The significance of determination of the fraction of creatinine-phosphokinase in patients with acute ischemic brain disease.

Heart and brain vascular diseases are the leading causes of mortality in the world. Cardiac complications can frequently occur during the development of cerebral ischemia. The aim of this study was to establish the possible changes in fractions of creatinine-phosphokinase as the sensitive laboratory index of parenchymal lesion of brain parenchyma and the presence/absence of risk factors for ischemic brain and heart disease. The study comprised 80 patients with acute ischemic brain disease (AIBD), without the history of previous coronary disease. Blood samples were taken in all patients within the first 48 hours from AIBD onset aiming to determine a total (muscular MM) and heart fraction of creatinine-phosphokinase (MB), and brain parenchyma ischemia was confirmed by CT or MR scan of the head. A detailed history of the risk factors for ischemic brain disease (IBD) and ischemic heart disease was taken from all patients with AIBD, and the profile of glycemia and lipid status were determined, and blood pressure was measured 6 times a day. Independent variables in statistical analysis were: age, degree of severity and the side of neurologic event, size of ischemic lesion and maximal values of systolic and dyastolic pressure. Dependent variables were the values of fractions of creatinine-phosphokinase (CPK). Control group (n = 40) comprised patients with neurologic diseases of non-vascular origin. All parameters as well as their interrelations were statistically analyzed. The results revealed significant correlation of the increased levels of CPK of MM and MB fraction with the size and place of ischemic lesion in the right cerebral hemisphere, which was highly significant for MB fraction in the total group of patients with AIBD, and for MM fraction, only for cases of more severe IBD. Highly significant increased values of those fractions were also observed compared to the control group of patients.

The value of ophthalmoscopy in the diagnosis of arterial hypertension in patients with ischemic brain disease.

Beside dyslipoproteinemia, one of the key risk factors for the onset of brain atherosclerosis, as well as ischemic brain disease (IBD) is arterial hypertension. Significant number of patients is not aware of their hypertension, and a paradoxical blood pressure decrease can occur at the onset of IBD, due to the failure of autoregulation mechanisms. Likewise, valid anamnestic data can not frequently be obtained due to difficulties in communication with patients. Regarding these facts, our hypothesis was that ophthalmoscopy in patients with IBD had the greatest sensitivity in the diagnosis of hypertensive disease, its duration and severity. For that reason, the purpose of this study was to determine the significance of ocular fundus examination in those patients with IBD who were not aware of their hypertension, or the high blood pressure was not registered at the admission. Study comprised 140 IBD patients selected upon the following criteria: ophthalmoscopy was performed by the same ophthalmologist, and IBD was diagnosed according to clinical criteria and by brain computerized tomography. Results of the study demonstrated that 26 (18.6%) patients, although not aware of having hypertensive disease, had grade I hypertonic fundus, 14 (10%) had grade II, and 8 (5.5%) had grade III hypertonic fundus, which indicated the high sensitivity of ophthalmoscopy in the diagnosis of hypertensive disease, as well as its duration and severity. This is particularly important in patients with negative history of hypertension, and also suggests the significance of routine ophthalmoscopy in normotensive patients.

[Significance of QT dispersion in the onset of ventricular arrhythmia in patients with heart failure]. / Znacaj QT disperzije za nastanak komorskih poremcaja ritma kod bolesnika sa srcanom slaboscu.

UNLABELLED: Prolonged QT dispersion which has been proposed as a marker of repolarisation inhomogeneity, may predispose to ventricular arrhythmias in a variety of cardiac disorders. The aim of this study was to compare some indices of QT dispersion in patients with heart failure compared to normal subjects. We have also tested the hypothesis that QT dispersion is a useful method for identifying the patients at high risk for ventricular arrhythmias. METHODS: There were 84 patients, divided into two groups. In the first group there were 62 patients with heart failure, in the sinus rhythm, while in second group there were 22 sex- and age-matched healthy subjects. Simultaneous 12-channel ECGs were recorded at a paper speed 50 mm/sec. Ventricular arrhythmias were quantified by 24-h Holter ECG and classified according to the Lown classification system. Only those patients with a class IVa, IVb, and V arrhythmia were considered to have complex ventricular premature contractions (PVCs). Measurements of QT, JT, and RR intervals were performed manually. Heart rate corrected QT and JT intervals (QTc and JTc) were calculated by Bazett's formula. RESULTS: RR intervals were similar in both groups (862 +/- 120 vs 840 +/- 86; ns). QT dispersion and rate corrected QT dispersion were significantly greater in heart failure patients than in controls (76 +/- 13 ms vs 37 +/- 11 ms and 89 +/- 21 ms vs 40 +/- 17 ms; p < 0.05). When, on the basis of the existing complex PVCs, heart failure patients were divided into two subgroups, QT dispersion and rate corrected QT dispersion were significantly greater in the subgroup with complex PVCs compared to patients without complex PVCs (84 +/- 14 ms vs 61 +/- 18 ms and 98 +/- 26 ms vs 66 +/- 21 ms; p < 0.05). CONCLUSION: All indices of QT dispersion were significantly higher in heart failure patients. QT dispersion is useful, noninvasive method for identifying heart failure patients at high risk for ventricular arrhythmia.

