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BACKGROUND AND PURPOSE: Orolingual angioedema (OA) represents a rare but life-threatening complication among patients with acute ischemic stroke treated with intravenous thrombolysis with alteplase. Novel agents, including icatibant, are recommended in resistant patients with alteplase-induced OA who have failed to respond to first-line therapies including corticosteroids, antihistamines, and/or adrenaline. METHODS: We present a patient with alteplase-induced OA who showed substantial clinical improvement following the administration of icatibant. RESULTS: We describe a 71-year-old woman with known arterial hypertension under treatment with angiotensin-converting enzyme inhibitor, who presented with acute ischemic stroke in the territory of the right middle cerebral artery and received intravenous alteplase. During intravenous thrombolysis, the case was complicated with OA without any response to standard anaphylactic treatment including corticosteroids, dimetindene, and adrenaline. Thirty minutes after symptom onset, icatibant, a synthetic selective bradykinin B2-receptor antagonist, was administered subcutaneously. Substantial symptomatic resolution was observed only following the icatibant administration. CONCLUSIONS: This case highlights the effectiveness of icatibant in the acute management of alteplase-induced OA. In particular, icatibant administration, following first-line therapies including corticosteroids, antihistamines, and/or adrenaline, may avert tracheostomy and intubation in resistant and refractory cases with OA following intravenous thrombolysis for acute ischemic stroke.
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Angioedema , Bradicinina/análogos & derivados , AVC Isquêmico , Acidente Vascular Cerebral , Feminino , Humanos , Idoso , Ativador de Plasminogênio Tecidual/uso terapêutico , Bradicinina/efeitos adversos , Respiração Artificial , Angioedema/induzido quimicamente , Angioedema/tratamento farmacológico , Epinefrina/efeitos adversos , Corticosteroides/uso terapêutico , Antagonistas dos Receptores Histamínicos/efeitos adversos , Acidente Vascular Cerebral/tratamento farmacológico , Fibrinolíticos/uso terapêuticoRESUMO
PURPOSE: Photogrammetry is a technique which includes taking multiple digital photographs from various angles and using those photographs to create three-dimensional virtual models. We aimed to review the outcomes of the implementation of photogrammetry in anatomy education. METHODS: We searched PubMed, Scopus and Cochrane library for studies with purpose to explore the outcomes of the use of photogrammetry-based digital models in anatomy teaching. From each included paper we extracted: authors, number of participants, anatomical region of interest, educational outcomes, and their level according to Kirkpatrick hierarchy. RESULTS: Seven studies were included. Four of them concerned neuroanatomy and three of them concerned other systems. All studies comprised participants' perceptions about the educational intervention, while two of them also evaluated anatomical knowledge acquisition. Overall, the participants rated photogrammetry-based models very highly and preferred them to other teaching tools. These models were also shown able to significantly enhance the anatomical knowledge. CONCLUSIONS: Photogrammetry-based digital objects seem to have a promising anatomy teaching potential. The value of these objects seems to be especially pertinent in teaching the relatively complex field of neuroanatomy. Further research may investigate the effectiveness of photogrammetry-based models in comparison with other anatomy education tools, and with other methods of creation of three-dimensional virtual objects.
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OBJECTIVE: Multiple sclerosis (MS) is the most common chronic inflammatory demyelinating disease of the central nervous system (CNS). The most common clinical manifestations of MS are spasticity, pain, vesico-urethral disorders, cognitive impairments, chronic fatigue and sexual dysfunction. This review aims to explore the possible therapeutic options for managing sexual dysfunction in people with MS (PwMS). METHOD: A thorough search of the PubMed Medline database was performed. Records were limited to clinical studies published between 01/01/2010 up to 01/01/2022. The results were screened by the authors in pairs. RESULTS: The search identified 36 records. After screening, 9 records met the inclusion-exclusion criteria and were assessed. The pharmacological approaches investigated the effectiveness of sildenafil, tadalafil and onabotulinumtoxinA. Of the interventional studies the non-pharmacological investigated, the effectiveness of aquatic exercises, the application of pelvic floor exercises,the combination of pelvic floor exercises and mindfulness technique, the combination of pelvic floor exercises and electro muscular stimulation with electromyograph biofeedback, the application of yoga techniques and the efficacy of assistive devices like the clitoral vacuum suction device and the vibration device. CONCLUSION: The management of sexual dysfunction in PwMS needs to be further investigated. A team of healthcare professionals should be involved in the management of SD in order to address not only the primary (MS-related) SD symptoms but the secondary and tertiary as well. The main limitations that were identified in the existing literature were related to MS disease features, sample characteristics and evaluation tools and batteries.
