[Cerebral vasospasm in patient with hemorrhagic stroke after amphetamine intake--case report]. / Krwiak sródmózgowy po zazyciu amfetaminy powiklany uogólnionym skurczem naczyn mózgowych--opis przypadku.

Amphetamine abuse increase risk of hemorrhagic stroke and may result in cerebral vasospasm. In this report we present 31 years old male with intracerebral hemorrhage subsequent to amphetamine intake. Diffuse cerebral vasospasm was found by angiography. Transcranial color coded Doppler sonography was applied for vasospasm monitoring and pharmacological treatment after surgical removal of the intracerebral hemorrhage. Basing on this case we can conclude that cerebral vasospasm should be suspected in patient with amphetamine abuse and hemorrhagic stroke.

Results of Destandau microendoscopic lumbar discectomy.

BACKGROUND AND PURPOSE: Endoscopic methods are increasingly used in spine surgery, including the operative treatment of lumbar disc herniation. In this study we present a clinical series of 45 patients with lumbar disc prolapse who were operated on endoscopically with ENDOSPINE instrumentation (Karl STORZ GmbH and Co. KG), using the Destandau technique. MATERIAL AND METHODS: Between 2005 and 2006 endoscopy was used in 76 operations of lumbar disc prolapse and in 45 patients the entire procedure was performed endoscopically. All procedures were carried out from a posterior approach using a 4 mm Hopkins 0 degrees -telescope placed in the working insert equipped with channels for suction tube, operative instruments and nerve root retractor. The outcome was assessed using modified McNab criteria both directly and three months (in 35 patients) postoperatively. RESULTS: Good to excellent outcome was achieved in 89% of patients, which is consistent with results reported by experienced authors and comparable with results of "classic" microdiscectomy. Five patients reported no improvement and 3 of them were subsequently reoperated using the open surgical approach. In 3 patients the dural sac was lacerated but none of the tears exceed a few millimetres in length and they were not associated with neural injury. They were easily repaired endoscopically with a patch of "Tachocomb" tissue sealant. CONCLUSIONS: Destandau microendoscopic discectomy (MED) is a novel, safe and effective method that minimizes invasiveness of the surgical approach. Results achieved with this method are comparable to those achieved with "classic" microdiscectomy.

[Use of "the Middlesex Elderly Assessment of Mental State" scale in the assessment of cognitive functioning in patients with aneurysmal subarachnoid haemorrhage]. / "The Middlesex Elderly Assessment of Mental State" w ocenie funkcjonowania poznawczego chorych po krwotoku podpajeczynówkowym z peknietego tetniaka mózgu w ostrym okresie choroby.

UNLABELLED: It is now well established that cognitive deficits are a frequent consequence of aneurysmal subarachnoid haemorrhage (SAH). The cognitive status in the acute phase of the illness may provide valuable prognostic information in relation to the effects of the proposed treatment and long-term functioning of the patient. A prerequisite for this task is the identification of instruments that might prove useful in the diagnosis of neuropsychological deficits in patients with SAH. For these purposes we used The Middlesex Elderly Assessment of Mental State (MEAMS) in order to assess the cognitive deficits consequent upon SAH. THE AIM OF THE STUDY: To assess the cognitive functioning of patients undergoing treatment for SAH of aneurysmal origin in the acute stage of the illness, using a modified form of the MEAMS. MATERIALS AND METHODS: 49 patients participated in the study, none of whom had a previous history of neurological or psychiatric illness. The age of the patients ranged between 23-70 years. 35 (71%) patients received surgical treatment (clipping of the aneurysm neck) and in 14 (29%) the aneurysm was embolised. The patients were assessed on two occasions: the first on admission to the Neurosurgery department following the SAH, and on the second, following treatment to secure the aneurysm. A modified version of the MEAMS in two parallel versions was used in the assessment. The results obtained were evaluated with reference to a control group. RESULTS: A range of cognitive impairments was identified with the aid of the MEAMS in patients undergoing treatment for aneurysmal SAH. These included deficits in visual and auditory memory, executive, perceptual and visuo-spatial functions together with the tendency to perseverate. In those patients who underwent surgery, deficits were observed in the following areas: disorientation in relation to self, time and place; perceptual, memory and visuo-spatial impairments. CONCLUSIONS: The results obtained indicate that the Middlesex Elderly Assessment of Mental State, in the form used in the present study appears to be a sensitive and useful instrument for the screening of cognitive impairments in patients following SAH, in the acute stages of the illness.

