Ultrasound Doppler Flow Parameters Are Independently Associated with Renal Cortex Contrast-Enhanced Multidetector Computed Tomography Perfusion and Kidney Function.

BACKGROUND: The assessment of kidney perfusion has an emerging significance in many diagnostic applications. However, whether and which of the ultrasound Doppler parameters better express renal cortical perfusion (RCP) was not shown. The study aimed to prove the usefulness of Doppler ultrasound parameters in the assessment of RCP regarding low-dose contrast-enhanced multidetector computer tomography (CE-MDCT) blood flow. METHODS: Thirty non-stenotic kidneys in twenty-five hypertensive patients (age 58.9 ± 19.0) with mild-to-severe renal dysfunction were included in the study. Resistive index (RI) and end-diastolic velocity (EDV) in segmental arteries, color Doppler dynamic RCP intensity (dRCP), RI (dRI), pulsatility index (dPI), and CE-MDCT blood flow (CBF) in the renal cortex were estimated. RESULTS: CBF correlated significantly with age, estimated glomerular filtration rate (eGFR), RI, EDV, dRI, dPI, and dRCP. In separate multivariable backward regression analyses, RI (R2 = 0.290, p = 0.003) and dRCP (R2 = 0.320, p = 0.001) were independently associated with CBF. However, in the common ultrasound model, only dRCP was independently related to CBF (R2 = 0.317, p = 0.001). Only CBF and EDV were independently associated with eGFR (R2 = 0.510, p < 0.001). CONCLUSIONS: Renal cortical perfusion intensity is the best ultrasound marker expressing renal cortical perfusion. In patients with hypertension and kidney dysfunction, renal resistive index and end-diastolic velocity express renal cortical perfusion and kidney function, respectively.

Lower Preoperative Verbal Memory Performance Is Associated with Delirium after Coronary Artery Bypass Graft Surgery: A Prospective Cohort Study.

OBJECTIVE: Cognitive impairment constitutes one of the major risk factors of delirium after coronary artery bypass graft (CABG) surgery; however, it is unclear whether only patients with global cognitive decline are at increased risk for delirium or if individuals with preserved global cognitive functions but impairments in specific cognitive domains are also more vulnerable to developing delirium. Thus, this study aimed to analyze the neurocognitive status of patients scheduled for CABG surgery with the use of an advanced computerized cognitive battery (CNS Vital Signs) and to investigate possible associations between impaired performance in selective cognitive areas and the risk of postoperative delirium development. METHODS: The study enrolled 127 participants with a median age of 67 years (IQR: 63-71). Postoperative delirium developed in 32 (25%) patients.Before surgery, the patients were screened for global cognitive impairment with the use of the Mini-Mental State Examination Test, and the individuals were asked to perform the CNS Vital Signs battery to investigate 12 specific cognitive domains. The Confusion Assessment Method and the Memorial Delirium Assessment Scale were used to screen for a diagnosis of delirium postoperatively. RESULTS: In multivariate models, a lower score of verbal memory-assessed preoperatively was independently associated with the risk of postoperative delirium development. Other independent predictors of delirium included more advanced age, gender female, depression, postoperative pyrexia, and the presence of extracorporeal circulation. CONCLUSIONS: As decreased verbal memory constitutes an independent risk factor for postoperative delirium, a verbal memory test may be a useful predictor of postoperative delirium development.

Assessment of brain and hippocampal volume in patients with Cushing's disease.

INTRODUCTION: The purpose of this study was to assess the volumes of the hippocampus, grey matter, and the whole brain in patients with active Cushing's disease compared to a control group. MATERIAL AND METHODS: We included 36 patients diagnosed with Cushing's disease, with pituitary magnetic resonance imaging (MRI) performed as a standard preoperative assessment. The sample size of the control group was 26 persons. MRI studies were acquired with a 3.0 Tesla MR scanner equipped with a 24-channel head coil. The MRI study protocol included a pre-contrast 3D T1-weighted gradient sequence. Volumetric segmentation of the brain structures was performed using version 6.0 of the FreeSurfer software. RESULTS: We observed statistically significant reduction in the grey matter volume in the study group as compared to the control group (p < 0.001), with no significant differences in the volume of the whole brain (p = 0.104), left hippocampus (p = 0.790), and right hippocampus (p = 0.517). There was a strong positive correlation between grey matter volume and brain volume (r = 0.75, p < 0.001), independent of the study group. CONCLUSIONS: The study showed unevenly distributed brain atrophy in patients suffering from Cushing's disease, with no significant hippocampal atrophy. Significant atrophy was observed within the grey matter, potentially constituting a preliminary stage of whole-brain atrophy.

