Hypoglossal nerve palsy in the course of dissection of the internal carotid arteries - Case reports.

Internal carotid artery dissection (ICAD) has become an increasingly recognized cause of cerebrovascular accidents in young and middle-aged patients. We report 2 cases of hypoglossal nerve palsy in the course of dissection of the internal carotid arteries. The first patient was admitted to the Department of Neurology due to swallowing difficulty, speech articulation disorders and numbness of the right half of the tongue for 4 weeks. Extracranial vessel ultrasound (US) and transcranial colour Doppler (TCD) visualized thrombus causing occlusion of the right internal carotid artery (RICA). Angio-CT revealed a compression on right XII nerve and a dissection of the RICA. The second patient was referred to the Department of Neurology due to articulation disorders and swallowing difficulties. On admission, neurological examination revealed tongue deviation towards the right side with evidence of atrophy of the right half of the tongue, deviation of the uvula to the right side, absence of palatal and pharyngeal reflexes, rhinolalia and dysphagia. Vessel imaging was taken using angio-MR showing mural thrombus of the RICA. CONCLUSION: The diagnosis of spontaneous non-traumatic dissection of the carotid arteries is a major challenge for clinicians. ICAD must be considered for young and middle-aged patients when severe headache is preceded by the co-existence of focal neurological symptoms. The probability of ICAD increases in the presence of predisposing diseases. The final diagnosis is based on imaging studies: color duplex ultrasound, CT angiography or MR angiography.

Antiplatelet and anticoagulant therapy in elderly people with type 2 diabetes mellitus in Poland (based on the PolSenior Study).

INTRODUCTION: Type 2 diabetes mellitus (T2DM) is an important and common cardiovascular risk factor. The purpose of the study was to evaluate the frequency of use of oral antiplatelet drugs (OAPs) and oral anticoagulant drugs (OACs) among the elderly with T2DM in Poland. MATERIAL AND METHODS: The study was based on the data collected in the Polish national PolSenior study. RESULTS: Among 4979 PolSenior participants aged 65 and over, 883 (17.8%) had previously diagnosed T2DM. Among them, 441 (49.9%) used at least one drug in pharmacological cardiovascular prevention, i.e. OAPs (mostly ASA) in 405 (45.9%) cases and OACs in 38 (4.3%). The use of these drugs significantly depended on the sex (p = 0.02) and personal income (p = 0.05). Age, place of residence and level of education did not affect the prevalence of pharmacological prevention. Previous stroke and myocardial infarction were mostly associated with OAPs, whereas a history of atrial fibrillation (AF) was related to OAC treatment. Among participants treated with OAPs, therapy was applied as secondary cardiovascular prevention in 211 (52.1%) subjects, and as primary prevention in 194 (47.9%) subjects. Among participants treated with OACs, 24 (64.9%) persons had a history of AF. Secondary cardiovascular pharmacological prevention should be considered in 45 untreated participants (12.5%), and primary cardiovascular pharmacological prevention (SCORE ≥ 10 and/or AF) in 154 participants (42.7%). CONCLUSIONS: Cardiovascular pharmacological prevention in the elderly with T2DM in Poland seems to be unsatisfactory. Educational programmes concerning current recommendations for pharmacological cardiovascular prevention should be developed among general practitioners.

[Neurosarcoidosis - clinical characteristics, diagnosis and treatment]. / Neurosarkoidoza - obraz kliniczny, diagnostyka i leczenie.

Neurosarcoidosis (NS) manifests itself clinically in approximately 8-13% of patients with sarcoidosis. Granulomas are localized in both the central and peripheral nervous system, mainly within the meninges and cranial nerves. Changes may spread interstitially, occupying different structures of the brain and spinal cord. Diagnosis of NS is made by characteristic clinical symptoms and the exclusion of other diseases, with the presence of specific changes in the magnetic resonance and cerebrospinal fluid, and it is mainly based on histopathological examination. The first choice treatment are corticosteroids. In case of failure or adverse events, methotrexate, azathioprine, cyclosporine, cyclophosphamide, mycophenolate mofetil and infliximab could be used.

Utility of serum concentration of protein S100 at admission to the medical intensive care unit in prediction of permanent neurological injury.