[Influence of digital subtraction cerebral angiography on blood flow in the middle cerebral artery]. / Wplyw cyfrowej angiografii subtrakcyjnej naczyn mózgowych na przeplyw krwi w tetnicy srodkowej mózgu.

UNLABELLED: The aim. Despite adhibition of new, improved enhancing agents some subjective signs during cerebral angiography are notified. This suggests that cerebral blood flow might be influenced by this procedure. The validity of transcranial color doppler sonography (TCCS) in cerebral blood flow evaluation is already proved and this method was selected for blood flow parameters estimation before and after cerebral angiography. MATERIAL AND METHODS: 33 subjects (17 female and 16 male) aged 50 +/- 13 were diagnosed by cerebral angiography. Before and immediately after angiographic examination cerebral blood flow parameters were evaluated in middle cerebral arteries by transcranial, sektor 2.5 MHz probe of Toshiba Aplio SSA 770A system. RESULTS: In comparison to pre-angiographic TCCS examination middle cerebral artery systolic velocity decreased about 3 cm/s (p<0.05). Mean and end-diastolic velocity in MCA insignificantly increased about 1 and 2 cm/s respectively (p>0.05). Impedance index values significantly decreased (Wilcoxon test, p<0.05) after angiography. CONCLUSION: Change of flow parameters in the middle cerebral artery prove increase of cerebral blood flow after diagnostic angiography.

[Intracranial temperature measurements in brain death]. / Temperatura wewnatrzczaszkowa u chorych w stanie smierci mózgu.

BACKGROUND AND PURPOSE: Intracranial temperature in many clinical situations can significantly differ from core trunk temperature. Little is known about temperature relations in these locations in brain death. MATERIAL AND METHODS: The oesophageal and rectal temperatures were monitored in 52 comatose (GCS score: 3-9) patients after head trauma or haemorrhagic stroke. Brain temperature was recorded in 44 patients who had been treated surgically. In 8 patients treated conservatively only tympanic temperature was monitored. Signs of brain death appeared in 27 patients. RESULTS: In patients who were unconscious but without signs of brain death, the brain and trunk temperature run parallel in time, the former being somewhat higher than the latter. The tympanic temperature matched well the temperature of the brain. With brain death symptoms all core temperatures fell by 2 to 4 degrees C during 6 to 12 hours. Most notably, the decrease in brain temperature far exceeded that of trunk temperature. As a result, intracranial temperature established itself as the lowest temperature of the body, being 2 to 4 degrees C lower than core trunk temperature. Tympanic temperature fall was less prominent, thus it no more mirrored brain temperature. CONCLUSIONS: After brain death intracranial temperature dissociates from core trunk temperature and from the tympanic temperature. Brain temperature lower than arterial blood temperature is incompatible with ongoing brain metabolism. So such temperature relations might be specific to brain death.

Middle cerebral artery spasm after subarachnoid hemorrhage: detection with transcranial color-coded duplex US.

