Blood pooling in extrathoracic veins after glossopharyngeal insufflation.

PURPOSE: Trained breath-hold divers hyperinflate their lungs by glossopharyngeal insufflation (GPI) to prolong submersion time and withstand lung collapse at depths. Pulmonary hyperinflation leads to profound hemodynamic changes. METHODS: Thirteen divers performed preparatory breath-holds followed by apnea with GPI. Filling of extrathoracic veins was determined by ultrasound and magnetic resonance imaging and peripheral extravasation of fluid was assessed by electrical impedance. Femoral vein diameter was measured by ultrasound throughout the easy-going and struggle phase of apnea with GPI in eight divers in a sub-study. RESULTS: After GPI, pulmonary volume increased by 0.8 ± 0.6 L above total lung capacity. The diameter of the superior caval (by 36 ± 17%) and intrathoracic part of the inferior caval vein decreased (by 21 ± 16%), while the diameters of the internal jugular (by 53 ± 34%), hepatic (by 28 ± 40%), abdominal part of the inferior caval (by 28 ± 28%), and femoral veins (by 65 ± 50%) all increased (P < 0.05). Blood volume of the internal jugular, the hepatic, the abdominal part of the inferior caval vein, and the combined common iliac and femoral veins increased by 145 ± 115, 80 ± 88, 61 ± 60, and 183 ± 197%, respectively. In the sub-study, femoral vein diameter increased by 44 ± 33% in the easy-going phase of apnea with GPI, subsequently decreasing by 20 ± 16% during the struggle phase. Electrical impedance remained unchanged over the thigh and forearm, thus excluding peripheral fluid extravasation. CONCLUSIONS: GPI leads to heart and pulmonary vessel compression, resulting in redistribution of blood to extrathoracic capacitance veins proximal to venous valves. This is partially reversed by the onset of involuntary breathing movements.

Organ perfusion during voluntary pulmonary hyperinflation; a magnetic resonance imaging study.

Pulmonary hyperinflation is used by competitive breath-hold divers and is accomplished by glossopharyngeal insufflation (GPI), which is known to compress the heart and pulmonary vessels, increasing sympathetic activity and lowering cardiac output (CO) without known consequence for organ perfusion. Myocardial, pulmonary, skeletal muscle, kidney, and liver perfusion were evaluated by magnetic resonance imaging in 10 elite breath-hold divers at rest and during moderate GPI. Cardiac chamber volumes, stroke volume, and thus CO were determined from cardiac short-axis cine images. Organ volumes were assessed from gradient echo sequences, and organ perfusion was evaluated from first-pass images after gadolinium injection. During GPI, lung volume increased by 5.2 ± 1.5 liters (mean ± SD; P < 0.001), while spleen and liver volume decreased by 46 ± 39 and 210 ± 160 ml, respectively (P < 0.05), and inferior caval vein diameter by 4 ± 3 mm (P < 0.05). Heart rate tended to increase (67 ± 10 to 86 ± 20 beats/min; P = 0.052) as right and left ventricular volumes were reduced (P < 0.05). Stroke volume (107 ± 21 to 53 ± 15 ml) and CO (7.2 ± 1.6 to 4.2 ± 0.8 l/min) decreased as assessed after 1 min of GPI (P < 0.01). Left ventricular myocardial perfusion maximum upslope and its perfusion index decreased by 1.52 ± 0.15 s(-1) (P < 0.001) and 0.02 ± 0.01 s(-1) (P < 0.05), respectively, without transmural differences. Pulmonary tissue, spleen, kidney, and pectoral-muscle perfusion also decreased (P < 0.05), and yet liver perfusion was maintained. Thus, during pulmonary hyperinflation by GPI, CO and organ perfusion, including the myocardium, as well as perfusion of skeletal muscles, are reduced, and yet perfusion of the liver is maintained. Liver perfusion seems to be prioritized when CO decreases during GPI.

