A young female adult patient with an ischaemic stroke and patent foramen ovale: a case report and literature review

Strokes in young adults are relatively rare. We present a 36-year old female patient, who came to the urgent neurological outpatient office of the Clinic for neurology due to symptoms presented two hours prior to the examination. The symptoms consisted of inability to move the left arm, partial mo- tor weakness of the left leg, slurred speech and difficulty swallowing. The urgent CT scan result was normal. Despite the fulfilled conditions, thrombolysis was not possible. Brain MRI results revealed a small hypersignal lesion in FLAIR with diffusion restriction on the right, cortically to subcortically, in gyrus praecentralis. The genetic testing for cardiovascular diseases showed that the patient is a ho- mozygote for the mutation C677T (OMIM® 607093.0003) in the gene for methylenetetrahydrofolate reductase (MTHFR) and heterozygote for the mutations eNOS G894T and LTA. The following gene polymorphisms were typed: PAI 5G/4G, HPA1 1b/1a, ACE deletion/insertion, EPCR A4600G A/A, EPCR G4678C C/G and APOE E3/E4. Trans-esophageal echocardiography discovered an aneurysm of the interatrial septum, with a present PFO channel, with a diameter of 6.8 mm. The bubble test was positive, and there were no visible thrombi in the left auricle. The cardiologist recommended closing of the PFO with a device and therapy with acetylsalicylic acid. The cause of the stroke was found and measures for secondary prevention were taken. The patient has returned to her work and private obli- gations. She upholds neurological consultations regularly and her recovery is closely observed

A young female adult patient with an ischaemic stroke and patent foramen ovale: a case report and literature review

Strokes in young adults are relatively rare. We present a 36-year old female patient, who came to the urgent neurological outpatient office of the Clinic for neurology due to symptoms presented two hours prior to the examination. The symptoms consisted of inability to move the left arm, partial mo- tor weakness of the left leg, slurred speech and difficulty swallowing. The urgent CT scan result was normal. Despite the fulfilled conditions, thrombolysis was not possible. Brain MRI results revealed a small hypersignal lesion in FLAIR with diffusion restriction on the right, cortically to subcortically, in gyrus praecentralis. The genetic testing for cardiovascular diseases showed that the patient is a ho- mozygote for the mutation C677T (OMIM® 607093.0003) in the gene for methylenetetrahydrofolate reductase (MTHFR) and heterozygote for the mutations eNOS G894T and LTA. The following gene polymorphisms were typed: PAI 5G/4G, HPA1 1b/1a, ACE deletion/insertion, EPCR A4600G A/A, EPCR G4678C C/G and APOE E3/E4. Trans-esophageal echocardiography discovered an aneurysm of the interatrial septum, with a present PFO channel, with a diameter of 6.8 mm. The bubble test was positive, and there were no visible thrombi in the left auricle. The cardiologist recommended closing of the PFO with a device and therapy with acetylsalicylic acid. The cause of the stroke was found and measures for secondary prevention were taken. The patient has returned to her work and private obli- gations. She upholds neurological consultations regularly and her recovery is closely observed

Acute encephalitis caused by Streptococcus pneumoniae: case report and review of the literature

