Comment on "Posterior reversible encephalopathy syndrome in a patient with metastatic breast cancer: A case report".

Posterior reversible encephalopathy syndrome (PRES) is a neurotoxic encephalopathic state, manifesting clinical symptoms of headache, altered consciousness, visual disturbances, and seizures. Although several diseases have been identified as causative of PRES, the underlying mechanism remains unclear. Song et al recently published "Posterior reversible encephalopathy syndrome (PRES) in a patient with metastatic breast cancer: A case report" in the World Journal of Clinical Cases, highlighting and discussing the role of hypercalcemia in PRES as related to uncontrolled hypertension. To build upon this case description, we provide further insight into the possible underlying mechanisms of PRES through this commentary.

Sleep Disorders in Acute Stroke.

Background: Stroke patients have sleep-wake disorders, mostly in form of insomnia, excessive daytime sleepiness/fatigue, or hypersomnia (increased sleep needs). Objective: The aim of this study was to analyze types of sleep disorder (SD) and their frequency in patients with sleep apnea and acute stroke in relation to the type of stroke and side of lesion. Methods: The study analyzed 110 patients with sleep apnea and acute stroke hospitalized in the Clinic of Neurology, University Clinical Centre Tuzla. Acute stroke has been verified either by computerized tomography or magnetic resonance imaging of the brain. SD was verified according to the Berlin Questionnaire Test, The Epworth Sleepiness Scale, The Stanford Sleepiness Scale and the General sleep questionnaire. Strokes were divided by: a) type, into hemorrhagic and ischemic, and b) the localization of the stroke, to right and left cerebral hemispheres. Results: Of the total number of respondents, all had some sleep disorder. 20% of respondents had severe level of SD, 35.4% moderate, 37.3% moderate- severe and 7.3% mild problems. There were no statistically significant differences in the frequency of SD among patients with ischemic and hemorrhagic stroke (p = 0.58). In relation to the side of lesion, there was more patient with SD and stroke in the both sides, but there were no statistically significant differences (X2=1.98, p=0.161). According Epworth Sleepiness Scale, Stanford Sleepiness Scale and Berlin Questionnaire test snoring was present in 81% and daytime sleepiness in all patients. Conclusion: SD as a neuropsychological disorder has a significant incidence in the acute phase of stroke in patients with sleep apnea. Sleep disorder is more common in ischemic stroke and stroke in the both hemisphere, but it is not statistically significant difference. Daytime sleepiness, fatigue and snoring are the most common sleep problems in patients with acute stroke and apnea, but it is not statistically significant.

Acute Stroke Patients with Sleep Apnea Acording to the Disability and Incidence of Relapse.

BACKGROUND: Sleep is a complex process involving the interactions of several brain regions, which play a key role in regulating the sleep process, particularly the brainstem, thalamus, and anterior basal brain regions. The process of sleep is accompanied by a change in body functions, as well as a change in cerebral electrical activity, which is under the control of the autonomic nervous system. OBJECTIVE: The aim of the study was to analyze the frequency of stroke recurrence and disability of patients with stroke and apnea. METHODS: It was analyzed 110 acute stroke patients with sleep apnea. All patients were evaluated with: Glasgow scale, The American National Institutes of Health Scale Assessment, Mini Mental Test, The Sleep and snoring Questionnaire Test, The Berlin Questionnaire Test, The Epworth Sleepiness Scale, The Stanford Sleepiness Scale, and The general sleep questionnaire. RESULTS: The largest number of patients with apnea on admission had a degree of disability of 4, and on discharge of 1. There was a statistically significant difference between the mean values of incapacity for admission and discharge. The student's t - test did not determine a statistically significant difference in disability according to the Rankin scale between patients with and without apnea at admission (t = 0.059, p = 0.95) and discharge (t = 0.71, p = 0.48). According to the NIHS scale, patients of both sexes with apnea had a neurological deficit of 7.55 ± 5.22 on admission and 7.1 ± 4.3 without apnea. Statistically significant difference was not found on the neurological deficit of both sexes, with and without apnea, at admission and discharge. With apnea, there were 13 relapses of stroke during one year, and without apnea in only 3 patients. CONCLUSION: Patients with acute stroke have a significantly higher correlation rate according to sleep apnea. There is no significant correlation in the degree of disability between patients with and without apnea.

Does Sleep Apnea Affect the Outcome of Stroke Patients?

