Early prognosis in patients with community-acquired severe sepsis and septic shock: analysis of 184 consecutive cases.

PURPOSE: To determine the risk factors on hospital mortality in patients with community-acquired severe sepsis and septic shock in the first 24 hours after admission to the intensive care unit. MATERIALS AND METHODS: The study was prospective, observational, single-centre and included adult patients with community-acquired severe sepsis and septic shock. Demographics, clinical, laboratory and microbiological data were recorded. The main outcome measure was hospital mortality. RESULTS: During the study period, 184 patients were included. The overall mortality rate was 51.6%, 44.4% with severe sepsis and 71.4% in patients with septic shock. The lung was the most common site of infection (65.8%) and respiratory failure was the most common organ failure (54.9%). Multivariate analysis identified four independent risk factors for mortality in patients with severe sepsis and septic shock: three or more organ dysfunctions (OR, 3.212; 95% CI, 1.585-6.506; p<0.001), acute respiratory failure (OR, 2.649 95% CI, 1.327-5.287; p=0.006), positive blood culture (OR, 2.708; 95% CI, 1.289-5.689; p=0.009) and chronic heart failure (OR, 2.112; 95% CI, 1.036-4.308; p=0.040). CONCLUSION: Our results highlight the importance of three or more organ dys-functions, acute respiratory failure, positive blood culture and chronic heart failure as independent risk factors for mortality in the first 24 hours after admission in patients with severe sepsis and septic shock. This will benefit the early identification of patients at high risk for poor outcomes that contributes to intensive management and appropriate treatment interventions.

Role of interleukin-8 in differentiation of uncomplicated from complicated parapneumonic effusion.

The aim of this study was to investigate the value and significance of interleukin-8 in differentiation of uncomplicated parapneumonic effusion (UCPPE) from complicated parapneumonic effusion (CPPE). Using an IMMULITE 1000 Analyzer, with chemiluminescent immunometric assay, levels of interleukin-8 (IL-8) were measured in the pleural fluid of patients with UCPPE (n=30), and CPPE (n=30), and three classical parameters (pH, glucose, and LDH) in these two groups. Receiver-operating curves were to assess the sensitivity and specifity of interleukin-8 for differentiating between the two patient groups. IL-8 levels were statistically higher in the CPPE group. A positive significant correlation, was found between levels of IL-8 and and lactate dehydrogenase (LDH) (r=0.68, p<0.05). There was also a positive significant correlation between IL-8 and protein level in pleural effusion (r=0.306, r<0.01). There was a significant negative correlation between levels of IL-8 and pH (r=-0.83, p<0.05), and of IL-8 and glucose in pleural fluid (r=-0.61, p<0.05). A cut-off value of 1805.81 pg/ml, differentiated CPPE from UPPE with a sensitivity of 100% and a specifity of 98%. IL-8 may be used as an alternative marker for the complication of parapneumonic effusion.

Postural intermittent headaches as the initial symptom of a cavernoma in the third ventricle.

Cavernous malformations (CM) occur very rarely in the ventricular system. We report a patient with a rare location in the third ventricle who had intermittent headaches as the initial symptom.

Manual percutaneous method for diagnosis of spinal tumors.

Summary. In a patient with malignant tumors of bone it is common to perform biopsy prior to surgery. There are a number of alternatives available for obtaining a specimen for pathological examination. We have introduced the technique of manual percutaneous discectomy (MPD), as a method for taking material for analysis. In a series of 13 symptomatic patients harbouring suspected spinal tumors the MPD was done and the accurate diagnosis was confirmed in all of them. Only three patients had a minor transient complication. This method enables us to obtain sufficient pathological material for analysis and has minimal morbidity and it could have priority over the other methods.

Comparative morphological variations and abnormalities of circles of Willis: a minireview including two personal cases.

Two rare cases of the circle of Willis are presented. One of them represents a fetal circle of Willis (crown-rump length, or CRL, 17 cm), the other one is adult circle from a male cadaver 65 years of age. Arterial variations and abnormalities of the represented circles of Willis are described. Interpretation of the appearance of variations and abnormalities is based on the acceptable embryological, anatomical, and clinical reports. Summarizing these opinions, we have supplemented them with a hypothesis that arterial variations and abnormalities could preserve their relationships because of constant interaction between primitive arterial remnants and cerebral arteries in postnatal life, unless some pathological lesions appear.

[Non-traumatic subarachnoid hemorrhage of unknown origin]. / Netraumska subarahnoidna hemoragija nepoznatog uzroka.

