Benefits of repeated CT scan in patients with neurosurgical-neurological problems in intensive care retrospective analysis.

INTRODUCTION: CT examination of the brain is an integral part of neurointensive care. The examination, however, represents a risk for patients and has side effects. Indications for the procedure should therefore be carefully considered. The aim of the study was to analyze the indications for brain CT and the influence of its result on further treatment. METHOD: A retrospective analysis of CT examinations of the brain performed during 2010 in 263 patients admitted to neurointensive care. The study assessed whether the indication for a CT scan was due to a change in the patient's neurological status or routine, and also whether pharmacological sedation was used. Implications of the CT scan results for the course of treatment were evaluated. RESULTS: 763 CT examinations of brain were performed in the study group. 81% of the patients were under pharmacological sedation at the time of the exam indication, 19% had no sedation and could be clinically evaluated. In both groups, 80% of examinations were indicated on a routine basis. More than half of all CT examination results were evaluated as no change or improvement. Two thirds of them had no impact on the course of further treatment. Results of CT scans indicated due to a change in neurological status led to a change of therapy more often than in routine indications (24.8 vs. 14.2%). The difference was even greater in patients indicated for surgery (19 vs. 8.4%). CONCLUSION: CT scans of the brain are and will continue to be a fundamental part of neurointensive care but cannot replace clinical examination, which is influenced by pharmacological sedation. Results of brain CT scans have led to a change in the course of therapy more frequently when indicated due to a change in neurological status. Rational indication of sedation can contribute to rational indication for brain imaging. Key words: neurointesive care - sedation - CT of the brain.

[The current view of the diagnosis and management of amebiasis in the light of the authors own case reports]. / Soucasný pohled na diagnostiku a lécbu amébózy ve svetle vlastní kazuistické zkusenosti.

This comprehensive review is focused on a serious protozoan disease, amebiasis. This disease is caused by the human parasite Entamoeba histolytica (E. histolytica), the second leading cause of mortality due to protozoan disease worldwide (the leading cause is malaria). The incidence of amebiasis in the Czech Republic is very low, but it may be underreported as the disease often escapes diagnosis. Intestinal colonisation by E. histolytica may be asymptomatic. The clinical picture ranges from diarrhea to colitis or fulminant colitis when the parasite progresses to the trophozoite stage. Secondary dissemination in the blood or lymph system may induce systemic signs of the disease. Liver abscess is the most common extraintestinal form of amebiasis. The diagnosis of intestinal amebiasis is based on the clinical picture and parasitological examination of the stool. To diagnose extraintestinal amebiasis, serology tests are used to detect antibodies in the blood. Recently, molecular methods have been increasingly used for the detection of the nucleic acids of the pathogen in biological specimens. The first line therapy for amebiasis are 5-nitroimidazole drugs, currently available in the Czech Republic. However, surgical intervention should also be considered in patients with a severe course of the disease. Included in the review are the case reports of patients with severe concomitant intestinal and extraintestinal amebiasis.

[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.

The MRI volumetry of the posterior fossa and its substructures in trigeminal neuralgia: a validated study.

PURPOSE: Our aim was to determine whether the anatomical configuration of the posterior fossa and its substructures might represent a predisposition factor for the occurrence of clinical neurovascular conflict in trigeminal neuralgia (TN). METHODS: We used MRI volumetry in 18 patients with TN and 15 controls. The volume of the pontomesencephalic cistern, Meckel's cave and the trigeminal nerve on the clinical and non-affected sides was compared. The reliability has been assessed in all measurements. RESULTS: The posterior fossa volume was not different in the clinical and control groups; there was no difference between the affected and non-affected sides when measuring the pontomesencephalic cistern and Meckel's cave volume either. The volume of the clinically affected trigeminal nerve was significantly reduced, but with a higher error of measurement. CONCLUSIONS: We did not find any association between the clinical neurovascular conflict (NVC) and the size of the posterior fossa and its substructures. MRI volumetry may show the atrophy of the affected trigeminal nerve in clinical NVC.

[Atypically localised hepatic haemangioma as a cause of dyspeptic syndrome]. / Atypicky lokalizovaný hemangiom jater jako prícina dyspeptického syndromu.

INTRODUCTION: Haemangioma is a benign mesenchymal tumor growing from the endothehum of blood vessels. Most hepatic haemangiomas are asymptomatic while symptomatic haemangioma are usually manifested by non-specific pain dyspeptic syndrome, quite rarely also by hemorrhage, or icterus Symptomatic haemangiomas or large haemangiomas with fast growth, are indicated for surgical treatment. CASE REPORT: The authors present a 50-year-old patient with chronic dyspeptic condition and pressure pain in the epigastria. USG, CT, MR, CT angiography and EUS have all shown two lesiones (haemangioma of the left hepatic lobe, a tumor in the left subphrenic area of uncertain origin). We proposed an operational solution, and, surprisingly, the finding was a single haemangioma (2 parts-- intra- and extraparenchymatous--connected by a vascular bridge). We then performed left lobectomy. DISCUSSION: In the diagnosis of haemangioma, MR is a method of choice with high specificity and sensitivity. Why did not it yield the correct diagnosis? The structure, the signal and the type of postcontrast enhancement of the second lesion corresponded to a haemangioma, but the extraparenchymatous location and also the considerable remoteness from the liver invalidated this possibility before operation. Regarding to the differential diagnostics of the lesiones in the subphrenic area, which according to the imaging techniques are not related to the hepatic parenchyma, it is advisable to consider the possibility of the incidence of pedunculated hepatic haemangioma.

Cyclosporine-related neurotoxicity in a patient after bilateral lung transplantation for cystic fibrosis.