Efficacy of Cerebrolysin Treatment as an Add-On Therapy to Mechanical Thrombectomy in Patients With Acute Ischemic Stroke Due to Large Vessel Occlusion: Study Protocol for a Prospective, Open Label, Single-Center Study With 12 Months of Follow-Up.

This study is designed to determine the efficacy of Cerebrolysin treatment as an add-on therapy to mechanical thrombectomy (MT) in reducing global disability in subjects with acute ischemic stroke (AIS). We have planned a single center, prospective, open-label, single-arm study with a 12-month follow-up of 50 patients with moderate to severe AIS, with a small established infarct core and with good collateral circulation who achieve significant reperfusion following MT and who receive additional Cerebrolysin within 8 h of stroke onset compared to 50 historical controls treated with MT alone, matched for age, clinical severity, occlusion location, baseline perfusion lesion volume, onset to reperfusion time, and use of iv thrombolytic therapy. The primary outcome measure will be the overall proportion of subjects receiving Cerebrolysin compared to the control group experiencing a favorable functional outcome (by modified Rankin Scale 0-2) at 90 days, following stroke onset. The secondary objectives are to determine the efficacy of Cerebrolysin as compared to the control group in reducing the risk of symptomatic secondary hemorrhagic transformation, improving neurological outcomes (NIHSS 0-2 at day 7, day 30, and 90), reducing mortality rates (over the 90-day and 12 months study period), and improving: activities of daily living (by Barthel Index), health-related quality of life (EQ-5D-5L) assessed at day 30, 90, and at 12 months. The other measures of efficacy in the Cerebrolysin group will include: assessment of final stroke volume and penumbral salvage (measured by CT/CTP at 30 days) and its change compared to baseline volume, changes over time in language function (by the 15-item Boston Naming Test), hemispatial neglect (by line bisection test), global cognitive function (by The Montreal Cognitive Assessment), and depression (by Hamilton Depression Rating Scale) between day 30 and day 90 assessments). The patients will receive 30 ml of Cerebrolysin within 8 h of AIS stroke onset and continue treatment once daily until day 21 (first cycle) and they will receive a second cycle of treatment (30 ml/d for 21 days given in the Outpatient Department or Neurorehabilitation Clinic) from day 69 to 90.

Oxidative stress and soluble receptor for advanced glycation end-products play a role in the pathophysiology of delirium after cardiac surgery.

Coronary-artery bypass graft (CABG) surgery is known to improve cardiac function and decrease mortality, albeit, this method of treatment is also associated with a neuropsychiatric complications including postoperative delirium. The pathophysiology of delirium after cardiac surgery remains poorly understood. Thus, the purpose of this study was to investigate whether oxidative stress reflected by decreased preoperative and postoperative plasma antioxidant activity is independently associated with delirium after cardiac surgery. The second aim was to assess whether decreased antioxidant activity is stress-related or mediated by other pathologies such as major depressive disorder (MDD), anxiety disorders, and cognitive impairment. Furthermore, the putative relationship between pre- and postoperative soluble receptor for advanced glycation end-products (sRAGE) overexpression and plasma antioxidant capacity was evaluated. The patients cognitive status was assessed 1 day preoperatively with the use of the Mini-Mental State Examination Test and the Clock Drawing Test. A diagnosis of MDD and anxiety disorders was established on the basis of DSM-5 criteria. Blood samples for antioxidant capacity and sRAGE levels were collected both preoperatively and postoperatively. The Confusion Assessment Method for the Intensive Care Unit was used within the first 5 days postoperatively to screen for a diagnosis of delirium. Postoperative delirium was diagnosed in 34% (61 of 177) of individuals. Multivariate logistic regression analysis revealed that low baseline antioxidant capacity was independently associated with postoperative delirium development. Moreover, increased risk of delirium was observed among patients with a preoperative diagnosis of MDD associated with antioxidant capacity decreased postoperatively. According to receiver operating characteristic analysis, the most optimal cutoff values of the preoperative and postoperative antioxidant capacity that predict the development of delirium were 1.72 mM and 1.89 mM, respectively. Pre- and postoperative antioxidant capacity levels were negatively correlated with postoperative sRAGE concentration (Spearman's Rank Correlation - 0.198 and - 0.158, p < 0.05, respectively). Patients with decreased preoperative antioxidant activity and those with depressive episodes complicated with lower postoperative antioxidant activity are at significantly higher risk of delirium after cardiac surgery development. sRAGE overexpression may be considered as protective mechanism against increased oxidative stress and subsequent cell damage.