INTRODUCTION: Admission to the intensive care unit (ICU) may be preceded by dramatic events leading to permanent neurological injury. Plasma S100 protein levels are proved to be clinically useful in predicting neurological outcome following cardiac arrest. It is unclear, however, whether this may be extrapolated to a broader population of ICU patients. AIM: To assess the utility of plasma S100 protein in predicting death, permanent neurological damage, or unfavourable outcome at admission to the intensive care unit. MATERIAL AND METHODS: The concentration of plasma S100 protein was established in 102 patients on admission to the ICU, regardless of their neurological status and the reason for admission. The majority of patients were admitted with various cardiac diseases, excluding trauma patients. The patients were classified into three groups with the following binary outcomes: permanent neurological deficit or restoration of consciousness; unfavourable outcome (death or survival with permanent neurological deficit) or favourable outcome; and death or survival. RESULTS: Plasma S100 protein levels at admission facilitated the identification of patients who later developed a permanent neurological deficit or regained consciousness (p < 0.0001). All patients with plasma S100 protein over 0.532 µg/l at ICU admission either developed a permanent neurological deficit or had an unfavourable outcome (death or survival with permanent neurological deficit). However, sensitivity for this cut-off value was only 48% and 40%, respectively. CONCLUSIONS: Plasma S100 protein levels over 0.532 µg/l are specific but not sensitive for both permanent neurological deficit and unfavourable outcome when assessed in a heterogeneous population at admission to the ICU.

Efficiency of transcatheter patent foramen ovale closure in children after paradoxical embolism events.

BACKGROUND AND AIM: Patent foramen ovale (PFO) may result in a cerebrovascular event - a presumed paradoxical embolism (PE). However, the presence of this phenomenon among paediatric patients was rarely evaluated. Transcatheter PFO closure was considered to be a method of treatment in such patients. METHODS: For evaluation clinical data and long-term outcome, we reviewed records of patients below 18 years of age, with history of cerebrovascular event related to PE, who underwent procedure of percutaneous PFO closure in years 1999-2014 in our department. RESULTS: Among 230 patients with cerebrovascular events who had PFO closed percutaneously, seven children (aged 12-16 years, five male) were selected. Indications for closure were cryptogenic stroke in two patients and transient ischaemic attack (TIA) in five patients. Diagnosis of PFO was established by transthoracic echocardiography, with right-to-left shunt (RLS) through PFO confirmed by transoesophageal echocardiography. Contrast transcranial Doppler (c-TCD) was performed preprocedurally in four patients, revealing significant RLS. For percutaneous closure of PFO different occluders (Starflex, Amplatzer PFO devices, Cardio-O-Fix) were used. Closure was successfully completed in all patients and no procedure-related complications were observed. Postprocedural c-TCD six months after closure revealed no significant RLS. During follow-up (3 to 10 years) one patient had an episode of recurrent TIA; however, in this patient paroxysmal atrial fibrillation was found during the follow-up period. CONCLUSIONS: Cerebral embolism due to PFO is uncommon in children. Transcatheter PFO closure in this group of patients is a safe and effective procedure. C-TCD is plausible technique for detection RLS and monitoring PFO closure efficacy in this group of patients.

Medium-term results of transcatheter closure of patent foramen ovale (PFO) with Amplatzer PFO and Cribriform occluders.

BACKGROUND: The use of an Amplatzer Cribriform Septal Occluder (ACSO) for percutaneous patent foramen ovale (PFO) closure (especially in cases with atrial septal aneurysm) has been recently described as superior compared to that of an Amplatzer PFO Occluder (APFO). AIM: To assess immediate and medium-term clinical outcomes of patients with PFO with paradoxical embolism event (EE) who underwent transcatheter PFO closure with an APFO or an ACSO. METHODS: Overall, 56 consecutive patients underwent percutaneous closure of PFO with an APFO device; the results were compared to those in seven patients treated with ACSO. Deaths due to embolism, stroke or transient ischaemic attack (TIA) were considered recurrent EE. Pre- and 6 month post-intervention right to left shunting (RLS) were evaluated with intravenous contrast injection by transcranial Doppler examination of the middle cerebral artery during Valsalva manoeuvre. RESULTS: The procedure was successfully completed in all patients in both groups. No procedure-related complications were observed during hospitalisation. Residual RLS was noted at six months in 14/56 (25%) patients in the APFO group and 4/7 (57%) patients in the ACSO group (p <0.05). Recurrent TIA was observed in three patients in the APFO group (one of them had small residual shunt immediately after procedure and at six-month follow-up). Another patient from that group experienced stroke one month after the procedure. No recurrence of EE was recorded in the ACSO group. CONCLUSIONS: Transcatheter PFO closure with both Amplatzer devices is a minimally invasive procedure with high success and low complication rates. Taking in consideration residual RLS in the medium-term period, the application of a Cribriform device is not superior to that of an Amplatzer PFO device. Results of randomised trials are necessary to confirm the effectiveness of transcatheter therapy in patients with PFO and a paradoxical thromboembolic event.

Estimates of stroke incidence and case fatality in Zabrze, 2005-2006.

