Delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage- areas at risk.

Delayed cerebral ischemia is a major neurological complication of aneurysmal subarachnoid hemorrhage. Its unpredictable course and potentially unfavorable outcome draw attention to clinicians to improve the methods for its prediction, prevention, and diagnosis. The computed tomography perfusion (CTP) technique of the brain is one of the promising methods for revealing brain areas endangered by cerebral vasospasm and delayed cerebral ischemia.

Predictors of unfavourable outcome in aneurysmal subarachnoid haemorrhage.

BACKGROUND: Mortality rates following aneurysmal subarachnoid haemorrhage (aSAH) have decreased due to improvements in diagnoses and the management of complications, as well as early obliteration of the aneurysms. Neurogenic pulmonary oedema (NPO) is a clinical syndrome associated with an acute increase in intracranial pressure and a release of catecholamines into the circulation. This study investigated independent predictors of unfavourable outcomes (Glasgow Outcome Scores 1, 2 or 3) in patients with aSAH. MATERIALS AND METHODS: A total of 262 patients with aSAH (162 females) were included in this prospective study. Clinical characteristics were assessed, and electrocardiographic, serum cardiac and inflammatory biomarker measurements were recorded on admission. Outcomes were assessed three months after admission. Univariate and multivariate analyses of these data were used to predict unfavourable outcomes. RESULTS: A total of 156 patients (59.54%) had unfavourable outcomes. Compared to those who had favourable outcomes, patients with unfavourable outcomes were significantly older (54.37 ± 10.56 vs. 49.13 ± 10.77 years; p < 0.001) and had more severe aSAHs (Hunt and Hess grades ≥ 3: 82.7% vs. 39.6%; p < 0.001). Patients with unfavourable outcomes were more likely to have NPO (10.3% vs. 2.8%; p = 0.023), hydrocephalus (34.0% vs. 20.8%; p = 0.02), and aneurysm reruptures (28.2% vs. 3.8%; p < 0.001). Independent predictors of an unfavourable outcome included Hunt and Hess grades ≥ 3 (odds ratio [OR], 4.291; 95% confidence interval [CI], 2.168-8.491; p < 0.001), increased systolic blood pressure on admission (OR, 1.020; 95% CI, 1.002-1.038; p = 0.03), increased heart rate (HR) on admission (OR, 1.024; 95% CI, 1.001-1.048; p = 0.04), and aneurysm rerupture (OR, 4.961; 95% CI, 1.461-16.845; p = 0.01). CONCLUSIONS: These findings suggest that aneurysm reruptures, as well as increased blood pressure and HR, are associated with unfavourable outcomes in patients with aSAH.

Could cardiac biomarkers predict neurogenic pulmonary edema in aneurysmal subarachnoid hemorrhage?

BACKGROUND: Neurogenic pulmonary edema (NPE) is a clinical syndrome characterized by the acute onset of pulmonary edema after a significant central nervous system (CNS) insult. NPE occurs as a result of release of catecholamines into the blood immediately after aneurysm rupture. The aim of this study is to investigate the connection between the value of cardiac biomarkers on admission and incidence of NPE in patients with aneurysmal subarachnoid hemorrhage (SAH). METHODS: A total of 262 SAH patients (162 women, 100 men) were prospectively included in the study. Clinical characteristics, electrocardiographic (ECG) changes, serum cardiac and inflammatory biomarkers were measured on admission and on the day of development of NPE. These data were analyzed in order to predict the development NPE. RESULTS: Nineteen patients (7.25%) developed NPE. Comparison revealed that patients who subsequently developed NPE, sustained more severe SAH. Cardiac damage was more severe in these patients, as represented by significantly higher mean values of all examined cardiac biomarkers (P = 0.000), except for troponin I value that was significantly lower (P = 0.000). Multivariate regression analysis revealed that elevated troponin I (OR, 4.980; 95% CI, 1.27-19.49; P = 0.021) and white blood cell count (OR, 22.195; 95% CI, 3.99-123.50; P = 0.000) are predictors of NPE. CONCLUSIONS: Significantly higher values of cardiac biomarkers were observed in SAH patients complicated with NPE. Elevated values of cardiac biomarkers appear to play an active role in prediction of NPE, although white blood cell count may be involved in the prediction of NPE. There is an influence of SAH therapy on predictors of NPE.

Pineal Tumor Surgery-The Choice of the Approach Related to Tumor Characteristics and Posterior Fossa Anatomy.

OBJECTIVE: This research aimed to determine whether an adequate surgical approach can be chosen based on clearly defined values of anatomical landmarks (tentorial angle) and tumor size and extension. METHODS: We conducted a retrospective analysis of patients operated on because of pineal tumors. The cohort was divided depending on the surgical approach. On preoperative magnetic resonance imaging, we measured maximal diameters, tumor volume, and tumor propagation. In the group of patients operated with the supracerebellar infratentorial approach, we also tested the correlation of tentorial angle with residual tumor. Differences among groups in resection, complications rate, and outcome were tested by the χ2 test. Finally, in both groups, the correlation of residual tumor with tumor volume, propagation, and diameters was tested using the receiver operating characteristic curve. RESULTS: In the group operated with a supracerebellar approach, total resection was achieved in 78% of the patients. The critical value of cranio-caudal diameter correlated with tumor residue was 31 mm, for lateral-lateral diameter 25 mm, for the lateral extension 14 mm, and tumor volume 12 cm3. Tentorial angle did not influence the extent of the resection. In the group operated with an occipital transtentorial approach, the critical tumor volume related to tumor residue was 9 mm3, anterior-posterior diameter 29 mm, and cranio-caudal diameter 28 mm. The extent of the resection was significantly higher in the supracerebellar group. CONCLUSIONS: In both approaches, tumors larger than 3 cm show an increased risk of subtotal resection. Except when most tumor volume is localized above the venous system, we advocate a supracerebellar corridor as an effective approach that is not limited by tentorial angle.

[Autosomal recessive polycystic kidney disease: case report].

INTRODUCTION: Autosomal recessive polycystic kidney disease is the most common heritable cystic renal disease occurring in infancy and childhood. The clinical spectrum of signs and symptoms of this disease is widely variable ranging from perinatal death to a milder progressive form, which cannot be diagnosed until adolescence. CASE OUTLINE: A female neonate born in the 35th/36th week of gestation. The findings of all standard medical examinations of the neonate done by the mother were within normal limits. A few days before delivery physicians at a regional medical centre revealed enlarged kidneys and oligohydramnios. The delivery was performed by caesarean section. The vital functions of the newborn were in critical condition so that she was referred to the University Children's Hospital in Belgrade. Soon after admission, despite all undertaken measures, the infant died. Autopsy was done at the Institute of Pathology of the Belgrade Clinical Centre. All findings were typical for autosomal recessive polycystic kidney disease. The kidneys were hugely enlarged, with cystically dilated collecting ducts that almost completely replaced the renal parenchyma. The lungs were mildly hypoplastic. The liver showed dilated portal spaces, with multiple irregularly branching bile ducts. The cause of death was respiratory distress and renal failure. CONCLUSION: In all cases of congenital anomalies of the kidney with lethal ending it is necessary to perform autopsy and aimed genetic investigation.