Development of a concept for a personalized approach in the perioperative antiplatelet therapy administration/discontinuation management based on multiple electrode aggregometry in patients undergoing coronary artery surgery.

In patients undergoing coronary artery surgery, improvements in clinical outcomes currently rely on continued refinements of the surgical technique and modulation of adjuvant pharmacotherapy. Despite medical and technological advances, negligible rate of bleeding and ischemic events still persist necessitating further improvements in patient management. Platelet function testing (PFT) might play an important role in meticulous balancing between the risk of bleeding and thrombotic events. A suitable balance can be achieved by implementing a personalized, PFT based approach in antiplatelet therapy (APT) administration/discontinuation management. Despite emerging evidence on the widespread variability in platelet inhibitory response to APT, numerous PFT devices and heterogeneity in reporting study results hamper pooling of the evidence which in turn results with a lack of consensus in "on treatment" platelet reactivity associated with ischemic and bleeding events in perioperative phase. The literature on multiple electrode aggregometry (Multiplate(®); Roche Diagnostics, Mannheim, Germany) in coronary artery disease patients was reviewed systematically. Based on the evidence evaluating the relationship between "drug specific" PFT and bleeding or adverse ischemic events, we sought to define therapeutic window for the most commonly administered antiplatelet drugs such as aspirin (ASPI test) and adenosine-diphosphate receptor blockers (ADP test). Preoperatively, APT administration was primarily focused to avoid bleeding complications. ASPI test value of 20 AUC and ADP test value of <73 AUC were set as cut-off values that delineate bleeding tendency. Postoperatively, "therapeutic window" was set to avoid both bleeding and adverse ischemic events. Therapeutic ranges were as follows: 20 AUC < ASPItest ≤ 30 AUC and 19AUC < ADP ≤ 46AUC, respectively. This is the first attempt to define PFT based "therapeutic window" according to, perioperative APT administration/discontinuation management would be targeted. It seems that the "one-size-fits-all" concept of perioperative APT administration management is outdated and further development of PFT based, personalized APT administration/discontinuation management is desirable. This concept therefore presents a possible step forward in patient care and provides a platform for further interventional trials whereby the impact of its application on clinical outcomes would be validated.

[Clinical recommendations for treating and monitoring patients with renal cancer]. / Klinicke upute za dijagnozu, lijecenje i pracenje bolesnika oboljelih od raka bubrega.

Clear cell renal carcinoma is the most common kidney cancer. It is generally asymptomatic. A small percentage of patients present with hematuria, flank pain and abdominal mass. It is usually detected accidentally during radiologic examination. The diagnosis of kidney cancer is confirmed by pathohistological findings after completion of the diagnostic process. The decision about treatment is made based on clinical assessment of disease stage and other risk factors. Depending on that, treatment options include surgery, and considering high resistance of kidney cancer on chemotherapy and hormone therapy, use of targeted therapies (immunotherapy, tyrosine kinase inhibitors) and palliative radiotherapy. The following text presents the clinical guidelines in order to standardize procedures and criteria for the diagnosis, management, treatment and monitoring of patients with kidney cancer in the Republic of Croatia.

CT perfusion and noncontrast CT in acute ischemic stroke diagnosing--is there influence on early thrombolytic therapy outcome?

The objective of this study was to compare noncontrast computed tomography (NCCT) and computed tomography perfusion (CTP) in early diagnosis of acute ischemic stroke and to define influence of these diagnostic procedures on early outcome of thrombolytic therapy (TLTH). The study included 45 patients, 35 patients submitted to NCCT and CTP and 10 patients who underwent only NCCT, before CTP was introduced. Based on the National Institute of Health Stroke Scale (NIHSS) score we compared early outcome of patients who received TLTH after NCCT only (group 1) with the early outcome of patients who received TLTH following NCCT and CTP (group 2). Statistically significant difference was found in acute stroke diagnosing between CTP and NCCT (p = 0.002). There were no statistically significant differences in TLTH early outcome between group 1 and group 2. In conclusion, CTP should be done regulary in patients presenting with acute ischemic stroke symptoms. More research needs to be done in defining exact influence of CTP implementation on the TLTH outcome.