BACKGROUND: Sleep apnea is described as an isolated risk factor for stroke or recurrent stroke which could be cause of death. In our study, the aim was to determine whether sleep apnea affects the outcome of stroke patients. SUBJECTS AND METHODS: This is a prospective study in which a group of 110 patients in the acute phase of a stroke was evaluated sleep apnea. Acute stroke has been diagnosed either by computed tomography and magnetic resonance imaging of the brain. There was no significant difference in patient's age with or without sleep apnea neither in men nor women. Neurological, neuropsychiatric, pulmonary test were performed in all patients at five different time periods. In these time periods, all patients were evaluated: Glasgow scale, The American National Institutes of Health Scale Assessment, Mini Mental Test, The Sleep and snoring Questionnaire Test, The Berlin Questionnaire Test, The Epworth Sleepiness Scale, The Stanford Sleepiness Scale and The general sleep questionnaire. RESULTS: One year after the onset of stroke, 91 (82.7%) of 110 patients with apnea survived. The survival rate of patients with sleep apnea is significantly lower than without sleep apnea (p=0.01). In men with apnea, the survival rate was significantly lower in patients without apnea (p=0.004). The largest number of survivors of apnea had diabetes mellitus, followed by survival of patients with heart disease, body mass index >29 kg/m2 and hypertension, with hyperlipoproteinemia and smoking. The highest number of survivors without apnea was body mass index >29 kg/m2, followed by survival of patients with hyperlipoproteinemia, heart disease, hypertension, smoking, and diabetes mellitus. CONCLUSION: Patients with sleep apnea have a significant correlation in survival rates compared with sexually and age-matched subjects, associated with concomitant risk factors such as hypertension, body mass index, and smoking.

Risk Factors in Acute Stroke Patients With and Without Sleep Apnea.

BACKGROUND: More than 50% of stroke patients have sleep-disordered breathing (SDB), mostly in the form of obstructive sleep apnea (OSA). SDB represents both a risk factor and a consequence of stroke. The presence of SDB has been linked with the poorer long-term outcome and increased long-term stroke mortality. About 20 to 40% of stroke patients have sleep-wake disorders (SWD), mostly in form of insomnia, excessive daytime sleepiness/fatigue, or hypersomnia (increased sleep needs). OBJECTIVE: The aim of this study was to analyze the frequency of risk factors in patients with acute stroke and sleep apnea. METHODS: The study included patients without cognitive impairment or with mild cognitive impairment. The diagnosis of apnea syndrome was made on the basis of the Snoring and Apnea Syndrome Questionnaire, the Epworth Sleep Scale, the Berlin Questionnaire, the Stanford Sleepiness Scale, and the General Sleep Questionnaire. The severity of stroke was assessed by the National Institutes of Health Stroke Scale and the Rankin Disability Scale. Patients with a Glasgow score <8 on the day of neuropsychiatric examination were excluded from the study, as well as patients with epileptic seizures at the onset of stroke, with aphasia, with Mini - mental test <23, with verified previous dementia / cognitive impairment. RESULTS: There is no statistically significant difference in the age of men and women, both with apnea and without apnea. In patients with apnea, heart disease was in the first place 91.8%, followed by hypertension 86.4%, Body mass index 79.1%, hyperlipidemia 50%, smoking 38.2 % and diabetes mellitus 20.9%. Hypertension was the most common risk factor in patients without apnea 83.6%, followed by heart disease 81.0%, Body mass index 60.9%, hyperlipidemia 48.21%, smoking 28.2 % and diabetes mellitus 20%. CONCLUSION: Heart diseases, hypertension and body mass index are significantly more frequent in patients with than in patients without sleep apnea.

Post-Stroke Depression.

INTRODUCTION: The depression is a common mental disorder, especially after a stroke, which further aggravates the recovery. AIM: To analyze depression within 48 hours and fifteen days after ischemic stroke in relation to gender and location (brain hemisphere and brain circulation). METHODS: We analyzed 40 patients (65.3±10.3 years), half of them were women. Mean age of women was 66.35±7.31 years and men 64.2±12.68 years (p= 0.5). Ischemic stroke was verified by computed tomography. Levels of depression were measured with self-estimated Zung's scale. On the tests, score of 50 and higher verified depression. Criteria made by Domasio were used to determine location of the IS. RESULTS: Mean value on depression scale in acute phase of ischemic stroke was 46.85 ± 8.6 and in subacute phase 43.4 ± 8 (p =0.06). In 19 (47.5%) patients (55% of women, 40% of men; p=0.3) depression was found during the first and in 10 (25%) patients (35% of women, 15 % of men; p=0.06) during the second evaluation (p<0.019). Mean value on depression in acute phase of illness in women was 49.1 ± 7.38, as well as in men 44.6 ± 9.22 (p=0.088) and in subacute phase in women 45.25 ± 8.04, as well as in men 41.5 ± 7.75 (p=0.16). Concerning location of ischemic stroke, there were no significant differences in levels of depression. CONCLUSION: Number of patients with post-stroke depression is significantly lower in subacute phase of ischemic stroke. Although the number of depressive women and their depression scores are higher, gender differences are not statistically significant. There is no correlation between post-stroke depression and location of lesion in acute and subacute phase of illness.