PURPOSE: To prospectively determine the accuracy of transcranial color-coded duplex ultrasonography (US) used alone and in conjunction with carotid artery US for diagnosis of middle cerebral artery (MCA) spasm, with intraarterial digital subtraction angiography (DSA) used as the reference standard. MATERIALS AND METHODS: The institutional ethics committee approved the study. Each patient, or members of the patient's family, gave informed consent. One hundred twenty consecutive patients (64 women, 56 men; mean age, 45.5 years +/- 13.6 [standard deviation]) were routinely referred for DSA after subarachnoid hemorrhage. Vasospasm was graded as mild (< or =25% reduction in vessel diameter), moderate (>25% to 50% reduction), or severe (>50% reduction). US was performed 2 hours or less before angiography. The ratio of flow velocity in the middle cerebral artery (V(MCA)) to flow velocity in the ipsilateral extracranial internal carotid artery (V(ICA)) was calculated. Diagnostic accuracy was evaluated by calculating the area under the receiver operating characteristic curve (Az). The significance of the difference between the two Az values (for US vs DSA) was determined by using the z test with correction for correlated data. RESULTS: Nine of 120 patients were excluded because of inadequacy of acoustic windows in the squama of temporal bones. Spasm was mild in 17, moderate in 16, and severe in only nine of 222 arteries studied. Arteries with moderate or severe vasospasm were combined in one group. The best-performing parameters were peak systolic velocity and V(MCA)/V(ICA) ratio. Az values for these two parameters in diagnosis of moderate-to-severe vasospasm were 0.93 and 0.95, and in diagnosis of mild vasospasm, 0.90 and 0.91. Accuracy of the V(MCA)/V(ICA) ratio calculated on the basis of end-diastolic velocity for diagnosis of mild MCA narrowing was significantly better than that of end-diastolic MCA velocity alone (Az = 0.88 vs 0.84, P < .05). The stepwise approach with use of the V(MCA)/V(ICA) ratio after flow velocity measurements in the MCA resulted in a decreased number of false-negative findings in both vasospasm subgroups. The thresholds of highest efficiency were at a mean velocity of 94 and 108 cm/sec and a peak systolic V(MCA)/V(ICA) ratio of 3.6 and 3.9 for diagnosis of mild and moderate-to-severe vasospasm, respectively. CONCLUSION: Transcranial color-coded duplex US alone or in conjunction with carotid artery US has excellent accuracy for angiographic detection of vasospasm. Use of MCA velocity measurements and V(MCA)/V(ICA) ratio can increase the accuracy of Doppler US.

[Diagnosis of middle cerebral artery spasm by determination of flow velocity and the Lindegaard index with transcranial color Doppler sonography]. / Diagnostyka skurczu tetnicy srodkowej mózgu metoda ultrasonografii dopplerowskiej z kolorowym obrazowaniem przeplywu z uwzglednieniem pomiarów predkosci krwi oraz wspólczynnika Lindegaarda.

BACKGROUND AND PURPOSE: Recent reports have demonstrated the high utility of transcranial color-coded duplex sonography (TCCS) in the diagnosis of advanced spasm of the middle cerebral artery, whereas its accuracy in the diagnosis of mild vasospasm is reported to be lower. Relation of blood flow velocity in the middle cerebral artery (MCA) to that in the extracranial internal carotid artery (VMCA/VICA index) is recommended as being helpful in the diagnosis of vasospasm (the so called Lindegaard Index). Nevertheless, the exact diagnostic value of this index using the TCCS method remains to be established. The purpose of this study is to estimate the accuracy of TCCS in the diagnosis of MCA vasospasm, as based on the VMCA/VICA index. MATERIAL AND METHODS: The VMCA/VICA index was calculated in 195 patients (285 middle cerebral arteries) who were scheduled for cerebral arteriography. The TCCS study and color-coded duplex sonography of the internal carotid arteries were performed immediately before arteriography. RESULTS: A mild grade of MCA spasm was diagnosed angiographically in 21, and moderate-to-severe spasm in 29 MCAs out of 285 successfully insonated arteries. Peak-systolic, mean and end-diastolic blood velocities were measured using transcranial color sonography in the MCA and related to the respective velocities in the ipsilateral extracranial internal carotid artery. Receiver-operating characteristic curves (ROC) were calculated for particular velocities and for the related VMCA/VICA indices. By comparison of the areas under the ROC curves it was shown that the use of the VMCA/VICA index does not improve the accuracy of TCCS in the diagnosis of advanced MCA spasm, whereas it improves accuracy in the diagnosis of mild vasospasm. In particular, accuracy can be improved by the use of the VMCA/VICA index based on the end-diastolic velocity. The optimal diagnostic threshold of the VMCA/VICA index was determined at 3.9. CONCLUSIONS: The use of VMCA/VICA index improves the accuracy of TCCS in the diagnosis of mild vasospasm of the middle cerebral artery.