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Esclerose Múltipla , Disfunções Sexuais Fisiológicas , Humanos , Esclerose Múltipla/complicações , Esclerose Múltipla/terapia , Esclerose Múltipla/psicologia , Disfunções Sexuais Fisiológicas/terapia , Disfunções Sexuais Fisiológicas/complicações , Citrato de Sildenafila , Dor/complicações , Terapia por Exercício/métodosRESUMO
OBJECTIVES: Phlebosclerosis is a fibrous degeneration of the vein wall, predominantly the intima, with or without calcification. The prevalence and etiology of phlebosclerosis of the great saphenous vein are not well documented. This study aimed to estimate the prevalence and define the risk factors of phlebosclerosis of the great saphenous vein. METHODS: The study was conducted on 300 volunteers who underwent duplex ultrasound. Volunteers with symptoms and signs of acute or chronic venous disease or known varicose veins, thrombosis, chronic vein insufficiency, and any operation in the lower extremities were excluded. The imaging hallmarks of phlebosclerosis include wall brightness, calcification, and increased wall thickness. Demographics of the volunteers (sex, age, weight, and height), Body Mass Index (BMI) and the presence of smoking, hypertension, diabetes mellitus, and dyslipidemia were recorded. Data obtained were consolidated and statistically evaluated using SPSS Version 16. RESULTS: Of the 300 volunteers who underwent duplex ultrasound, 60.3% were females, and 39.7% were males. The mean age was 60 ± 13, while the mean BMI was 26.01 ± 4.76. Moreover, 66.3% were non-smokers, and 62.3%, 81.3%, and 58.7% did not suffer from hypertension, diabetes mellitus, and dyslipidemia, respectively. The prevalence of phlebosclerosis was found to be 2.3%. Hypertension was a risk factor for the development of phlebosclerosis (p = 0.045). Moreover, there was a link between phlebosclerosis and age, as volunteers with phlebosclerosis were older than volunteers without phlebosclerosis (74.2 vs 59.11 years, p < 0.001). CONCLUSIONS: The prevalence of phlebosclerosis of the great saphenous vein is low, specifically 2.3%. Hypertension and increased age are risk factors for the development of phlebosclerosis. Both sexes are equally affected, while BMI, smoking, diabetes mellitus, and dyslipidemia do not contribute to the development of phlebosclerosis.
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OBJECTIVES: The great saphenous vein is the lower limb's longest and thickest-walled superficial vein. Its anatomy is complex, while its anatomical variations are widespread. This study aimed to illustrate the anatomy and variations of the great saphenous vein at the saphenofemoral junction. METHODS: The study was conducted on 75 fresh-frozen cadaveric lower limbs. Cadavers with evidence of prior leg surgery or trauma and any congenital abnormality or gross deformity were excluded. The saphenofemoral junction was studied in detail with emphasis on the number, incidence, draining pattern of tributaries, and duplication of the great saphenous vein. RESULTS: Out of the 75 cadaveric lower limbs, 57.3% were obtained from males, and 42.7% were obtained from females. The mean age of the cadaveric lower extremities was 66.6 years (range 42-91). The number of tributaries at the saphenofemoral junction varied from 0 to 7, with a mean of 3.8. The most frequent number of branches was 4-5 in 61.3% of cases. The most consistent tributary was the superficial external pudendal vein, while the posterior accessory great saphenous vein was the least frequent tributary. 80% of the branches drained into the saphenofemoral junction directly (53.3%) or by a common trunk (26.7%%). The most frequent common trunk was the superficial epigastric and superficial circumflex iliac vein (10.7%). The rest 20% of the tributaries drained directly into the common femoral vein. The commonest branch reaching the common femoral vein was the superficial external pudendal vein (10.7%). Duplication of the great saphenous vein was observed in 2.7% of the cases. CONCLUSIONS: There is a significant variation of tributaries at the saphenofemoral junction regarding the number, incidence, draining pattern of branches, and duplication of the great saphenous vein.
