in all cases of Marfan syndrome and pregnancy.

Aneurysmal and partially thrombosed orifice of a coronary artery fistula into the right atrium combined with patent foramen ovale.

We report a case of a right atrial sessile tumor combined with a patent foramen ovale and the characteristics of fat containing tumor in magnetic resonance imaging. Histologic study revealed this to be an aneurysmal and partially thrombosed formation of a coronary artery fistula.

[Multiple heart valve diseases: differential therapeutic considerations]. / Mehrfachklappenerkrankungen--differenzialtherapeutische Uberlegungen.

After more than 40 years of heart valve surgery, the indication for double valve procedures still represents a problem in the presence of an obviously leading single valve disease. If the isolated valves do not already represent a clear indication for surgery then this situation is the best example for a good deal of thought in cardiac surgery and discussion with competent cardiologists.

[Multiple-valve disease]. / Mehrfachklappenerkrankungen - differenzialtherapeutische Überlegungen.

After more than 40 years of heart valve surgery, the indication for double valve procedures still represents a problem in the presence of an obviously leading single valve disease. If the isolated valves do not already represent a clear indication for surgery then this situation is the best example for a good deal of thought in cardiac surgery and discussion with competent cardiologists.

Huntington's disease: the relationship between clinical signs, CAG repeats and the atrophy of the caudate nucleus in CT scans.

We compared clinical data from 45 patients with Huntington's Disease (HD) with CAG triplet repeats and the planimetric measurement of the caudate nucleus head area (CNHA) in CT scans. The mean age of patients was 50.4 yrs (SD +/- 10.2), the mean duration of HD 7.4 yrs (4.6), the mean age at the onset of HD 43.1 yrs (11.1). HD started with motor symptoms in 28 patients, with psychiatric symptoms in 14 patients, the history was unknown in 3 patients. The paternal transmission was observed in 29 patients, the maternal one in 12 patients, unknown in 4 patients. The mean number of CAG repeats was 46.6 (6.1). The mean CNHA was 0.4 cm2 (0.1). We found statistically significant reversed correlation between CAG repeats and the age at the onset of HD (p < 0.0001, r -0.6). The earlier onset of HD in patients with the paternal transmission compared to the maternal one was found statistically significant (p < 0.05). This phenomenon was not related to the larger number of CAG triplets in patients with the paternal transmission. No differences either of the age at the onset of HD or numbers of CAG repeats were found between subgroups of HD patients starting with motor or psychiatric symptoms. We also observed the significant reversed correlation between the duration of HD and CNHA measurement (p < 0.001, r -0.5). Even in the earliest stage of HD patients showed the marked atrophy of CNHA.