BACKGROUND AND PURPOSE: Epidemiological rates for stroke obtained in the United States and Western Europe indicate a decrease in incidence and case fatality. Data published for Poland, as for other Central-Eastern European countries, reported unfavourable results, but this was based on data from the 1990s. The authors evaluated current stroke rates in a population study of the southern Poland city of Zabrze. MATERIAL AND METHODS: A retrospective registry of all stroke cases treated in Zabrze, southern Poland, in 2005-2006, was established, based on data from the National Health Fund. Cases were identified by verifying patient files. Epidemiological rates were calculated and standardized to the European population in both groups: all stroke patients, including recurrent (all strokes, AS), and patients with first-ever stroke (FES) in their history. RESULTS: We registered 731 strokes, including 572 FES cases (78.3%) and 159 recurrent strokes (21.7%). There were 385 strokes in men (52.7%), and 346 in women (47.2%); 88.6% were ischaemic strokes (IS), and 11.4% were intra-ce-rebral haemorrhages (ICH). The standardized incidence rate for AS patients was 167/100 000 (211 for men, 130 for women), and in the FES group 131/100 000 (161 for men, 104 for women). Twenty-eight day case fatality for the AS group was 18.3% (15.4% for IS, 41% for ICH), and 16.6% for FES (13.4% for IS, 40.9% for ICH). CONCLUSIONS: Incidence rates in this southern Poland city are comparable to those reported previously for Poland. Early case fatality decreased, compared to previous data, probably as a result of improved management of acute stroke and hospitalizing all stroke patients.

Incidence and prediction of permanent neurological deficits after cardiac surgery - are the existing models of prediction truly global?

OBJECTIVE: Permanent neurological deficit (PND) is a relatively rare but serious complication of cardiac surgery, associated with a high mortality and a poor prognosis for an acceptable quality of life. A few predictive models of PND have been developed; however, it is not certain whether they may be extrapolated to any cardiac surgical population. We aimed to assess the epidemiology and identify predictors of PND on the basis of a single, prospective hospital database from Eastern Europe. METHODS: We performed a retrospective review of 6016 consecutive adult patients (coronary revascularisation with or without cardiopulmonary bypass - 3,613 patients; isolated single-, double- or triple-valve repair or replacement - 1,221 patients; CABG+valve repair or replacement - 563 patients; aortic aneurysm surgery - 228 patients; and other procedures - 391 patients). PND was defined as a new focal or global disorder of cerebral function lasting longer than 24h and still present at the time of hospital discharge or the patient's death. Thirty independent preoperative, intra-operative and postoperative variables that might influence PND were selected and analysed. RESULTS: In total, PND was identified in 2.5% of patients (coronary surgery - 1.7%, isolated valve surgery - 2.9%, combined procedures - 5.3%, aortic aneurysm surgery - 7.5% and others - 2.2%). The overall mortality among patients with PND was very high in comparison to the remaining patients (40.4% vs 2.2%, p<0.001). In a multivariate analysis, PND was associated with five variables: cardiopulmonary bypass time >2h (odds ratio (OR) 3.35), emergency surgery (OR 3.34), early rethoracotomy (OR 3.17), age >65 years (OR 1.70) and unstable course of cardiac disease (OR 1.60). CONCLUSION: PND after cardiac operation is associated with a high mortality and poor prognosis. The incidence of PND varies depending on the procedure. Predictive models of neurological injury post-cardiac surgery should be more centre-specific.

[Adaptation of different neuroprotection devices during carotid stenting procedures]. / Zastosowanie róznych systemów neuroprotekcji podczas zabiegów stentowania tetnicy szyjnej wewnetrznej na podstawie opisu wybranych przypadków.

Carotid artery stenting (CAS) is, apart from surgical endarterectomy, a common method of treatment of atherosclerosis in carotid arteries. Percutaneous angioplasty of carotid artery narrowings has been developing in recent years due to introduction of neuroprotection systems, which significantly reduced number of complications. Nowadays three neuroprotection systems are in common use: filters, temporary occlusion and aspiration systems and flow reversal systems. We present three cases of successful CAS with application of three different neuroprotection systems. We discuss indications, contraindications and limitations of every device.

[Doppler duplex ultrasound applications in cerebrovascular diseases]. / Zastosowanie ultrasonografii w chorobach naczyniowych mózgu.

Cerebrovascular diseases are still common cause of patient mortality and disability. New methods of treatment and prevention are still searched for. Ultrasound examinations of extra- and intracranial arteries allow stroke course monitoring, evaluation of treatment and prevention of new cases. This article is a review of ultrasound techniques and their clinical applications, referred to factors involved in stroke prevalence, clinical management of and possibilities of prevention.