[Doppler ultrasonography in diagnosis of internal carotid artery dissection--case report]. / Ultrasonografia dopplerowska w diagnostyce rozwarstwienia tetnicy szyjnej wewnetrznej--opis przypadku.

This study considers diagnostic problems in the case of a 52 year old patient presenting with left sided headache and Horner's syndrome. Color Doppler sonography of the internal carotid artery with transcranial duplex sonography showed decreased blood flow velocity and increased impedance of flow in the left internal carotid artery. Flow velocity in the left middle cerebral artery was moderately decreased whereas flow in the proximal segment of the anterior cerebral artery and in the posterior communicans artery was re-directed towards the left internal carotid artery. These findings indicated the need for cerebral angiography which revealed that a vast section of the distal segment of the left internal carotid artery was dissected. Pharmacological treatment with low molecule heparine brought prompt resolution of the signs and symptoms as well as normalization of the blood flow parameters, as examined with Doppler ultrasonography Color Doppler ultrasonography would appear to have high utility in the initial diagnosis of internal carotid artery dissection and the usefulness of this method in the monitoring of treatment.

[Surgical evacuation of an embolization coil from the middle cerebral artery]. / Chirurgiczne usuniecie spirali embolizacyjnej przemieszczonej do tetnicy srodkowej mózgu.

We report the case of a 54-year-old woman with a right intracavernous internal carotid artery aneurysm treated endovascularly with MDS coils. During the procedure, one of the coils migrated to the middle cerebral artery (MCA), resulting in left hemiplegia. The attempt to remove the migrated coil endovascularly failed and the patient had emergency front-temporal craniotomy. After the dissection of the Sylvian fissure, the M1 portion of the MCA was exposed with the coil visible through the distended wall of the artery. Because it was feared that the M1 arteriotomy could tear the MCA, the coil was removed through the anterior temporal artery, a small branch of the M2 segment. Hemiplegia gradually resolved and the patient recovered completely. This case depicts an alternative route via a distal arteriotomy to remove the migrating coil. Additionally, it implies that endovascular procedures in neurosurgical patients should be performed by the interventional neurosurgeon (neurosurgeon trained to perform endovascular procedures) or at least with the support of a neurosurgical department for immediate intervention in the case of life-threatening complications.

[Correlation of brain stem evoked response audiometry (BERA) with Glasgow Coma Scale (GCS) and Glasgow Outcome Scale (GOS)]. / Korelacja audiometrii odpowiedzi elektrycznych z pnia mózgu ze Skala Spiaczki Glasgow oraz Skala Wyników Leczenia Glasgow.

The diagnostic value of electric responses from the brain stem (BERA) in neurosurgical patients is still a matter for debate in the literature. Therefore in the study an attempt was made to determine the relationship between GCS scores and BERA recordings. Participants in the study were 64 patients with various types of brain damage. Evoked potentials from the brain stem were registered using the Hortmann BERAmodul apparatus. To facilitate the interpretation of results a special scale was developed for quantitative measurement of changes in BERA recordings. Abnormalities in BERA recordings were reflected in changes in GCS scores, and correlation between the two dimensions was found to be statistically significant. The relationship between BERA recordings and GOS scores was also significant: pathological changes in BERA recordings assessed as severe were associated with an unfavorable therapeutic outcome in the GOS. The presented findings indicate auditory evoked brain stem response (BERA) usefulness for objective evaluation of brain-damaged patients' clinical state.

Standardization of flow velocities with respect to age and sex improves the accuracy of transcranial color Doppler sonography of middle cerebral artery spasm.