Lamotrigine therapy for resistant pain in radicular lesions of cervical segments C4-C5 and C5-C6: a case report.

Radicular pain syndromes caused by disk herniation are often accompanied by incomplete central cord syndrome. Intensive pain is difficult to control with standard analgesics. Antiepileptics of new generation have shown significant efficacy in treating pain syndromes, trigeminal neuralgia, diabetic neuropathy, migraines, etc. The treatment of radicular pain with lamotrigine, a new generation antiepileptic, turned out to be effective in lumbar disk radicular conflicts, justifying its application for resistant pain in cervical segment. In our patient, pain intensity was significantly reduced with gradual titration of lamotrigine to a dose of 200 mg/day. Pain intensity measured by the visual analog scale significantly decreased from 100 to 20 mm during eight weeks of titration. The blood concentration of the drug measured by the method of high performance liquid chromatography was 13.65 micromol/L. The patient's quality of life improved greatly. It is necessary to further evaluate the efficacy of lamotrigine in the treatment of resistant radicular damage.

Neuropsychiatric systemic lupus erythematosus: diagnostic and clinical features according to revised ACR criteria.

Neuropsychiatric disorders appear in about 70% of the patients diagnosed with systemic lupus erythematosus (SLE). The aim of this study was to evaluate morphological and functional abnormalities of central nervous system (CNS) in SLE patients with neuropsychiatric manifestations (NP) of disease by testing their relationship. We tested 10 patients (9 females, 1 male) with clinical manifestations of neuropsychiatric systemic lupus erythematosus (NP-SLE). That means clinical evaluation of symptoms, standard immunoserological tests, electroencephalogram (EEG), component of audio--evoked potentials P300, MMPI-202 test, Rey Complex Test and magnetic resonance imaging (MRI). MRI abnormalities were seen in all of our patients, while in 9 patients abnormalities in neuropsychological and neurophysiologic tests have been proved. The most common structural brain change, detected by MRI, was cortical atrophy (in 8 out of 10 patients). According to revised classification of the American College of Rheumatology (ACR) NP-SLE, the most frequent disorder was cognitive dysfunction (in 9 out of 10 patients). Cortical atrophic brain changes have been established in 7 out of 9 patients with cognitive dysfunction. Because of already known correlation of cortical atrophy with cognitive dysfunction in SLE patients, without neuropsychiatric manifestation, we can conclude that neuropsychological examination is required in every patient with systemic lupus erythematosus.

[Amusia and aphasia of Bolero's creator--influence of the right hemisphere on music]. / Amuzija i afazija tvorca Boléra--utjecaj desne hemisfere na glazbu.