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BACKGROUND: Small vessel disease (SVD), and most specifically hereditary forms like CADASIL and cerebral amyloid angiopathy (hCAA), are conditions of increasing clinical importance. We report a rare case of hCAA in a Greek family that presented with a CADASIL clinical and neuroimaging phenotype. METHODS: A 65-year-old man was admitted with recurrent transient episodes of right leg numbness. The patient's medical history started at the age of 50 years with depression and behavioral disorders. His family history was positive for stroke (father), dementia (father and brother), migraine (daughter) and depression (father and daughter). RESULTS: Neurological examination disclosed anomic aphasia with severely impaired cognitive status, and brisk reflexes. Brain computed tomography and magnetic resonance imaging showed CADASIL-like leukoencephalopathy (hyperintense lesions in bilateral temporopolar area, external capsule, thalami, centrum semiovale and superior frontal regions) with occipital calcifications and cerebral microbleeds. Screen for variants in NOTCH3 gene was negative. Exome sequencing revealed a novel pathogenic mutation for hCAA. CONCLUSIONS: We report a novel amyloid precursor protein mutation which results in a CADASIL-like clinical phenotype (progressive cognitive and motor decline, stroke, migraine and behavioral disorders) and CADASIL-leukoencephalopathy coupled with occipital calcifications. Earlier recognition and swift hCAA diagnosis may prompt rational preventive and potential disease-modifying interventions.
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CADASIL , Angiopatia Amiloide Cerebral Familiar , Idoso , CADASIL/diagnóstico por imagem , CADASIL/genética , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Mutação , Fenótipo , Receptor Notch3/genéticaRESUMO
INTRODUCTION: Oculodentodigital syndrome (ODDS) is a rare genetic disorder caused by mutations in the gap junction GJA1 gene encoding connexin-43 (chromosome 6q22). A typical ODDS case is presented. MATERIAL AND METHODS: A 40-year-old male patient was examined neurologically and genetically. He had a history of recent parieto-occipital leukodystrophy, some episodes of temporary hearing loss, and characteristic facial features of ODDS. Sequencing of the GJA1 gene was performed in patient's total genomic DNA sample isolated from peripheral blood cells. RESULTS: A novel heterozygous missense mutation (443G>A) was identified in the GJA1 gene, resulting in coding for a different amino acid (Arg148Gln). CONCLUSION: The molecular genetic analysis confirmed the diagnosis of ODDS. The novel mutation, located within a calmodulin binding region of connexin-43, probably affects proper channel function.
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Anormalidades Craniofaciais , Deformidades Congênitas do Pé , Sindactilia , Anormalidades Dentárias , Adulto , Anormalidades Craniofaciais/genética , Anormalidades do Olho , Deformidades Congênitas do Pé/genética , Humanos , Masculino , Mutação , Fenótipo , Sindactilia/genética , Anormalidades Dentárias/genéticaRESUMO
PURPOSE: The study highlights azygos vein (AV) topography, arrangement and confluence morphometry in dyspnoea and tachycardia patients of extrapulmonary and extracardiac aetiology. METHOD: Computed-tomography angiography of 25 male and 26 female patients (mean age 66.5 years) were studied for: thoracic vertebral (T) height of AV- superior vena cava-SVC confluence, AV course and deviations from vertebral column (VC) midline, AV and SVC diameters, distance (AV arch- lower border of carina) and gender and age impact. RESULTS: Commonest heights of the AV-SVC confluence were T5 (56.9%), T4 (31.4%), T6 (9.8%) and T3 (2%). The AV terminated into SVC after crossing the left side of VC midline in 56.9%, slightly deviated right of the midline in 37.3% and coursed right of VC in 5.9%. Mean AV and SVC diameters were 0.96 ± 0.18 cm and 1.86 ± 0.27 cm. Male predominance in AV and SVC diameters and a slight AV diameter significant increase with the age were found. The (AV highest point-lower border of carina) mean distance was 2.05 ± 0.44 cm and male predominance existed. CONCLUSION: The commonest termination height of the AV was T5, while T3 was the rarest one. Aging induces the AV leftward displacement, while gender had no impact. AV and SVC diameters had higher significant values in males, while ageing had a significant impact only in AV diameter. The AV higher diameters will be used as predictors for higher values of SVC diameter and mediastinum pathology. Such findings can be useful in mediastinal surgery, mediastinoscopy and surgery of VC deformations, neurovascular surgery of retroperitoneal organs, disc herniation and T fractures.