Introduction: Streptococcus pneumoniae (pneumococcus), is a Gram-positive, spherical bacteria, member of the genus Streptococcus. It resides asymptomatically in healthy carriers typically colonizing the respiratory tract, sinuses, and nasal cavity. However, in susceptible individuals with weaker im- mune systems, pneumococcus may become pathogenic and spread to other locations causing cardiores- piratory and bone diseases as well as meningitis. Encephalitis and brain abscesses caused by Streptococ- cus pneumoniae are rare entities and they account for less than 1% of all bacterial brain abscesses. Purpose: We aim to present a case report of an acute encephalitis in a 16 years old female patient caused by Streptococcus pneumoniae, with review of the literature. Case Report: A 16 years old, right-handed female, was hospitalized at the clinic due to impaired con- sciousness (coma) and decerebrate posturing. The symptoms started the previous days with vomiting, drowsiness, subfebrile temperature and were originally perceived as food poisoning. Laboratory blood analysis were normal at the beginning and despite supportive therapy, deterioration of the clinical con- dition occurred, followed by confusion, muscle weakness and collapse. These symptoms were initially addressed as a functional neurological symptom disorder and the patient was referred to a psychiatrist. However, the patient’s condition got worse, with febrile symptoms, while the control laboratory blood examination showed signs of infectious syndrome. The patient was seen by infectologist and COV- ID-19 test was performed, with negative result. The analysis of CSF found bacterial infiltration, while the PCR test isolated Streptococcus pneumoniae. MRI of the brain (native and with contrast) showed bilateral multiple microabscesses, predominantly in the frontal and parietal regions. After the diagnosis was confirmed, the patient was treated promptly with antiedematous, antibiotic, neuroprotective and other symptomatic therapy for a period of 2 months. Her condition gradually improved completely, with amelioration of the state of consciousness and muscle weakness as well. Control laboratory blood analysis and CSF examination showed improvement as well, while the MRI of the brain displayed reduction of the previously described lesions and edema. Conclusion: The atypical clinical picture may sometimes mislead the treating physician. Cases with encephalitis caused by Streptococcus pneumoniae have been rarely described in the literature, however, early recognition and adequate treatment are crucial for the positive outcome

Prevalence and Predictors of Depression after Stroke - Results from a Prospective Study

BACKGROUND: A depression following a stroke (Post Stoke Depression-PSD) is the most common complication of a stroke that has a negative effect on the result after the stroke. A better definition of the risk factors of the disease will provide for better prediction and treatment.AIM: To research identification of the risk factors for PSD, typical for the Macedonian population, which will help in early prediction, timely diagnosis and treatment of the disease?MATERIAL AND METHODS: We carried out a prospective study in order to determine the prevalence and the risk factors of PSD in 100 patients treated at the hospital in Tetovo. The severity, localisation and the functional outcome of the stroke have been examined as potential risk factors for discharge and after 5 months. The symptoms of depression were quantified using the Hamilton Depression Rating Scale (HAM-d).RESULTS: On discharge, 81% of the patients were diagnosed with PSD, and 67% had PSD after 5 months. A statistically significant codependence of p < 0.05 was registered between PSD and the level of functional dependence for activities of daily living (ADL); PSD and the severity of the stroke; and PSD and the level of disability on both examinations. In most patients with PSD, an ischemic stroke in the right middle cerebral artery has been diagnosed; the percentage difference between the other localisations is statistically significant (p = 0.0436; p = 0.0002).CONCLUSION: There is an increased risk of PSD for immobile patients, those incapable of activities of daily living (ADL), with ischemic stroke in the right middle cerebral artery. A PSD screening and additional studies for better prediction are required

Ponovljena intravenska tromboliza kod bolesnika s recidivom ishemijskog moždanog udara – prikaz slučaja i prikaz iz literature