Cyclosporine (CsA) is a widely used immunosuppressant following solid organ transplantation. CsA administration is associated with a number of systemic complications, including neurotoxicity. A 33-year-old man with cystic fibrosis, who underwent bilateral lung transplantation, presented with severe neurotoxic symptoms leading to coma in association with CsA administration combined with high doses of methylprednisolone for treatment of an acute rejection episode. After discontinuation of CsA, a quick resolution of his clinical status was observed, as well as of the pathological findings on magnetic resonance imaging (MRI). CsA was replaced with tacrolimus leading to an uneventful course.

[Use of the auditory brainstem neuroprosthesis in the Czech Republic]. / Sluchová kmenová neuroprotéza v Ceské republice.

BACKGROUND: Auditory brainstem implant (ABI) is an electroprosthetic device enabling sound sensations in deaf persons with a bilateral lesion of auditory nerves. Stimulation of auditory nuclei in the floor of the IVth ventricle is realized by an electrode array introduced during surgery in the lateral recess of the IVth ventricle. METHODS AND RESULTS: The main indication group for ABI is represented by patients with neurofibromatosis 2 (NF2) suffering from bilateral vestibular schwannomas. During surgery aimed at tumour removal, auditory nerve function and integrity are almost always destroyed, therefore, an ABI can be introduced as an one stage procedure. Implantees use the device mainly as the aid in lipreading, only very rarely they can comprehend speech without visual cues. Auditory brainstem implant programme has been introduced in the Czech Republic in the year 1999. It was the very first ABI surgery in the Central Europe. Since that time, 5 patients had received the auditory brainstem implant, from which the first four use the device for a longer time. CONCLUSIONS: The last operated patient has not been activated yet. It may be said, that ABI represents a benefit to all our patients, in one implanted this benefit is significant, since he can understand speech without lipreading, the other implantees use the device as an aid in lipreading. In one female patient, the device benefit is severely limited by a motoric handicap after partial cerebellar resection during surgery. Nevertheless, she uses the implant on a daily basis, but contact with her is limited and difficult.

[Importance and reliability of preoperative localization in primary hyperparathyroidism]. / Otázka nutnosti a spolehlivosti predoperacních lokalizacních vysetrení u primární hyperparatyreózy.

On the basis of experience with a group of 176 performed operations for primary hyperparathyreosis at the 3rd Surgical Clinic of 1st Medical Faculty of Charles University in Prague in cooperation with the 3rd Internal Clinic of 1st Medical Faculty of Charles University in Prague, we together share the opinion to perform necessary preoperative localization examinations. Sonography is routinely performed and after evaluation of its objective result scintigraphy and MRI is individually indicated. Preoperative localization of adenomas shortens the time of operative procedure. Sufficient experience with preoperative localization examinations become more important especially in the diagnosis before reoperations of parathyroidal adenomas which are sometimes necessary.

[Surgical problems in primary hyperparathyroidism with concomitant nodular goiter]. / Problematika operací pro primární hyperparatyreózu v terénu nodózní strumy.

In our group of 176 performed operations with diagnosis of primary hyperparathyreosis during the period of 1994-1999 present thyreopathy has been established peroperatively as well as postoperatively in altogether 47% of patients. Due to high percentage of coincidence of these diagnoses the condition of establishing indication for surgical therapy appears to be necessary not only on parathyroidal glands, but also determining the extent of resection on the thyroidal gland. In terms of preoperative screening, besides usual investigation of sonography and scintigraphy, we can recommend MRI test, which is highly positive for patients with thyreopathy, particularly in the area of nodular thyroid mass. The advantage of MRI investigation enables more precise localization of ectopic parathyroidal adenoma.

[Surgical approach in mediastinal adenomas and parathyroid carcinomas]. / Operacní prístup k mediastinálním adenomum a karcinomum paratyroidey.

The authors performed retrospective analysis of medical records in a group of 176 patients, who underwent surgical treatment of primary hyperparathyroidism. Surgical strategy was the major issue of interest. Cervical collar incision represented a first-choice approach to cervical exploration in most of cases except those, in whom ectopic mediastinal localization have been diagnosed before the operation. Partial sternotomy was the most common option in surgical re-explorations as a second step following failed parathyroid surgery. We conclude that partial sternotomy is necessary further step in patients with primary hyperparathyroidism complicated by malignant hypercalcaemia on condition that the surgeon is not able to reveal adenomas from neck exploration and sternotomy is than performed immediately during the same operation.

[Rupture of the pancreas in children--present trends in diagnosis and therapy]. / Ruptura pankreatu v detském veku--soucasné trendy v diagnostice a terapii.

Evaluation of pancreatic injuries is presented in the professional literature in retrospective studies and views on treatment vary. The authors evaluated also in a retrospective study a group of eight child patients with a serious injury of the pancreas. The patients were 3-13 years old and were hospitalized at the Clinic of Paediatric Surgery at the Faculty Hospital Motol in 1985-1999. The group is formed by patients with pancreatic injuries (according to the Japanese classification type II and III). The authors evaluate not only diagnostic but also therapeutic procedures. In the diagnosis they evaluate the ultrasonographic examination (USG) as the examination of first choice which however need not record the extent and severity of the pancreatic injury. Computing tomography (CT) and magnetic resonance (MRI) can make the original suspicion of injury more accurate, ERCP is an examination which reveals in particular type III injuries--i.e. those with affection of the pancreatic duct. Injured children where a serious pancreatic lesion was not diagnosed primarily, had to be subjected to repeated surgical revisions. All children in the presented group recovered, none of the patients died.