General recommendations for the management of aneurysmal subarachnoid hemorrhage.

Subarachnoid hemorrhage is a neurologic emergency and a detrimental cerebrovascular event with a high rate of death and complications. Recommendations have been developed and based on literature search, evaluation of the results of large international clinical trials, collective experience of the authors, and endorsed by the Croatian Society of Neurovascular Disorders, Croatian Society of Neurology including Section for Neurocritical Care, Croatian Neurosurgical Society, Croatian Society for Difficult Airway Management and Croatian Medical Association. The aim of these guidelines is to provide current and comprehensive recommendations and to assist physicians in making appropriate decisions in the management of subarachnoid hemorrhage. Evidence based information on the epidemiology, risk factors and prognosis, as well as recommendations on diagnostic work up, monitoring and management are provided, with regard to treatment possibilities in Croatia.

Recommendations for the management of medical complications in patients following aneurysmal subarachnoid hemorrhage.

These are evidence based guidelines for the management of medical complications in patients following aneurysmal subarachnoid hemorrhage, developed and endorsed by the Croatian Society of Neurovascular Disorders, Croatian Society of Neurology including Section for Neurocritical Care, Croatian Neurosurgical Society, Croatian Society for Difficult Airway Management and Croatian Medical Association. They consist of recommendations for best monitoring, medical treatment and interventions based on the literature, evaluation of the results of large international clinical trials, and collective experience of the authors.

[Guidelines for diagnosis, therapy and follow up of Anderson-Fabry disease]. / Smjernice za dijagnostiku, lijecenje i pracenje Anderson-Fabryjeve bolesti.

Fabry disease (Anderson-Fabry disease) is one of the most common lysosomal storage diseases (after Gaucher disease) caused by deficient activity of the α-galactosidase A (α-Gal A) enzyme, which leads to progressive accumulation of globotriaosylceramide in various cells, predominantly in endothelium and vascular smooth muscles, with multisystem clinical manifestations. Estimates of the incidence range from one per 40,000 to 60,000 in males, and 1:117,000 in the general population. Pain is usually the first symptom and is present in 60%-80% of affected children, as well as gastrointestinal disturbances, ophthalmologic abnormalities and hearing loss. Renal failure, hypertrophic cardiomyopathy, or stroke as the presenting symptom may also be found even as isolated symptoms of the disease. Life expectancy is reduced by approximately 20 years in males and 10-15 years in females, therefore enzyme replacement therapy should be introduced in patients of any age and either sex, who meet treatment criteria for Anderson-Fabry disease.

Guidelines for diagnosis, therapy and follow up of Anderson-Fabry disease.

Fabry disease (Anderson-Fabry disease) is one of the most common lysosomal storage diseases (after Gaucher disease) caused by deficient activity of the alpha-galactosidase A (alpha-Gal A) enzyme, which leads to progressive accumulation of globotriaosylceramide in various cells, predominantly in endothelium and vascular smooth muscles, with multisystem clinical manifestations. Estimates of the incidence range from one per 40,000 to 60,000 in males, and 1:117,000 in the general population. Pain is usually the first symptom and is present in 60%-80% of affected children, as well as gastrointestinal disturbances, ophthalmologic abnormalities and hearing loss. Renal failure, hypertrophic cardiomyopathy, or stroke as the presenting symptom may also be found even as isolated symptoms of the disease. Life expectancy is reduced by approximately 20 years in males and 10-15 years in females, therefore enzyme replacement therapy should be introduced in patients of any age and either sex, who meet treatment criteria for Anderson-Fabry disease.

Recommendations for diagnosis and management of multiple sclerosis.

Multiple sclerosis (MS) is a chronic demyelinating neurologic disorder that mainly affects young individuals (aged 20 to 50 years). Approximately 85% of patients experience an initial course with relapses and remissions (relapsing-remitting multiple sclerosis). Guidelines for the management of MS should be focused on three main areas: (a) the diagnosis of MS; (b) treatment of relapses; and (c) long-term preventive treatment including clinical follow up, dose adjustment, drug switch, control of therapeutic efficacy, and disease progression. Diagnosis should be established according to clinical and paraclinical criteria. Discussion on therapeutic recommendations is focused on the disease-modifying agents in acute phases and drugs for long-term treatment and symptomatic treatment. Differential diagnoses must be taken into account on making the diagnosis of MS. Therefore, diagnosis of MS should be established on clinical and radiological diagnostic criteria, cerebrospinal fluid analysis and evoked potentials.

Report of the Croatian Society for Neurovascular Disorders, Croatian Medical Association. Evidence based guidelines for treatment of primary headaches--2012 update.

These guidelines have been developed to assist the physician in making appropriate choices in work-up and treatment of patients with headaches. The specific aim of the Evidence Based Guidelines for Treatment of Primary Headaches--2012 Update is to provide recommendations for establishing an accurate diagnosis and choose the most appropriate therapy in the group of patients with primary headaches, based on a comprehensive review and meta-analysis of scientific evidence with regard to treatment possibilities in Croatia. These data are based on our previous Evidence Based Guidelines for Treatment of Primary Headaches published in 2005 and other recommendations and guidelines for headache treatment.

Impact of hyperglycemia on ischemic stroke mortality in diabetic and non-diabetic patients.