OBJECTIVE: The overall accuracy of transcranial Doppler sonography in the diagnosis of middle cerebral artery spasm has not been established. Moreover, the factors of age and sex have not been addressed in most studies. In this article, we present receiver operating characteristic (ROC) curve analysis of the accuracy of transcranial color Doppler sonography in diagnosing middle cerebral artery spasm on the basis of flow velocities standardized for age and sex. SUBJECTS AND METHODS. We prospectively studied 214 consecutive patients (110 male, 104 female; age range, 12-77 years) who were routinely referred for cerebral angiography. Middle cerebral artery spasm was graded as mild ( 25% reduction). Angle-corrected blood velocity measurements were obtained using a 2.5-MHz probe. The velocity values were reexpressed as a percentage of the mean of normal reference values for the relevant age, for subjects younger than 40 years, and for sex. RESULTS: The prevalence of spasm among 335 arteries studied was 8.1% for mild and 12.8% for moderate to severe middle cerebral artery narrowing. For distinguishing all or moderate to severe vasospasm from lesser grades of vasospasm, peak systolic velocity was the best parameter. Areas under ROC curves for all and moderate to severe middle cerebral artery spasms were 0.83 and 0.92, respectively. After standardization, the ROC areas increased significantly (p < 0.05) for all, to 0.86, and only slightly, to 0.93, for moderate to severe spasms. For all grades of middle cerebral artery spasm, the best efficiencies were found at standardized velocity value of 170%. CONCLUSION: The accuracy of transcranial color Doppler sonography is high in the identification of middle cerebral artery spasm. Standardization of velocities with respect to age and sex increases the accuracy of the method in diagnosing mild middle cerebral artery spasms.

Hydrogen-1 MR spectroscopy of the peritumoral zone in patients with cerebral glioma: assessment of the value of the method.

RATIONALE AND OBJECTIVES: The determination of tumor boundaries, especially in high-grade glioma, is critically important for the proper planning of treatment, but the standard diagnostic imaging methods do not enable precise delimitation of the extent of tumor cell infiltration into the surrounding tissue. The objective of this study was to assess the usefulness of hydrogen-1 (H-1) magnetic resonance (MR) spectroscopy for determining the extent of gliomatous infiltrate in the "uncertain zone'--the peritumoral area that appears unchanged on standard diagnostic MR images. MATERIALS AND METHODS: The study group consisted of 64 patients with cerebral glioma scheduled for tumor resection and subsequent radiation therapy. All patients were examined prior to resection with MR imaging and MR spectroscopy. MR spectra were obtained from examination of the solid part of the tumor and from two peritumoral volumes of interest located approximately along the axis of surgical access to the tumor. MR spectra obtained from a group of 32 healthy volunteers were used as control data. RESULTS: Analysis of the consequent voxels in the peritumoral zone revealed statistically significant differences in lipid/creatine and lactate/creatine metabolite ratios between patient subgroups with recurrent malignant lesions and without recurrent lesions. Significant differences also were found between the patient group and the control group in most metabolite ratios assessed. CONCLUSION: H-1 MR spectroscopic demonstration of metabolic changes in the peritumoral zone can guide treatment for cerebral glioma, enabling the physician to identify patients who have a high risk of recurrence.

[Transcranial color Doppler sonography (TCCD) in the diagnosis of vasospasm in the middle cerebral artery. Evaluation of TCCD diagnostic effectiveness by means of receiver operating characteristics curve (ROC) analysis]. / Przezczaszkowa ultrasonografia dopplerowska z kolorowym odwzorowaniem przeplywu w rozpoznawaniu skurczu tetnicy srodkowej mózgu. Ocena skutecznosci diagnostycznej za pomoca krzywej charakterystyki odbiornika.