Neurobrucellosis and cerebral venous sinus thrombosis: a case report.

OBJECTIVES: To present a case of co-occurrence of neurobrucellosis and cerebral venous sinus thrombosis. METHODS: Case report. CLINICAL PRESENTATION:  We presented 49-year-old Caucasian domicile female-farmer with a history of headache, weakness, and vomiting for a period of three months. Also, she had significant papilledema. We diagnosed rare co-morbidity of neurobrucellosis (confirmed after ELISA-test in serum samples and CSF analysis of pleocytosis/increase in protein/decrease in glucose level) in the setting of cerebral venous thrombosis developed in left sigmoid/left transverse sinus (confirmed after MRV of brain). Favorable outcome was achieved by applying protracted polymicrobial antibiotic therapy and heparin. DISCUSSION: It may be challenging to diagnose neurobrucellosis, especially in patients with atypical presentation and abortive clinical forms. The co-morbidity of neurobrucellosis and cerebral venous sinus thrombosis is uncommon. However, it provides a possibility of brucella-colonization in cerebral venous sinuses as a potential hidden link between them. CONCLUSION: Patients with severe and persistent headache, as well as other neurological symptoms/signs should be considered for neurobrucellosis in endemic, but also in brucella non-endemic regions due to migrations. According to literature survey, this co-occurrence of neurobrucellosis and cerebral venous sinus thrombosis is third one reported from Europe.

One Year Outcome of Acute Stroke Patients with Sleep Apnea.

UNLABELLED: The aim of this study was to analyze one year outcome of the acute stroke patients with sleep apnea in order to gender and age. METHODS: It was analyzed 110 patients with acute stroke and sleep apnea. Among them 65(59%) were men. Average age of all participant was 65.13±9.27 years. The same number and gender distribution of participants with stroke and without apnea were in control group. Evaluation of sleep apnea has been done with: "The Sleep Disorders Questionnaire", "Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome" and "The Epworth Sleepiness Scale". RESULTS: One year after stroke onset survived 91 (82.7%) out of 110 patients with apnea. Average age of survived patients was 63.66±8.78 years. Among them 52(80%) were men. In control group, without apnea survived 104 (94.5%) patients with average age of 65.00±8.62 years. Among them 62 (95.4%) were men. In men with apnea there is significantly lower survival range in order to patients without apnea (X(2)=8.22, p=0.004). In women there is no difference. Survival of both gender in patients with apnea (22; 64.7%) was the lowest in group older than 70 years of age. Sex ratio (men : women) was 15 (68.2%):7(58.3%). Survival in both gender in patients without apnea was the same in group older than 70 years of age: 27 (81.2%) out of 33. Average age of patients who died with apnea was significantly higher in order to patients without (t=1.97, p=0.03). CONCLUSION: One year after stroke, significantly more patients survived without (94.5%) than with apnea (82.7%) (p=0.01). In order to sex survived range was significantly (p=0.004) lover in men with apnea than without but in women there is no difference. Survival range of both gender in patients with apnea was the lowest in group older than 70 years (p=0.03).

Falls in hospitalized acute stroke patients.

UNLABELLED: THE AIM of this study was to analyze the fall frequency and some of its characteristics in hospitalized acute stroke patients. PATIENTS AND METHODS: It was analyzed 1809 acute stroke patients hospitalized at the Department of Neurology in period of one year. A fall was defined as any unplanned "touch to the floor" of any part of a patient's body, excluding the feet. RESULTS: Out of 1809 acute stroke patients, 1544 (85.35%) had cerebral infarction (CI) and 265 (14.65%) intracerebral hemorrhage (IH). In group of patients that fell (61/3.3%), 49 (80.33%) had infarction and 12 (19.67%) (p = 0.25) had hemorrhage. Out of 61 patients that fell, 42 (68.86%) suffered from impaired spatial orientation and 47 (77.05) were aphasic. The neurological deficit, impairments of spatial orientation and presents of aphasia were highly correlated with falls (p < 0.001). The most frequent falls occurred by night night (38 or 62.29%) and in the first five days of hospitalization (44 or 72%). In most cases (52%) the falls caused minor injuries like contusion and lacerations of skin and did not require special medical treatment. CONCLUSION: Hospitalized acute stroke patients have no high risk of falling (3.3%), and the incidence of serious injury is low. The falls are more frequent in the first five days of hospitalization (72%) and occur mostly during the night (62.29%). Severity of neurological deficit, impaired spatial orientation and aphasia are highly correlated with falls.