[Neurologic manifestations after surgical interventions]. / Neuroloske manifestacije nakon hirurskih intervencija.

Administration of general anesthesia is rarely accompanied with newly developed postoperative neurological complications. We analyzed postoperative complications after general anesthesia where an urgent neurologic assistance was necessary. The investigation included 120 patients. The same neurologist performed neurologic examination and electroencephalography, and computerized tomography (CT) was performed if necessary. In 96 (80%) patients focal stimulative or destructive phenomena such as epi-seizures or neurologic deficit were not detected by neurologic examination. In 9 (7.5%) patients were detected consciousness crisis. In 6 patients (5%) were registered right extremities weakness with motor dysphasia, which was withdrawn in first 24 hours. In these cases EEG revealed weak activity in theta frequency, above frontoparietal regions, bilaterally. In 6 (5%) patients was registered neurologic deficit of hemiparesis or semi-severe degree with development of ischemic lesion confirmed by CT. In 6 (5%) patients, CT scan revealed the presence of mild brain edema. Also, positive correlation between duration of anesthesia, age and metabolic disorders, specially diabetes mellitus, was found. We concluded that age, type of surgical intervention and duration of general anesthesia had the greatest influence on the development of neurologic disorders during and after general anesthesia, and the presence of metabolic disorders and previous brain damage increase the risk for the onset of these complications.

The influence of the degree of cerebral atherosclerosis on the changes in hemostatic system in patients with ischemic brain disease and atherosclerotic encephalopathy.

Vascular brain diseases are ranked the third as the cause of morbidity and mortality, in spite of the progress in diagnostic, therapeutic and preventive procedures. In the majority of cases of vascular brain diseases, it is ischemic brain disease, which is the final and the most severe stage of cerebral arteries atherosclerosis. Etiopathogenesis of atherosclerosis is not closer defined yet, but oxidative hypothesis is distinguished among the numerous theories. Within this theory, main place is attached to oxidative modification of LDL and Lp(a), together with numerous physiopathologic facts with the central role of reactive oxidative matters, where endothelial dysfunction is the main disorder responsible for the onset of numerous impairments, such as changes in coagulation-anticoagulation system. Considering these facts, it was established the hypothesis that in patients with IBD existed changes in hemostatic system, which were in positive correlation with the degree of cerebral atherosclerosis. The study comprised 36 patients with acute IBD and 28 patients with atherosclerotic encephalopathy. Control group was comprised of 30 patients with non-vascular diseases of similar characteristics. We investigated the correlation of the changes in hemostatic system (platelet aggregation, anti-thrombin III, D-dimer, protein C, factor VII, factor VIII, PAI-1) compared to the degree of cerebral atherosclerosis (ultrasonographically) and compared to the observed groups of patients. On the basis of all, the results of this study revealed significant increase of procoagulant factors concentration in patients with IBD, and similar changes were observed in patients with atherosclerotic encephalopathy, but less pronounced. All these changes in the total sample of patients, and particularly in patients with the pronounced cerebral atherosclerosis, are of primary and chronic character.

[Role of nimodipine in the therapy of subarachnoid and intracerebral hemorrhage]. / Mjesto i vrijednost nimodipina u terapijskom programu subarahnoidne i intracerebralne hemoragije.

Syndromes of intracranial hemorrhage, and particularly subarachnoidal, i.e., intracerebral hemorrhage (SAH and IH) present clinical entities that are the most severe conditions in neurology. Timely recognition, diagnosis and adequate therapy are imperative. The most important factor that aggravates an already difficult prognosis of those entities is cerebral vasospasm. Upon the presented facts, the aim of this investigation was to establish the value and role of administration of selective calcium channel blocker--nimodipine in patients with SAH and IH compared to the degree of neurological and functional impairment, as well as the recovery of the function of consciousness compared to the patients with those syndromes from an earlier period, who were not treated with this medicament. Investigation comprised 30 patients who received nimodipine and 20 patients without this agent in therapeutic program. Results of the investigation confirmed significant difference concerning the neurological recovery, improvement of functional capability and recovery or consciousness disturbances, respectively, in patients who received nimodipine compared to the group without this agent. It can be concluded that nimodipine as calcium channel blocker with multitopic pharmacological effects on mechanism of SAH or IH development, respectively, as well as on the development of complications of those syndromes, particularly to the development of vasospasm and reactive ischemia, with the improvement of hemorrheologic disorders deserves to be included as the unavoidable segment of therapeutic program of SAH and IH syndrome immediately after clinical phenomenology is revealed.

Clinical predictors of cardiac complications in patients with acute ischemic brain disease.