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Variação Anatômica , Veia Ázigos/anatomia & histologia , Veia Cava Superior/anatomia & histologia , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Veia Ázigos/diagnóstico por imagem , Angiografia por Tomografia Computadorizada , Dispneia/diagnóstico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taquicardia/diagnóstico , Veia Cava Superior/diagnóstico por imagem , Adulto JovemRESUMO
Phlebosclerosis is a venous wall degenerative disease which has gained little popularity in the literature due to its uncertain clinical significance. The objective of this review is to evaluate the epidemiology, etiology and clinical significance of phlebosclerosis in lower extremities veins, particularly the effect of preexisting phlebosclerosis of the great saphenous vein on vein graft patency. Medline was searched from inception until November 1, 2019. Reference lists of included studies were scanned. Only articles published after 1949 were included. Two reviewers independently screened titles/abstracts and full-text papers for any study design in relation to phlebosclerosis in lower extremities veins and abstracted data. A total of 16 Cohort studies and one case-control study (3708 participants, mean age 61.8 years, 59.3 % men, and 40.7 % women) were included after screening 317 titles and abstracts, and 80 full-text articles. The incidence of phlebosclerosis ranged from 1.5-9.7 % depending on the radiological features. On the contrary, the incidence of the phlebosclerotic great saphenous vein prior to its use as a vein graft was 26.9-91 % on histological examination. The small saphenous vein was the most common location of phlebosclerosis followed by the great saphenous vein. There is a link between phlebosclerosis and age, venous insufficiency and haemodialysis. As for the vein graft patency seven studies demonstrated a correlation between preexisting phlebosclerosis and vein graft stenosis, whereas three studies failed to prove any association. In conclusion, the radiological incidence of phlebosclerosis depended on the ultrasound findings. Its presence in the great saphenous vein prior to its use as a vein graft is established on histological examination. The small saphenous vein is mainly affected. Risk factors included age, haemodialysis, and venous insufficiency. Preexisting wall thickness of the great saphenous vein graft seemed to affect negatively its patency in bypass surgery.
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Doenças Vasculares , Estudos de Casos e Controles , Oclusão de Enxerto Vascular , Humanos , Extremidade Inferior , Veia SafenaRESUMO
The purpose of this cadaveric study is to determine safe zones utilizing volar portals for wrist arthroscopy, by quantitatively describing the neurovascular relationships of a volar radial and a volar ulnar wrist arthroscopy portals in comparison with those of a newly described volar central portal (7) , considering the advantages in visualization of volar portals for wrist arthroscopy over the standard dorsal (19) . The neurovascular structures and the tendons of nine frozen human cadaveric upper limbs were exposed, while the aforementioned volar portal sites were pointed out with pins. The horizontal distance between the portals and the closest neurovascular branch or tendon was measured with a digital caliper, followed by statistical analysis of the data. The median interquartile range distances from portals to structures at risk were measured and safe zones around each portal were established. This study provides a safe approach to the volar radial and ulnar aspects of the radiocarpal and midcarpal joints, while volar radial and ulnar portals should be considered for inclusion in the arthroscopic examination of any patient with radial and ulnar sided wrist pain respectively (17,18) . Regarding the volar central portal, it is reproducible, safe and both the above joints can be inspected through one single incision (7) .