Transcranial Doppler sonography is commonly used for diagnosis of cerebral vasospasm. However, the overall diagnostic performance of this method in detection of arterial narrowing has not been established. Blood velocity threshold, diagnostic for vasospasm, has been proposed for conventional, "blind" transcranial Doppler sonography (TCD). Nevertheless it cannot be used for transcranial color Doppler sonography (TCCD), because in this method the obtained blood velocities in the major cerebral arteries are higher than are in TCD. The aim of this study was to estimate the accuracy of transcranial color Doppler sonography in detection of middle cerebral artery (MCA) narrowing by means of receiver operating characteristic curve analysis (ROC). One hundred thirty four patients were studied with TCCD immediately before cerebral angiography. There were 75 men and 59 women, age range from 18 to 74 years, mean age 49 years. Of the 268 MCAs examined, 227 arteries were finally included in the construction of the ROC curve. Angiographic vasospasm was graded as none, mild (equal to or less than 25% of vessel caliber reduction--16 patients) and moderate-to-severe (more than 25% of vessel caliber reduction--29 patients). The overall diagnostic performance of transcranial color Doppler sonography in the detection of moderate-to-severe vasospasm of middle cerebral artery was found to be very high. The value of associated area under the ROC curve was 0.94. The value of this area for all vasospasms was 0.85, and this indicates good accuracy of a test. The best performing TCCD parameter for the detection of MCA narrowing was revealed to be peak-systolic velocity. The optimal trade-off between sensitivity and specificity was achieved with a peak systolic velocity of 182 cm/s. Therefore this velocity threshold is proposed as most universal for the diagnosis of vasospasm in the middle cerebral artery.

[The role of platelet activating factor (PAF) in physiology and pathology of the central nervous system]. / Rola czynnika aktywujacego plytki (PAF) w fizjologii i patologii osrodkowego ukladu nerwowego.

This review describes the role of platelet activating factor (PAF) in the central nervous system injury. Cerebral ischaemia, traumatic injury of central nervous system, metabolic, toxic and degenerative neuropathy, and also the increase in Ca2+ concentration in the cell, are strong stimulators of PAF synthesis and its release from cell membranes. Neurons, glial and microglial cells, monocyte cell populations, macrophages and endothelial cells of blood vessels are the targets of platelet activating factor. The release of PAF leads to ischaemia of nervous tissue, acute traumatic or nontraumatic injuries, degenerative and metabolic nervous system disorders in adults. The use of PAF receptor antagonists prevents partially cell injury in central nervous system and leukocyte adhesion to endothelial cells.

Accuracy of transcranial color Doppler ultrasonography in the diagnosis of middle cerebral artery spasm determined by receiver operating characteristic analysis.

OBJECT: The value of transcranial Doppler ultrasonography for the detection of middle cerebral artery (MCA) spasm has been asserted. None of the published studies, however, has adequately scrutinized the overall diagnostic accuracy of this procedure. There are only sporadic reports concerning the utility of transcranial color Doppler (TCCD) ultrasonography, although this method has been proved to be more precise. In this study the authors attempted to estimate the performance of TCCD ultrasonography in detecting MCA narrowing by using receiver operating characteristic (ROC) curve analysis, based on TCCD studies obtained in a relatively large, randomly selected population of patients. METHODS: Transcranial color Doppler ultrasonography studies were obtained in 100 consecutive patients (54 men and 46 women ages 18-74 years, median age 50 years) routinely referred by neurosurgeons for intraarterial angiography. The M1 segment of the MCA was insonated using a 2.5-MHz probe via a temporal acoustic window, and angle-corrected flow velocities were obtained. Angiographically depicted vasospasm was graded as none, mild (< or = 25% vessel caliber reduction), and moderate to severe (> 25% vessel caliber reduction). The effectiveness of TCCD ultrasonography in diagnosing MCA spasm was evaluated by calculating the areas under the ROC curves (Az). Of the 200 MCAs examined, 173 were successfully visualized with the aid of TCCD ultrasonography. Mild vasospasm was angiographically diagnosed in 15 arteries and moderate-to-severe vasospasm in 28. The best-performing TCCD parameter for the detection of MCA narrowing was revealed to be peak systolic velocity. The Az value for moderate-to-severe vasospasm only was 0.93 and that for all vasospasms was 0.8. The best efficiency, that is, the optimal tradeoff between sensitivity and specificity in diagnosing vasospasms, was associated with a peak systolic velocity of 182 cm/second. CONCLUSIONS: The performance of TCCD ultrasonography in the diagnosis of advanced MCA narrowing is very good, and is acceptable for all vasospasms. The best-performing parameter was peak systolic velocity.