Elevated Monocyte Chemoattractant Protein-1 as the Independent Risk Factor of Delirium after Cardiac Surgery. A Prospective Cohort Study.

BACKGROUND: The pathogenesis of postoperative delirium is largely unknown. The primary objective of this study is to assess whether increased levels of monocyte chemoattractant protein-1 (MCP-1) and high-sensitivity C-reactive protein (hsCRP) are associated with postoperative delirium in patients who have undergone cardiac surgery. The secondary objective is to investigate whether any association between raised inflammatory biomarkers levels and delirium is related to surgical and anesthetic procedures or mediated by pre-existing psychiatric conditions associated with raised pro-inflammatory markers levels. METHODS: The patients were screened for cognitive impairment one day preoperatively with the use of the Mini-Mental State Examination Test and the Clock Drawing Test. A diagnosis of major depressive disorder (MDD) and anxiety disorders was established on the basis of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria. Blood samples were collected pre- and postoperatively for hsCRP and chemokine levels. RESULTS: Postoperative delirium developed in 34% (61 of 177) of patients. Both pre- and postoperative hsCRP, and preoperative MCP-1 levels were associated with postoperative delirium in univariate comparisons; p = 0.001; p < 0.001; p < 0.001, respectively. However, according to a multivariable logistic regression analysis, only a raised MCP-1 concentration before surgery was independently associated with postoperative delirium, and related to advancing age, preoperative anxiety disorders and prolonged intubation. CONCLUSIONS: The present study suggests that an elevated preoperative MCP-1 concentration is associated with delirium after cardiac surgery. Monitoring of this inflammatory marker may reveal the cardiovascular disease (CVD) patients who are at risk of neuropsychiatric syndromes development.

The mean platelet volume on admission predicts unfavorable stroke outcomes in patients treated with IV thrombolysis.

PURPOSE: The role of biomarkers in the prediction of acute ischemic stroke (AIS) outcome or response to thrombolytic therapy (with recombinant tissue plasminogen activator [rt-PA]) remains limited. The aim of this study was to evaluate whether mean platelet volume (MPV) could predict short-term functional outcome in patients with AIS following rt-PA treatment. PATIENTS AND METHODS: This was a retrospective analysis of 237 AIS patients (mean age 71.04±0.8 years, 50.6% women) consecutively admitted to a tertiary care center between 2011 and 2015. RESULTS: The mean MPV in the cohort was 9.8±0.35 fL (lowest tertile <7.29 fL, median 7.29-8.8 fL, and highest tertile >8.8 fL). Patients in the lowest tertile compared to median and highest tertiles were less often dependent (modified Rankin scale [mRS] ≥3) at admission (87.2% vs 96.1% and 96.1%, respectively, P=0.04) and less often had a poor stroke outcome (mRS 4-6) at discharge (28.2% vs 55.3% and 44.7%, P<0.01). However, there was no significant difference between tertiles with regard to AIS etiology, CT (Alberta Stroke Program Early CT) score, frequency of stroke due to large artery occlusion, risk of secondary hemorrhage, and early neurologic deterioration. Multivariable analysis after adjustment for confounders showed that patients in the second and third tertiles had a significantly higher risk of poor stroke outcome (OR =1.9, 95% CI =1.01-4), lack of early improvement (OR =1.91, 95% CI =1.05-3.47), lower chance of good outcome (mRS 0-2; OR =0.38, 95% CI =0.18-0.78), or minor stroke at discharge (OR =0.47, 95% CI =0.26-0.84). Receiver operating characteristic analysis for prediction of poor stroke outcome showed that the optimal cut-off point of MPV was 8.8 fL (area under the curve 0.586 [0.512-0.659], P=0.03) with a sensitivity of 82.7% and a specificity of 43.9%. CONCLUSION: Disabling or fatal ischemic stroke in thrombolyzed patients was observed more often in patients with high admission MPV. The prognostic value of MPV was independent of other well-defined individual risk factors.