In a series of 441 patients with signs and symptoms of spontaneous subarachnoid haemorrhage (SAH) in 62 subjects haemorrhagic aetiology could not be established. All patients were admitted during the first week of haemorrhage (most of them within 72 hours). The majority belonged to Hunt's and Hess' 1 and 2 degrees of bleeding (80.64%). Blood in subarachnoid region could not be verified by CT in 30.03% of patients. Among patients with manifested haemorrhages in 59% haemorrhage was localized in perimencephalic cisternae, and in the others a kind of SAH with characteristics of aneurysmal rupture was observed. Digital substratum angiography (DSA) of four cerebral blood vessels was performed in all patients; in 17 patients the procedure had to be repeated, but without a new pathologic substrate. The recovery of the majority of patients (91.93%) was good, and only one patient died one year after the insult. The patients with aneurysmal SAH were separately treated. In these patients the recovery was noted in 73.33% of subjects, and the rest manifested a mild invalidity. In general, patients with SAH of unknown aetiology have a better prognosis than those with aneurysmal SAH.

[Lumbar spinal stenosis. Symptomatology and methods of treatment]. / Lumbalna spinalna stenoza. Simptomatologija i nacin lecenja.

INTRODUCTION: Lumbar spinal stenosis (LSS) may be defined as any type of the narrowing of the spinal nerve root canal (the lateral recess), intervertebral foramina, or its combination. It may be local, segmental or generalized; it can be caused by bone or soft tissue, and the narrowing can involve the bony canal or the dural sac or both. The normal sagital diameter of the lumbar canal is 15 to 25 mm and measurements below this are regarded as suggestively abnormal; a diameter less than 12 mm confirms the presence of stenosis. On the other hand, the lateral recess height less than 3 mm is suggestive, and less than 2 mm is a diagnostic sign of stenosis. There are two large groups of LSS: congenital-developmental stenosis and acquired stenosis with many subgroups (Scheme 1). The number of surgical operations due to LSS is increased during the ensuing years especially in elderly persons. This is why we would like to emphasize the important role of this phenomenon as there are only a few published papers in domestic literature. MATERIAL AND METHODS: In a consecutive series of 38 patients with LSS diagnosed for the last five years (January 1990-December 1994), aged from 20 to 70 years (average age 48.55) there were 21 males (Table 1); 34 of them had LSS as a result of bony changes, while the rest of 4 were iatrogenic (3 after disc extirpation and one after laminectomy) (Fig. 1). Herniation of the nucleus pulposus in combination with LSS was found in 12 patients (31.57%). Local segmental stenosis was identified in 16 patients (42.10%). (Graph. 1) (Fig. 2); the others had the generalized type of stenosis involving two levels (17 patients-44.7%); three levels (4 patients-10.52%) or 4 levels (one patient-2.63%) (Fig. 3). As far as symptomatology is concerned 31 patients had low-back pain with acute radicular complaints and motor weakness as the result of lesion of one or two spinal roots (20 patients). There were no neurogenic claudication or cauda equina compression syndromes. Electromyoneurographic studies (EMNG) in surgically treated patients revealed preoperative signs of muscle denervation in 15 patients (7.42%) (Table 2); the rest of them had signs of chronic irritative lesions of the corresponding root. RESULTS: Twenty one patients were operated on: 19 with signs and symptoms of generalized type of LSS and only two with lateral recess stenosis (Table 2). Congenital developmental stenosis was identified in 6 young patients (20 to 40 years of age) (Fig. 4). Single-level laminectomy with medial facetectomy and nerve root decompression was performed in 10 patients, and the rest of them had two level or three level decompressive laminectomies with medial facetectomy and roots decompression (Fig. 5). Dissectomy was done in 8 patients (Graph 2). None of our patients had concomitant arthrodesis, or needed reoperation. Postoperative EMNG improvement was confirmed in 13 patients of 15 (86.66%); this is about 61.90% in comparison to all operated patients (Table 3). The main complaints after the operation were: low-back pain (70%), leg numbness (70%), slight walking difficulties (60%); however all were able to walk more than 500 meters. The answer to the question how they felt after the operation, 15 patients responded to feel better or much better (71.42%), 3 felt the same (14.28%), and 3 felt worse than before the operation. Five patients retired before the operation, 7 changed their occupation taking an easier job, 9 returned to the same job, and none retired after the operation (Table 3). DISCUSSION: A certain number of patients had congenital-developmental stenosis with thickening of the laminae and development of short, squat pedicles with a decreased anterior-posterior diameter of the spinal canal. There are numerous variations of this pattern which remain asymptomatic until later developmental changes precipitate the typical radiculopathy and cauda equina changes in LSS. (ABSTRACT TRUNCATED)

[Multiple intracranial aneurysms and asymmetrical circle of Willis]. / Multiple intrakranijalne aneurizme i asimetricni Willisov prsten.

In a consecutive series of 268 patients harboring saccular aneurysms confirmed by digital subtraction angiography (DSA) all major blood vessels of the brain, 36 patients (13.4%) with multiple aneurysms were identified. Majority of them (around 58%) were between 40 to 60 years of age, around 22% were below 40 years of age, but no was younger than 30 years of age. The asymmetric Willis circle was identified in 26 patients (74.2%) A hypoplastic A1 segment of the anterior cerebral artery was revealed in 10 patients; a combination of the hypoplastic A1 segment and the fetal type of the posterior communicating artery with a hypoplastic P1 segment of the posterior cerebral artery were found in 9 cases, while 7 patients had only the fetal posterior communicating artery. A suggestion was put that the asymmetric circle of Willis, prenatal or acquired in postnatal life is inclined of developing aneurysm (multiple aneurysms) only if there exist a hemodynamic stress in postnatal life producing degenerative lesions of the circle of Willis at the site of the augmented hemodynamic vascular wave.