Gerstmann'S syndrome in acute stroke patients.

OBJECTIVE: Gerstmann in 1924. observed in a few patients a concomitant impairment in discriminating their own fingers, writing by hand, distinguishing left from right and performing calculations. He claimed that this tetrad of symptoms constituted a syndromal entity, assigned it to a lesion of the dominant parietal lobe. Since than, Gerstmann`s syndrome (GS) was enigma for neuropsychologists. The aim of this study was to analyze frequency and clinical features of GS among acute stroke patients. PATIENTS AND METHODS: We prospectively analyzed 194 acute stroke patients (average age 65±11.06 years, male 113 (58.2%), female 81 (41.8%) hospitalized at department of Neurology, University Clinical Center tuzla, during the six mounths in 2010. For clinical assessment of agraphia, alexia and acalculia we used Minessota test for differential diagnosis of aphasia's. RESULTS: Among these acute stroke patients, 59 (30.40%) had alexia, agraphia and acalculia or different combinations of these disorders. two patients (3.4%) had agraphia and acalculia associated with other part of tetrad of GS: fi nger agnosia and left-right disorientation. they both where men, right handed, and cranial computed tomography scan showed ischemic lesion in the left parietal and left temporoparietal lobe. CONCLUSION: Gerstmann`s syndrome is rare clinical entity, and has the high value in localization and the lesion is mainly localized to angular gyrus of the dominant hemisphere.

Incidence and types of sleep disorders in patients with stroke.

INTRODUCTION: Sleep disorders (SD) after stroke (stroke) are common occurrences, and most often in sleep apnea, insomnia and daytime sleepiness. GOALS. Research goals were to determine the types of SD and their frequency in patients with stroke in relation to the type of stroke and side of lesion. MATERIALS AND METHODS: The study analyzed 200 patients with acute stroke hospitalized in the Clinic of Neurology, University Clinical Centre Tuzla in the period from 1st August 2007 to 1st June 2008. All patients have confirmed the existence of stroke by computerized tomography. SD was verified according to the General Curriculum of sleep, the Berlin questionnaire and Epvort scale. Stroke, by type, were divided into hemorrhagic and ischemic, and the localization of the stroke to right and left cerebral hemispheres. RESULTS: Of the total number of respondents, 78% had SD. Very serious level of SD had 42% of respondents, 20% moderate, and 16% of medium-severe degree. There was no statistically significant differences in the frequency of SD among patients with ischemic and hemorrhagic stroke (76.8%: 82.5%, p = 0.58). In relation to the side of lesion there was more patient with SD and stroke in the right cerebral hemisphere, but there were no statistically significant differences (39.5%: 33%, p = 0.1). According Epvort scale sleep apnea and snoring was present in 86%, daytime sleepiness in 49.5% and narcolepsy 0.5%. CONCLUSIONS: Sleep disturbance as a neuropsychological disorder has a significant incidence in the acute phase of stroke. SD is slightly more common in hemorrhagic stroke and stroke in the right hemisphere. Sleep Apnea and snoring are the most common types of SD in patients with stroke.

Sex differences in patients with acute ischemic stroke in Tuzla region, Bosnia and Herzegovina.