Clinical Application of Autologous Adipose Stem Cells in Patients with Multiple Sclerosis: Preliminary Results.

The clinical outcome of autologous adipose stem cell (ASC) treatment of patients with multiple sclerosis (MS) was investigated following one year of observation. Methods. The clinical and MRI outcomes of 16 ASC-treated patients with RRMS and SPMS are reported after a one-year follow-up period. Results. At 18 months of follow-up, some patients showed "enticing" improvements on some exploratory efficacy measures, although a significant benefit was not observed for any measure across the entire group. Neither the progression of disability nor relapses were observed in any cases. In four patients, we found new gadolinium+ (Gd+) lesions on MRI. Our results indicate that ASC therapy is safe and does not produce any substantial side effects. Disease progression-free survival (PFS) of 18 months was seen in all patients with RRMS and SPMS. In these patients, EDSS scores did not progress above baseline scores. Gd-enhancing lesions were observed in two cases with RRMS, but these patients did not exhibit changes in EDSS score. Conclusion. Intrathecal treatment with ASCs is an attractive form of therapy for patients with MS but should be reserved for cases with aggressive disease progression, for cases that are still in the inflammatory phase, and for the malignant form.

Hemodynamic characteristics and the occurrence of renal biopsy-related arteriovenous fistulas in native kidneys.

PURPOSE: Renal biopsy-related arteriovenous fistula (RB-AVF), although usually asymptomatic, may sometimes result in serious clinical implications. The aim of the study was to prospectively evaluate the incidence of RB-AVF in native kidneys, together with the assessment of hemodynamic characteristics and the impact of the histopathological results of biopsy. METHODS: The study included 138 patients (age 46.2 ± 15.2; 70 F, 68 M), who underwent percutaneous renal biopsy (PRB) of the native kidney. In all patients, 2D and color Doppler ultrasound was performed 24 h after PRB in order to exclude RB-AVF. RESULTS: Bleeding complications in the form of hematomas were found in 136 patients (98.55 %), and 23 cases of RB-AVF were observed (16.67 %). RB-AVF group had an increased maximal hematoma diameter and reduced number of glomeruli in PRB. The segmental arteries supplying the fistulas are characterized by higher maximum flow velocity (FV) and a lower resistance index (RI) compared to the normal segmental arteries (difference 45.9 ± 20.0 cm/s and 0.252 ± 0.104, respectively). In the ROC analysis, RI ≤ 0.524 allowed to detect RB-AVF with a sensitivity of 91 % and specificity of 100 % (AUC 0.998, p < 0.001). In approximately 39 % of RB-AVF cases, 2D ultrasound detected a hyperechogenic ischemic area between the fistula and the renal capsule. CONCLUSIONS: Arteriovenous fistula is a quite frequent complication of native renal biopsy and can cause ischemia in the renal parenchyma detected by ultrasound. The arteries supplying the fistula are characterized by an increased flow velocity and reduced resistance index.

Early operative comparison of two epicardial left atrial appendage occluding systems applied during off-pump coronary revascularisation in patients with persistent atrial fibrillation.