Heart and brain vascular diseases present leading causes of death in civilized world. During development of brain ischemia cardiac complications are possible. The aim of this study was to determine the existence of cardiac complications' clinical predictors by assessing certain electrocardiographic changes in patients with acute ischemic brain disease (AIBD). Forty patients with AIBD, without previous coronary disease history were included in the study. All patients underwent 24 hour Holter monitoring during first 48 hours after the onset of AIBD which was diagnosed by computerized brain tomography. ECG-s were analyzed by computer and interpreted by the same cardiologist. Independent variables in statistical analyses were: age, AIBD, cardiological therapy atherosclerosis risk factors, heart disease history, degree of severity and lateralization of neurological incident and maximal arterial blood pressure values. Dependent variables were: presence/absence of ST depression and presence/absence of ventricular arrhythmias (VA). All parameters as well as their interreaction, were statistically analyzed. Results point that age and side of neurological incident present independent important predictive factors for appearance of ST depression, as well as simultaneous heart ischemia, while the same parameters have border value as predictive factors for VA.

[Analysis of antihypertensive therapy in patients before acute cerebral ischemic disease]. / Analiza antihipertenzivne terapije kod bolesnika sa akutnom ishemijskombolescu mozga pre neuroloskog dogadjaja.

The adequacy of therapeutic program for hypertensive disease in the patients with ischemic brain disease was analyzed in the study related to the administration of the drugs divided by the groups of antihypertensive drugs. The results had demonstrated that in over 50% patients the therapy had to be changed by introducing at least one hypertensive drug from the other group. In many cases were observed inadequate doses of antihypertensive drugs and the prescription of antihypertensive drug in minimal dose, although therapeutic response was not adequate. In significant number of cases (over 80%), the patients were irregularly taking the prescribed therapy, and only 18% had the regular controls. The results of this investigation indicated that on one side did not exist the adequate therapeutic program for hypertension control and on the other the significant number of patients irregularly used the proposed therapy and did not control the disease regularly.

[Combined myocardial infarct of the left and right ventricle]. / Kombinovani infarkt miokarda leve i desne komore.

Combined myocardial infarction of left and right ventricle (CMILRV) of inferoposterior localization represents simultaneous acute necrosis of both myocardial ventricles and belongs, due to associated and frequent complications, to more severe damages of the myocardium with high mortality. Our group consisted of 100 patients of both sexes, mean age of 67.4 years, of which 50 were with inferoposterior left ventricular infarction and 50 with CMILRV of the same localization. The diagnosis was confirmed clinically, by ECG, by the analysis of enzymes, echocardiographically and scintigraphically using radionuclide ventriculography with 99Tcm PyP. Selective coronarography was performed in all the survived patients, and autopsy of the dead. On the basis of clinical presentation of some forms of dynamic weakness of the heart, in acute stage of CMIRLV, we have established that there are 4 categories of these patients, so that each of these groups represents also a special clinical form, which are: 1. CMIRLV without signs of heart failure, established in 20 (40%) cases, which clinically and prognostically do not differ from inferoposterior left ventricular infarction. 2. CMIRLV with predominant failure of the right ventricle was found in 17 (34%) of the patients with a specific clinical feature and the way of treatment. 3. CMIRLV with marked failure of the left ventricle, found in 8 (16%) of the patients, which required combined treatment measures. 4. CMIRLV with general heart failure, established in 5 (10%) cases, is characterized by cardiogenic shock and falls into the most severe forms of this kind of myocardial infarction. Total mortality in the patients with CMILRV was 10% (5.50), that is 40% (2.5) in both the second and the fourth subgroup, 20% (1/5) in the third group, while in the first one as well as in the control group with inferoposterior infarction there was no mortality. Good knowledge of the above mentioned clinical forms of CMILRV are necessary prerequisite for application of specific and corresponding therapeutic measures and the best prevention of associated complications and high mortality of such patients.

[Value of the stress test in the evaluation of the severity of ischemic heart disease]. / Vrednost testa opterecenja u proceni tezine ishemijske bolesti srca.

Loading test was used in 156 patients with ischemic heart disease and the results of their selection are presented. In all patients occlusive coronary disease was detected by selective coronarography. They were divided in three groups. Two groups of patients had a high risk ischemic heart disease requiring surgical revascularization of the myocardium and selective coronarography. The first of these two groups comprised 48 patients with significant stenosis of the main tree of the coronary artery and the second comprised 35 patients with equivalent stenosis of this artery. The third group comprised 73 patients with ischemic heart disease of small risk in whom occlusive changes of the coronary arteries were of distal localization. The statistically significant difference was found between the two groups of patients with high risk and the third group with small risk according to early development of ST depression in the first minutes of loading, its degree, number of leads with ST depression, form and its maintenance after cessation of loading. The difference was also significant regarding the submaximal pulse rate and systolic blood pressure during loading test. It has been concluded that by using loading test as a functional diagnostic method patients with a high risk ischemic heart disease can be selected stressing the advantage of physiology over morphology.