Although many aspects of stroke are similar at both sexes, however, there are some differences and characteristics as well. The aim of this study was to analyze sex differences in patients with acute ischemic stroke (IS) regarding to risk factors, subtypes, stroke severity and outcome. From January 1st 2001 to December 31st 2005 at the Department of Neurology Tuzla 2833 patients were admitted with acute ischemic stroke (IS). We were analyzed risk factors, subtypes, stroke severity (Scandinavian Stroke Scale), and thirty-day outcome. There were 1484 (52.3%) female, and they were older than male (67.8 +/- 10.6 vs. 65.7 +/- 10.5, p<0.0001). Hypertension (78% vs. 67%, p<0.0001), heart diseases (50% vs. 45%, p=0.009), atrial fibrillation (22% vs. 14%, p<0.0001) and diabetes mellitus (33% vs. 21%, p<0.0001) were frequently in female, while smoking (45% vs. 14%) and alcohol overuse (18% vs. 0,6%) in male (p<0.0001). Atherothrombotic type of ischemic stroke was frequently in male (37.4% vs. 31.6%, p=0.0013) and cardioembolic in female (21.7% vs. 15.5%, p<0.0001). At admission female had lower SS (SS 31.0 +/- 15 vs. 34.0 +/- 15, p<0.0001). Thirty-day mortality was significantly higher in female (23.3% vs. 18.4%, p=0.0015), and favourable outcome within one month (Rankin Scale

Risk factors impact on the long-term survival after hemorrhagic stroke.

AIM: To analyze the impact of risk factors on the survival rate within a period of five years after hemorrhagic stroke (HS). PATIENTS AND METHODS: In this study 303 patients were analyzed with a first ever hemorrhagic stroke admitted at the Department of Neurology Tuzla, from January 1st 1997 to December 31st 1998. Data were collected from patient's medical records, whereas the final examination of all patients, who survived HS, took place five years after stroke. Medical history was obtained and presence of risk factors was evaluated on the day of admission. Computed tomography (CT) of the brain was performed in all patients during hospitalization. The average age of patients was 62 +/- 11 (from 31 to 90) years, 180 (59%) were women. The most frequent risk factor was hypertension, registered in 252 (83%) patients, followed by history of heart diseases in 182 patients (60%), smoking in 72 (23.8%), diabetes mellitus in 26 (8.5%), history of transient ischemic attack in 24 (8%) and alcohol intake in 13 (4.3%) patients. The risk factors were not registered in 22 (7.3%) patients. RESULTS: Five years after HS 82 (26.7%) patients survived. No statistical significance was found in survival between men and women (p = 0.2). The lowest number of patient that survived were over 70 years old (9%), while the highest number of survived was between 41-50 years (60.5%). The average number of risk factors was 2.5 +/- 1.0 and significantly higher in men compared to women (2.7 +/- 1 : 2.3 +/- 1) (p < 0.001). Significant difference was found in patients with hypertension (n = 252) (p < 0.0001), alcohol intake (n = 13) (p = 0.0170), as well as in patients with diabetes mellitus (n = 26) (p = 0.005). Regarding other risk factors such as heart diseases, cigarette smoking and transient ischemic attack there were no significant difference in survival in patients with hemorrhagic stroke (p = 0.2; p = 0.7; p = 0.8; retrospectively). CONCLUSION: We found that hemorrhagic stroke is associated with a very high risk for death in the acute and subacute phase. The survival rate after hemorrhagic stroke was 26.7% within a period of five years. Long-term survival rate prognosis is significantly better among the younger patients, without hypertension, alcohol intake and diabetes mellitus.

Five-year survival-after first-ever stroke.

The aim of the study was to analyze the 5-year survival after first-ever ischemic stroke and intracerebral hemorrhage. In this study 836 patients were analyzed with a first-ever stroke admitted at the Department of Neurology Tuzla, Bosnia and Herzegovina, from January 1(st) 1997 to December 31(st) 1998. Of these 613 (73,3%) were ischemic strokes and 223 intracerebral hemorrhages (26,7%) Subarachnoid hemorrhages were excluded. After hospitalization surviving patients examined periodically, and a final examination was performed 5 years after the stroke. Overall, case-fatility at the first month was 36% (301/836) and the mortality rate was significantly higher in the patients with intracerebral hemorrhage (58,3% vs. 27,9%, p<0,0001). The first year survived 60% patients with ischemic stroke, and 38% with intracerebral hemorrhage. After 5 years, 188 (31%) patients with ischemic stroke and 53 (24%) with intracerebral hemorrhage were alive (p=0,5), and the cumulative survival rate for the entire study was 29%. Among 30-day survivors (n=535) surviving rate after 5 years was significantly higher in patients with intracerebral hemorrhage (57% vs. 42,5%, p=0,01). The survival rate was the highest for those 50 years and younger (57%), and the lowest for those aged over 70 years (9%). Predictors of 5-year mortality were older age and hypertension for both types of stroke, heart diseases for ischemic stroke and diabetes for intracerebral hemorrhage. Long-term survival after first-ever ischemic stroke and intracerebral hemorrhage is similar. However, among 30-day survivors the 5-year survival is better in patients with intracerebral hemorrhage.