OBJECTIVES: The experience with cortical localization (BA 44, 45, 22) of language (Broca, Wernicke and others) in the left hemisphere has been repeatedly tested over the last 150 years and is now generally accepted. A single case report with autopsy findings (Leborgne, Tan tan), has enabled to localize the seat of spoken language in the left third frontal convolution. As music and language have a lot in common and even share the same hearing system, it is logical to try to localize the cognitive centers for music too. METHODS: The disabling neurological disease illness of Maurice Ravel (1875-1937), a French impressionist composer, is not the right example to localize music center as that of Broca's language center, but it demonstrates the role of the right hemisphere in music production. In the last five years of his life, Ravel suffered from an unknown disease that affected the left hemisphere causing aphasia, apraxia, alexia, agraphia and amusia. It was the reason why Ravel could not compose during the last years of his life. In contrast to Ravel, Shebalin and Britten continued writing music works of their own although aphasic after having sustained two strokes to the left hemisphere. While lacking clinical cases with selective ablative brain lesions, research into the music localization can be done using modern imaging technologies such as fMRI and PET. RESULTS: Exercising music (professionally) develops analytical process in the left hemisphere whereas other individuals process music in their right hemisphere. There is right ear (left hemisphere) predominance in musicians and vice versa in musical amateurs. Music lateralization towards the right hemisphere is seen in women and in inattentive listeners. It can be subject to cultural influence, so the Japanese process their traditional popular music in the left hemisphere, whereas Westerners process the same music in the right hemisphere. Music and language are processed separately; they are localized in homologous regions of the opposite hemispheres. In 1937, Ravel underwent neurosurgical procedure performed by Vincent; autopsy was not done. It is believed that the cause of hi disease was primary progressive aphasia associated with Pick's disease. CONCLUSION: Boléro and Concerto for the Left Hand were the last Ravel's works (the onset of his disease), so it is possible that the projected the influence of the healthy right hemisphere onto his music (and on the creative process) because Ravel's left hemispher was damaged. Indeed, in these last music works one can feel the predominance of changes in pitch (timbre), i. e. right hemisphere, in comparison to only few changes of melody (left hemisphere).

[Electrosurgery, the cornerstone of current achievements of brain tumor surgery--on the occasion of 80th anniversary]. / Elektrokirurgija, temelj suvremenih dosega operacija tumora mozga--prigodom 80. Obljetnice.

Neurosurgical pioneers had so many obstacles that prevented safe work and favorable outcome of the patients operated on. The mortality rate was high and discouraging. The operations were fast and rude whereafter the patients were dying or suffered prolonged hemorrhagic shock. The three cornerstones of neurosurgery, i. e. cerebral localization, asepsis and narcosis, had not yet been discovered and the only diagnostic tools available were recently discovered x-rays, ventriculography and angiography. However, the greatest challenge for the neurosurgeon was that even if luckily localized through a craniotomy, how to remove the brain tumor while avoiding uncontrollable bleeding. Therefore, an array of techniques and tricks were developed such as bone wax, Cushing silver clips, packing of the wound, etc. but all of them were insufficient in case of intracerebral hemostasis. Electrosurgery revolutionized this unacceptable situation thoroughly. It was introduced in neurosurgery 80 years ago (on October 1, 1926) by great Cushing, whereupon its usage has spread rapidly worldwide. The mortality rate was lowered to 13%! The coagulator was constructed by Harvard's physicist Bovie, after whom is named. Owing to the new technique, the control of bleeding in neurosurgery has become much safer, craniotomies are larger than before and the operation time is esentially longer. Since the perfection of bipolar coagulation (by Greenwood and Malis brothers), and after the introduction of the operating microscope (Donaghy, Krayenbühl, Yasargil) in 1970, this half of a century-long monopolar era was over, and the new time of microneurosurgery has begun. It enables better, easier and more precise hemostasis of the magnified brain blood vessels (microscope).

[Unusual open craniocerebral injury caused by sickle's tip]. / Neobicna otvorena kraniocerebralna ozljeda zetelackim srpom.

A nine years old girl suffered an unusual penetrating injury to the head caused by a sickle's tip sticked into the skull bones during a lavender harvest on island of Hvar. GCS score was 15. A sickle's blade and its handle were clearly seen coming out of the frontal bone, hanging free, while its tip was firmly sitting in the skull bones! After a neuroradiological diagnostical work up (skull x rays and CT scans) that confirmed intracranial penetration she was operated as an emergency. An osteoclastic craniotomy was done, a and a sickle thereafter easily extracted. Lacerated and contused brain and the penetrating canal were debrided and dura defect covered with a patch. Broad spectrum antibiotics were administered after antitetanic prophylaxis. Postoperative course was uneventful especially regarding infection. One year after the accident she goes normaly to school.

[Sensitivity and specificity of clinical assessment in the diagnosis of acute brain diseases]. / Osjetljivost i specifijnost klinicke procjene u dijagnostici akutnih mozdanih zbivanja.