[Temporary arterial occlusion and intraoperative monitoring of somatosensory evoked potentials during treatment of cerebral aneurysms]. / Privremena okluzija arterije i intraoperacioni monitoring somatosenzitivnih evociranih potencijala u toku lecenja cerebralnih aneurizmi.

Temporary occlusion of the main artery feeding aneurysm with intraoperative monitoring of somatosensitive evoked potentials was performed in 10 patients: in the majority of them because premature aneurysm rupture, and in 3 patients to facilitate the dissection of the aneurysm and application of a definitive clip. The duration of temporary occlusion was between 5 to 20 minutes. The basic changes of SEP abnormalities were manifested in the prolongation of absolute latencies and the central conduction time. The changes were reversible. One patient died 30 days after the operation from lung infection; the condition of one was unchanged; two patients with mental sequelae had good but long recovery; outcome in one patient was good and in the others it was excellent. Temporary occlusion may not have disastrous consequences, and it can be well tolerated if performed in a reasonable period of time. The SEP monitoring is helpful in the operative management of aneurysms showing early signs of ischaemia.

Somatosensory evoked potential monitoring during intracranial surgery.

In the neurosurgical approach to intracranial aneurysms which are often accompanied by arterial spasm and cortical ischaemia, monitoring procedures aim to obtain useful information on cerebral function. SEPs evoked by stimulation of the median nerve at the wrist and of the tibial nerve at the medial malleolus were registered in 45 patients with intracranial aneurysms during neurosurgical procedures. Our results show SEP abnormalities during different stages of neurosurgical procedures in 36 patients out of the monitored 45. Significant abnormalities of SEPs with respect to the control group were decrease of the amplitude of N 20-P 25 complex, lengthening of the absolute latency of the waves N 20- and P 25 and lengthening of the central conduction time (CCT) (N 13-N 20). The greatest SEP abnormalities were registered during the neurosurgical approach to aneurysm and during the clipping procedure. However, the changes were reversible in the majority of the patients. The aim of this paper was to focus on early detection of some cerebral function disturbances during the neurosurgical procedure as well as the prevention of possible brain damage.

Asymmetry and anomalies of the circle of Willis in fetal brain. Microsurgical study and functional remarks.

The arteries of the circle of Willis in fetal brains of 20-40 weeks of gestational age were studied with the operating microscope. The majority of fetuses were between 24-32 weeks of age. Our findings were as follows: 1) the average diameters of all segments were 4-5 times narrower than the average diameters in adults, and the average lengths of the same segments were 2-2.5 times shorter than the same lengths in adults; 2) the number of perforators corresponded with the perforating arteries in adults; 3) hypoplastic segments, as well as anomalies and variations, were identified; 4) calibers almost equal in size between the right and left corresponding segments were found in a high proportion of cases; 5) in the majority of cases a polygon, much like the "precarious" circle in adults, was dissected. The "fetal" or the "ideal" circles were found in a low proportion of cases.

Cysticercosis cerebri involving the lateral ventricle.

Cysticercosis cerebri involving the lateral ventricle is very rare. Two cases with such localization are presented. One of the patients, with occlusion of the foramen of Monro, was successfully treated by operation. A larval form in the lateral ventricle was revealed incidentally at autopsy in the second patient after rupture of a large basilar artery aneurysm.

Anastomosis between internal carotid artery and anterior cerebral artery with other anomalies of the circle of Willis in a fetal brain.

A rare vascular anomaly was found in a 21-week-old fetal brain. It consisted of an anastomotic loop between the internal carotid artery and the anterior cerebral artery. Other variations and anomalies were also found. Anomalies and variations of the circle of Willis are probably genetically determined and develop at an early embryonic stage. They are frequently found in association with other cerebrovascular diseases, such as aneurysms.

[Microvascular extracranil bypass. Our first experience]. / Mikrovaskularni ekstrakranijalni bypass. Nasa prva iskustva.

From the experiments presented by the authors the following conclusions could be got: 1. The microvascular arterial BY-PASS is a procedure, which has probably got a preventive significance, especially for cases with TRANSISTRORY ISCHEMIC ATTACK (TIA) and REVERSIBLE ISCHEMIC NEUROLOGICAL DEFICIT (RIND), as well as for the cerebrovascular insult with a mild and moderate neurological deficit. 2) All by itself, (the microvascular arterial by-pass) has got a very low mortality and morbidity, or better said, it carries with itself the risk as any other operation does. 3) The percentage of the preserved anastomoses is quite high. 4) Most probably persons with serious neurological deficit after a complete vascular insult, and persons with an acute vascular insult, will have no advantage of the arterial anastomosis.