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Artroscopia/métodos , Articulação do Punho/cirurgia , Artroscopia/efeitos adversos , Cadáver , Cartilagem/cirurgia , Feminino , Humanos , Ligamentos/cirurgia , Masculino , Nervo Mediano/anatomia & histologia , Nervo Mediano/cirurgia , Artéria Radial/anatomia & histologia , Artéria Radial/cirurgia , Nervo Radial/anatomia & histologia , Nervo Radial/cirurgia , Artéria Ulnar/anatomia & histologia , Artéria Ulnar/cirurgia , Nervo Ulnar/anatomia & histologia , Nervo Ulnar/cirurgia , Articulação do Punho/anatomia & histologia , Articulação do Punho/irrigação sanguínea , Articulação do Punho/inervaçãoRESUMO
INTRODUCTION: There are limited data regarding cerebrospinal fluid (CSF) and plasma biomarkers among patients with Cerebral Amyloid Angiopathy (CAA). We sought to investigate the levels of four biomarkers [ß-amyloids (Aß42 and Aß40), total tau (tau) and phosphorylated tau (p-tau)] in CAA patients compared to healthy controls (HC) and patients with Alzheimer Disease (AD). PATIENTS AND METHODS: A systematic review and meta-analysis of published studies, including also a 5 year single-center cohort study, with available data on CSF and plasma biomarkers in symptomatic sporadic CAA versus HC and AD was conducted. Biomarkers' comparisons were investigated using random-effects models based on the ratio of mean (RoM) biomarker concentrations. RoM < 1 and RoM > 1 indicate lower and higher biomarker concentration in CAA compared to another population, respectively. RESULTS: We identified nine cohorts, comprising 327 CAA patients (mean age: 71 ± 5 years; women: 45%) versus 336 HC (mean age: 65 ± 5 years; women: 45%) and 384 AD patients (mean age: 68 ± 3 years; women: 53%) with available data on CSF biomarkers. CSF Aß42 levels [RoM: 0.47; 95% CI: 0.36-0.62; p < 0.0001], Aß40 levels [RoM: 0.70; 95% CI: 0.63-0.79; p < 0.0001] and the ratio Aß42/Aß40 [RoM: 0.62; 95% CI: 0.39-0.98; p = 0.0438] differentiated CAA from HC. CSF Aß40 levels [RoM: 0.73; 95% CI: 0.64-0.83; p = 0.0003] differentiated CAA from AD. CSF tau and p-tau levels differentiated CAA from HC [RoM: 1.71; 95% CI: 1.41-2.09; p = 0.0002 and RoM: 1.44; 95% CI: 1.20-1.73; p = 0.0014, respectively] and from AD [RoM: 0.65; 95% CI: 0.58-0.72; p < 0.0001 and RoM: 0.64; 95% CI: 0.57-0.71; p < 0.0001, respectively]. Plasma Aß42 [RoM: 1.14; 95% CI: 0.89-1.45; p = 0.2079] and Aß40 [RoM: 1.07; 95% CI: 0.91-1.25; p = 0.3306] levels were comparable between CAA and HC. CONCLUSIONS: CAA is characterized by a distinct CSF biomarker pattern compared to HC and AD. CSF Aß40 levels are lower in CAA compared to HC and AD, while tau and p-tau levels are higher in CAA compared to HC, but lower in comparison to AD patients.
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INTRODUCTION: Cognitive impairment is a core symptom of multiple sclerosis, leading to disability in 40-70% of patients. The most common cognitive domains affected by MS are information processing speed, complex attention, executive functions and less frequently, episodic declarative memory. Cardiovascular disease comorbidities have been shown to increase the decline rate in many neurological conditions. Our study aims to examine the possible impact of CVD risk factors in the cognitive decline rate of PwMS. METHODS: Over the course of a year, 248 PwMS with and without Cardiovascular comorbidity were cognitively evaluated using the written version of SDMT and the MoCA. RESULTS: Compared to control, MS patients with comorbid CVD had greater general cognitive decline and decreased processing speed. Patients with comorbid diabetes and dyslipidemia had the highest impairment, followed by those with hypertension, compared to the control group and those patients with a high BMI. CONCLUSION: The presence of cardiovascular comorbidities and especially dyslipidemia increases the rate of cognitive decline in MS patients. In such cases, patients should be evaluated every 6 months instead of a year and the use of the SDMT is advised since it's time efficient,it requires minimal training and correlates with MRI findings.