INTRODUCTION: Atrial fibrillation (AF) increases long-term mortality and stroke rate in patients having coronary artery bypass grafting (CABG). Because oral anticoagulation (OAC) is associated with both a significant incidence of discontinuation and well known complication rates, left atrial appendage occlusion might be beneficial for stroke prevention. This study presents the first clinical and practical comparison of two epicardial left appendage occluders (LAAO) accruing experience in application during off-pump coronary revascularisation in patients with persistent AF. MATERIAL AND METHODS: Fifteen consecutive patients with persistent AF were assigned to intraoperative LAA occlusion with either TigerPaw System II (n = 8) or AtriClip (n = 7) device during off-pump CABG and concomitant left atrial epicardial ablation. Both systems were analysed in terms of ease and safety of application along with intraoperative LAA occlusion success. RESULTS: Surgical risk was increased in the study population (mean EuroScore II: 3.2 ± 0.3%). In all patients in the AtriClip group successful off-pump LAA occlusion confirmed by intraoperative transoesophageal echocardiography was achieved. The TigerPaw application was quicker and easier, but in 2 patients it was unsuccessful. During the hospital stay there were no bleeding or thromboembolic events recorded. CONCLUSIONS: In a pilot cohort epicardial LAAO during off-pump CABG in patients with persistent AF was performed safely and successfully with an AtriClip device. The TigerPaw System requires technological improvement. It might be useful to adapt the use of the type of occluding device to the LAA morphologic type and target revascularisation vessels to avoid the additional use of a heart positioner or obviate coronary compression.

Combined thrombolysis in posterior circulation stroke caused by bilateral vertebral artery dissection in squash player.

BACKGROUND AND PURPOSE: Growing number of vertebral artery dissection has been detected due to higher awareness and improved imaging techniques, even after seemingly minor head turning in young- or middle-aged adults without predisposing risk factors for cerebrovascular disease. Treatment options for this condition at this time are limited and there is a troubling shortage of controlled studies. SUMMARY OF CASE: Our patient suffered a bilateral vertebral artery dissection complicated by posterior circulation stroke. We decided to treat acute stroke with intravenous thrombolytic therapy. Patient's condition worsened despite the treatment so emergency angiography was performed to assess the arterial patency. Additional dose of recombinant tissue plasminogen activator together with mechanical thrombectomy was administered using intraarterial route. The patient recovered well and at 12-month follow-up visit he had only right marginal incomplete hemianopia. CONCLUSIONS: Vertebral artery dissection should be taken into consideration in differential diagnosis of posterior circulation stroke or TIA in young patients with a history of even as subtle precipitating events as forceful head movements. Combined thrombolytic therapy may provide safe and effective treatment of stroke-complicated cases. This case report shows that expanded diagnostic protocol for acute ischemic stroke, including computed tomography perfusion study and angiography of cervical and cranial vessels, assures rapid and correct diagnosis.

Partial thyroid arterial embolization for the treatment of hyperthyroidism.

BACKGROUND: Hyperactive thyroid gland in patients that are unable to tolerate or accept standard therapy is a common clinical problem. Aim of the study was to evaluate effectiveness of partial thyroid arterial embolization in patients with hyperthyroidism. MATERIAL/METHODS: From May 2004 to November 2005 partial thyroid gland embolization was performed in 15 patients. Mean thyroid gland volume was 162 ml. Embolization of one to three thyroid arteries was performed with the mixture of Histoacryl and Lipiodol. Selective angiography was performed after embolization to ensure that the targeted arteries were completely occluded. Follow-up study covered 12 patients. RESULTS: The embolization procedure was well tolerated by all patients. Three days after embolization fT3 and fT4 levels were higher than before the procedure. Further laboratory tests showed quick reversal to near-normal or normal levels of thyroid hormones. 12 weeks follow-up showed: normal serum levels of fT3, fT4 and TSH in 9 of 12 patients (75%), hyperthyroidism in 3 of 12 patients (25%), goiter volume reduction of approximately 32% of its original volume (from 13 to 76.3%), mean thyroid gland volume of 94ml. One year after embolization 7 of 12 patients required thyreostatic drugs. At two and four years follow-up thyreostatics doses were significantly lower and thyroid tissue was fibrotic. CONCLUSIONS: Based on our results the treatment of the thyroid gland goiters using arterial thyroid gland partial embolization may be offered as an effective alternative for patients who will not or cannot accept standard therapy.

The use of routine imaging data in diagnosis of cerebral pseudoaneurysm prior to angiography.