Acute brain diseases require timely and correct diagnosis. The basic guideline in treating these patients is clinical-neurological assessment. We tested the sensitivity and specificity of clinical assessment of acute brain disease according to definitive diagnosis determined by neuroradiology and computerized tomography (CT). We found a statistically significant correlation between the disease assessment and brain CT in patients with ischemic stroke. In patients with hemorrhagic stroke and brain tumors, the clinical-neurological assessment was found to be of statistically significantly lower sensitivity and specificity. Clinical assessment may produce false-positive and false-negative findings concerning hemorrhagic stroke and brain tumors. Study results indicated brain CT to be an unavoidable diagnostic method, along with clinical assessment of acute brain disorders.

Leptomeningeal metastases of an astrocytoma of the conus medullaris: a case report.

We describe a case of spinal leptomeningeal metastases of an astrocytoma of the conus medullaris that presented with quadriplegia. The patient was a 50-year-old woman with a previously treated astrocytoma of the conus medullaris and a spinal cord metastasis at the Th2-L level. Four years after the initial treatment, the patient developed weakness of the upper extremities with a decreased muscular tonus. Magnetic resonance imaging of the cervical spine showed an intradural extramedullary metastatic tumor deposit at the C3-C6 level. Spinal leptomeningeal metastases need to be suspected in patients with a history of intramedullary astrocytoma.

Thrombosis of sinus sagitalis during puerperium caused by thrombophilic gene mutation.

Cerebral veno-sinus thrombosis (CVT) during puerperium may have fatal consequences. A nonspecific clinical picture must be complete with computed tomography of the brain and digital substract angiography of the brain blood vessels, and, once the clinical diagnosis is confirmed, coagulation tests and genetic analysis of the coagulation factor are to be made as well. Genetic polymorphisms associated with thrombophilia such as factor V Leiden, prothrombin G20210A, MTHFR C677T, ACE and PIA1/A2 may be the cause of the hypercoagulability that results in CVT.

[Traumatic carotid-cavernous fistula]. / Traumatska karotidno-kavernozna fistula.

Carotid-cavernous fistula is uncommon consequence of craniocerebral trauma. Earlier recognition of the patients with carotid-cavernous fistula and shorter time of delay in treatment could save patients from complications and vision loss. A 27-year-old man presented with severe craniocerebral injury after an car accident. He required emergent craniotomy for an open depressed cranial fractures, haemostasis and epidural hematoma. Three months later, the patient began to exhibit progressive chemosis and proptosis of left eye. Computed tomography and cerebral angiography revealed findings consistent with a carotid-cavernous fistula. Angiography revealed a fistula between carotid artery and the cavernous sinus. The patient was treated by transarterial embolization resulting in immediate and permanent occlusion of the fistula and improved visual acuity after six months follow-up. Posttraumatic carotid-cavernous fistula may be treated successfully with the use of transarterial coil embolization.

Hemifacial spasm in vertebrobasilar dolichoectasia.

Vascular compression of the facial nerve is a well recognized cause of hemifacial spasm (HFS). Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) provide vascular and brain tissue diagnosis in a single non-invasive examination and should be recommended as primary neuroradiological procedure in HFS. We report a rare case of symptomatic HFS caused by a vertebrobasilar dolichoectasia. A 49-year-old women experienced left hemifacial spasm for 10 months. MRI showed an enlarged vertebrobasilar dolichoectasia of the left vertebral artery which compressed the seventh cranial nerve at its exit from the caude pons. MRI is essential in establishing the cause of HFS. Together with MR angiography it shows the correlation among the seventh cranial nerve, blood vessels and the structures of mid-brain. Vertebrobasilar delichoestasia is just one of the blood vessel anomalies which causes HFS and which can be shown by MRI. HFS caused by vertebrobasilar dolichoectasia is quite rare.