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Doenças Cardiovasculares , Disfunção Cognitiva , Esclerose Múltipla , Humanos , Esclerose Múltipla/complicações , Esclerose Múltipla/epidemiologia , Doenças Cardiovasculares/complicações , Doenças Cardiovasculares/epidemiologia , Cognição , Disfunção Cognitiva/epidemiologia , Disfunção Cognitiva/etiologia , Disfunção Cognitiva/diagnóstico , Comorbidade , Testes NeuropsicológicosRESUMO
The aim was to evaluate the performance of the latest quantitative marker for intrathecal IgG synthesis and to compare it with other established markers used for the same purpose. We retrospectively applied Auer's and Reiber's intrathecal IgG synthesis formulae in a cohort of 372 patients under investigation for central nervous system demyelination who had undergone lumbar puncture and oligoclonal bands (OCBs) detection for demonstrating intrathecal IgG synthesis. A ROC analysis revealed Auer's formula had lower sensitivity (68%) compared to Reiber's formula (83%) and IgG index (89%), in our cohort of patients that exhibited normal to mildly elevated albumin quotients (4.48 ± 3.93). By excluding possible sources of errors, we assume that Auer's formula is less sensitive than other established tools for the "prediction" of the detection of OCBs in routine cerebrospinal fluid (CSF) analyses due to the mathematical model used. Given the ability of Reiber's hyperbolic formula to describe the blood-CSF IgG distribution across a wide range of blood-brain barrier functionality, its use and the use of similar formulae are recommended for the discrimination between CNS-derived and blood-derived molecules in clinical laboratories.
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Introduction Dizziness and vertigo represent well-established symptoms of COVID-19. An overexpression of cytokines, a condition often described with the term "cytokine storm" or "hypercytokinemia", is a key characteristic of SARS-Cov-2 infection and plays a pivotal role in disease progression and prognosis. Among them, IL-6 is of major importance. Purpose The purpose of this study is to investigate any probable IL-6 serum titer difference in COVID-19 patients with vertigo (V+) or without vertigo (V-) admitted to the COVID-19 internal medicine departments of Attikon University Hospital, Athens, Greece, within 12 months. Methods The sample consisted of 52 COVID-19 patients who were diagnosed between January 1, 2020, and December 31, 2020. Of those, 31 reported vertigos during their admission (V+), while the remaining 21 COVID-19 patients did not complain of such symptoms (V-). Results Higher IL-6 serum levels post-COVID-19 infections lead to higher incidence rates of vertigo symptoms (p<.005), regardless of gender and age (p.005).
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BACKGROUND: Periodic Limb Movements during Sleep (PLMS) have been described to be frequently present in stroke patients. We aimed to evaluate the prevalence and severity of PLMS in acute stroke patients and clarify the association between PLMS and coexisting Sleep Disordered Breathing (SDB). Additionally, we focused on identifying variables that could independently predict the presence of PLMS in patients with acute stroke. The potential impact of PLMS on stroke outcome at three months was investigated as well. METHODS: In this study, we performed overnight polysomnography on consecutive stroke patients within 72 h from symptom onset. Data regarding clinical and imaging characteristics were prospectively collected. National Institute of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS) and Epworth-Sleepiness Scale (ESS) were used to evaluate stroke severity on admission, stroke outcome at three months and history of daytime sleepiness, respectively. We documented PLMS and SDB using standard polysomnography criteria. RESULTS: We prospectively assessed 126 patients with acute stroke [109 with ischemic and 17 with hemorrhagic stroke, mean age 60 ± 11 years, 68% men, median NIHSS score on admission: 3 (IQR: 2-7)]. The overall rate of PLMS in our cohort was 76%, and the rate of SDB among patients with PLMS was 83%. PLMS detection rates differed significantly (p-value: <0.001) according to SDB, with PLMS prevalence increasing with greater SDB severity. SDB could independently (OR:4.869, 95% CI: 1.884-12.784, p-value: 0.001) predict the presence of PLMS in the acute stroke phase in multivariable analyses adjusting for potential confounders. Moreover, baseline stroke severity (NIHSS-score increase in per-1 point: OR: 0.819, 95% CI: 0.737-0.895, p-value < 0.001) and PLMS (OR:0.099, 95% CI: 0.009-0.482, p-value = 0.015) were significantly associated with the likelihood of excellent functional outcome (mRS-scores: 0-1) at 3 months. CONCLUSION: The common presence of mostly severe PLMS in patients with acute stroke and their negative effect on stroke outcomes point out the necessity for early PLMS detection and treatment.