PURPOSE: A false aneurysm is rare and underdiagnosed complication of intracranial hemorrhage. Objective of the study was to point out diagnostic imaging signs of false aneurysm and to determine frequency and diagnostic significance of these signs. MATERIALS AND METHODS: Cerebral arteriography performed in our center from November 2007 to September 2010 revealed the false aneurysm in 8 patients (4 male, 4 female, mean age was 38 years). During the same angiographic procedure 6 patients were treated by endovascular embolization using coils, mixture of Histoacryl and Lipiodol or Onyx (liquid embolic material). Authors retrospectively analyzed preprocedural studies (computed tomography, magnetic resonance imaging) and angiographic findings to identify signs specific to false aneurysm. RESULTS: Computed tomographic findings that are not specific but should raise suspicion of the false aneurysm include: enlargement of parenchymal hematoma dimensions, unusual or delayed evolution of hematoma and spot sign associated with acute hematoma expansion. More specific signs can be revealed in digital subtraction angiography that shows a globular shaped neckless aneurysmal sac, delayed filling and emptying of contrast agent and stagnation of contrast with regard to the head position. CONCLUSION: Although preangiographic imaging studies findings in patients with false aneurysms are not specific, they should lead to angiographic validation, especially enlarging parenchymal hematoma and atypical hematoma evolution. Digital subtraction angiography makes it possible to diagnose the lesion and to use endovascular embolization techniques, which are currently the method of choice for treatment of pseudoaneurysms.

Idiopathic retroperitoneal fibrosis: case report.

A 45-year-old woman was admitted to the hospital because of abdominal pain, fever, and weight loss. Laboratory tests performed on admission revealed raised inflammatory markers. Ultrasonography of the abdomen showed dilatation of the pyelocalyceal system of the left kidney, while computed tomography showed retroperitoneal concentric periaortic mass extending to common iliac arteries and entrapping the left ureter. We established the diagnosis of idiopathic retroperitoneal fibrosis (RPF). JJ catheter was placed in the left ureter, and treatment with corticosteroids and azathioprine was started. Follow-up examinations showed a gradual improvement, namely a progressive remission of the retroperitoneal mass and normalization of both erythrocyte sedimentation rate and C-reactive protein concentration. Case reports, including our paper, and small case series showed azathioprine to be particularly effective in the treatment of RPF.

The effect of glycoprotein IIIa A1/A2 gene polymorphism on one-year outcome in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention.

INTRODUCTION: Glycoprotein IIb/IIIa (GP IIb/IIIa) is a platelet receptor composed of two subunits coded by individual genes. GP IIIa gene has two alleles: A1 and A2. The A2 allele determines higher platelet activity and was investigated many times as a potential risk factor of ACS. The influence of A1/A2 polymorphism on the prognosis in patients with ST-segment elevation myocardial infarction (STEMI) has not been analysed so far. AIM: Evaluation of the relationship between GP IIb/IIIa A1/A2 gene polymorphism and one-year prognosis in patients with STEMI treated with primary percutaneous coronary intervention (pPCI). METHODS: 171 patients (23.9%--women, 39.7%--anterior MI) with STEMI treated successfully with pPCI as well as 121 healthy subjects from a reference group were enrolled in the study. Genotyping was performed using restriction fragment length polymorphism analysis (RFLP). In one-year follow-up the primary end point included deaths and infarctions. The following methods were used in statistical analysis: chi(2) as well as Mann-Whitney test, Kaplan-Meier survival analysis, Cox regression model and multivariate analysis. RESULTS: The percentage of A2 allele carriers was similar in STEMI patients and in subjects from the reference group (27.4% vs. 21.5%, p=0.24). No statistically significant difference in the incidence of primary end point between the A1A1 homozygotes and A2 allele carriers (A1A2/A2A2 genotype) was observed among STEMI patients. In Cox regression analysis, the variables associated with death or MI were: ejection fraction (RR 0.912, p=0.01) and systolic blood pressure on admission (RR 0.97, p=0.049). The variables categorised as unfavourable predictors included: Killip class >2 and heart ratio on admission >100/min (p <0.05, log-rank test). CONCLUSION: No relationship between GP IIb/IIIa A1/A2 gene polymorphism and STEMI incidence as well as one-year prognosis in patients with STEMI treated with pPCI was documented.