BACKGROUND: Previous studies suggest that infarct expansion may be responsible for increased mortality after stroke onset in patients with prolonged stress hyperglycemia. Therefore, we evaluated the influence of prolonged stress hyperglycemia on stroke mortality in patients with and without diabetes. PATIENTS AND METHODS: For 630 stroke patients admitted to the neurological intensive care department within 24 hours of stroke onset, we correlated mean blood glucose levels (MBGL) at admission and 72 hours after admission in diabetic and non-diabetic patients with final outcome. Blood glucose levels higher then 6.1 mmol/L (121 mg/dL) were treated as hyperglycemia. RESULTS: Of 630 patients (mean age 71 A+/- 6), 410 were non-diabetic (mortality, 25%) and 220 patients were diabetic (mortality, 20%). All patients who died within 28 days of hospitalization had prolonged hyperglycemia (at admission and after 72 hours, despite insulin therapy). The unadjusted relative risk of in-hospital mortality within 28 days for all stroke patients was 0.68 (95% CI, 0.14-1.9) for non-diabetic patients and 0.39 (95% CI, 0.27- 1.56) for diabetic patients. The unadjusted relative risk of in-hospital mortality within 28 days in ischemic stroke in patients with MBGL > 6.1-8.0 mmol/L (121-144 mg/dL) at admission and after 72 hours was 1.83 (95% CI, 0.41-5.5) for non-diabetic patients and 1.13 (95% CI, 0.78-4.5) for diabetic patients. Non-diabetic patients with hyperglycemia had a 1.7 times higher relative risk of in-hospital 28-day mortality than patients with diabetes. CONCLUSION: Prolonged stress hyperglycemia in ischemic stroke patients increases the risk of in-hospital 28- day mortality, especially in non-diabetic patients.

The dissections of craniocervical arteries.

Dissection of craniocervical arteries internal carotid artery (ICA), or vertebral artery (VA) is an increasingly recognized entity and infrequent cause of stroke. We investigated 8 patients (4 women and 4 men) with dissections of the craniocervical arteries. Diagnostic procedures for detection of craniocervical dissection included: extracranial ultrasound-color Doppler flow imaging (CDFI) of carotid and vertebral arteries, transcranial Doppler sonography (TCD) and radiological computed tomography (CT) and digital subtractive angiography (DSA) examinations. Ultrasound findings (CDFI of carotid and vertebral arteries) were positive for vessel dissection in seven patients (or 87.5 per cent) and negative in one patient. DSA was consistent with dissection in five patients (or 62.5 per cent), negative in one, while in two patients the examination was not performed due to known allergy to contrast media. Five patients (62.5 per cent) were treated with anticoagulants, one with suppressors of platelet aggregation, and two patients were operated. Six patients (75 per cent) after the treatment showed partial recovery of neurological defects, and an improvement of ultrasound finding of dissected arteries. In one patient, following operation, stroke developed with deterioration of motor deficit, and one patient was readmitted three months later due to a newly developed stroke and soon died. The diagnosis should be suspected in any young or middle-age patient with new onset of otherwise unexplained unremitting headache or neck ache, especially in association with transient or permanent focal neurological deficits.

Ultrasound measurement of the volume of musculus quadriceps after knee joint injury.

The monitoring of the recovery of femoral muscles, after the knee-joint injury, is possible by the method of ultrasound measurement of the muscular volume. In a clearly defined longitudinal study, our object was to standardize the method of ultrasound measurement of muscular volume and to evaluate its adequacy in practical application in quadriceps muscle rehabilitation. The ultrasound measurements of m. rectus femoris and m. vastus intermedius were conducted in three intervals: in the first 24 hours after the injury; after 1 week, when immobilization was removed; and after 6 weeks, when rehabilitation was finished. The study comprised 30 patients with knee-joint injury, and 30 asymptomatic subjects, who formed the control group. The results showed significant decrease of muscular volume (mm3) after joint immobilization on injured leg and a significant increase of volume after rehabilitation. The same differences were observed on healthy legs, but without significance. Within the same intervals, there were no changes in the muscular mass in the control group. M. rectus femoris was completely recovered in greater number of patients (54.1%), comparing to m. vastus intermedius (25.4%). We conclude that the ultrasound is an appropriate method for monitoring the process of muscular atrophy during immobilization, as well as the course of muscular restitution during the physical therapy.

Hormone replacement therapy--is there a place for its use in neurology?

Stroke remains the third leading cause of mortality in developed countries despite declining tendency over the past decades. As the leading cause of disability and second cause of dementia, primary prevention should be the main way to fight the disease, since therapy is not efficient enough. Several observations pointed to estrogen as a protective agent that may reduce stroke risk, however, studies have shown conflicting data. There is no strong evidence that hormone replacement therapy (HRT) increases stroke risk. Several studies have shown that HRT may reduce the risk of fatal stroke. Conflicting results have been found for Alzheimer's disease and HRT as well. An association between higher serum concentration of estradiol and decreased risk of cognitive decline has been found in some studies, supporting the hypothesis that estrogen concentration may play a significant role in brain protection. Having in mind results of recent randomized trials, it is suggested that HRT should not be recommended on general basis for the primary or secondary prevention of cardiovascular/cerebrovascular diseases or for primary prevention of degenerative diseases such as Alzheimer's disease. Osteoporosis, cognitive decline and climacteric symptoms that are likely to impact on quality of life, speak in favor for recommendation of HRT use. On the other side, family history of breast carcinoma, mastopathy, thromboembolism, in certain cases gallbladder disease, will discourage the commencement of HRT. Respecting the patient's preferences and having benefits and risks in mind as well as science advisory statements, individual counseling regarding HRT should be the leading concept in the healthcare of postmenopausal women.