Background Recurrent strokes occur in 25% of the cases during the first 5 years after the initial event. Each recur- rent stroke increases the risk for severe disability and mortality. Intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator (rtPA) is one of the therapeutic options when secondary prevention is not efficient and recurrent stroke occurs. Aim Aim of this paper is to present the first ever case of repeated IVT with rtPA in a female patient with recurrent stroke, hospitalized at the Department for Urgent Neurology, University Clinic of Neurology in Skopje, North Macedonia with a review from the literature. Case presentation A 59 years old female patient was admitted due to acute onset of motor and sensory dysphasia and right-sided hemiplegia. The symptoms occurred 1,5 hours before admission. Urgent computed tomography (CT) of the brain showed chronic cerebral infarction in the left and parietal regions, which causing traction of the left lateral ventricle. The patient experienced her first ischemic stroke 2,5 years ago and she was treated with IVT at the time. At the second hospital admission, the patient was conscious, with vital signs and urgent laboratory parameters within normal range. NIHSS score was 13 and a decision for IVT treatment was made. During the application of rtPA, her vital parameters were stable and no side effects were observed. Neurological status of the patient also improved, with NIHSS of 7 at the end of the IVT treatment. Control CT scan performed 24 hours after was without any new lesions. The patient was discharged in a stable condition, with a NIHSS of 4 and mRS of 3. Conclusion Repeated IVT in recurrent stroke is feasible and safe in carefully selected patients. Assessment of risk factors and neuroimaging are crucial when deciding on repeated IVT.Uvod Recidivi moždanih udara javljaju se u 25% slučajeva tijekom prvih 5 godina nakon inicijalnog događaja. Svaki ponovljeni moždani udar povećava rizik za težu onesposobljenost i smrtnost. Intravenska tromboliza (IVT) s rekombinantnim tkivnim aktivatorom plazminogena (rtPA) jedna je od terapijskih mogućnosti u slučajevima kada sekundarna prevencija moždanog udara nije učinkovita te nastupi recidiv moždanog udara. Prikaz slučaja Predstavljamo prvi slučaj na našoj klinici s recidivom moždanim udarom liječenim ponovljenim IVT. 59-godišnja pacijentica primljena je zbog akutne pojave senzomotore disfazije i desne hemiplegije. Simptomi su se javili 1,5 sata prije prijema u bolnicu. Hitna kompjuterizirana tomografija (CT) mozga nije pokazala nove lezije, dok su se prikazale malacijske lezije u lijevoj frontalnoj i parijetalnoj regiji uzrokujući retraktilne promjene na lijevu lateralnu moždanu klijetku. Pacijentica je prvi ishemijski moždani udar doživjela prije 2,5 godine i tada je liječena IVT-om. Pri ovom prijemu u bolnicu, paci- jentica je bila pri svijesti, s vitalnim znakovima i hitnim laboratorijskim parametrima unutar normal- nih granica. NIHSS rezultat je bio 13 i donesena je odluka o IVT liječenju. Tijekom primjene rtPA, vitalni su joj parametri bili stabilni i nisu primijećene nuspojave. Neurološki status pacijenta također se poboljšao na NIHSS od 7 na kraju IVT-a. Kontrolno CT snimnanje mozga nakon 24 sata nije poka- zalo novih lezija. Pacijentica je otpušten u stabilnom stanju, s NIHSS 4 i mRS 3. Zaključak Ponovljeni IVT kod ponovljenog moždanog udara izvediv je i siguran kod pažljivo odabranih bole- snika. Procjena čimbenika rizika i nalaz neuoslikovnih metoda prikaza mozga presudni su pri odluci o ponovljenoj primjeni IVT-a

Анализа на етиолошки фактори за појава на ендометријална хиперплазија во перименопаузa

The aim of this study was to evaluate the possible reasons for the emergence of endometrial hyperplasia in perimenopause. Material and methods: A total of 71 patients with irregular bleeding were analyzed, at the age of 40-50 years, who should have undergone diagnostic curettage. Depending on the histopathological findings, we divided them into 2 groups: group 1-findings for endometrial hyperplasia, group 2 - atrophic or endometrium with deficient secretory changes. Body mass index (BMI) was determined (obesity defined with BMI >30 kg/m2); we measured blood pressure (cut-off value was 135/90 mmHg), waist circumference (cut-off value was 88 cm) as well as data of anamnesis (age, physical activity, type of diet, smoking cigarettes). All these data were analyzed as etiological factors in the emergence of endometrial hyperplasia.Results: The mean age of patients was 47 years, and the results obtained were very similar in both examined groups. BMI and waist circumference were increased, more than 60% of patients had hypertension, but not all had a statistical significance. Most of them were with completed secondary education, and city living statistically significantly increases the risk of endometrial hyperplasia (p <0.05). As for the lifestyle (physical activity, caloric diet, smoking), the results have shown that a small number of patients are active, almost half of them consume caloric food and smoke, but without a statistical significance.Conclusion: Increased body weight and elevated blood pressure have a major impact on the onset and progression of pathological changes in the endometrium. As clinicians, we should always think of hyperplasia in obesity and patients with hypertension who are irregularly bleeding. At the same time, we should educate them to change the lifestyle in order to prevent gynecological and internistic morbidity.Целта на оваа студија беше да се евалуираат можните причини  за појава на ендометријална хиперплазија во перименопауза. Материјал и методи: Беа анализирани 71  пациентка  со неправилно  крвавење, на возраст од 40-50 години, кај кои беше индицирана фракционирана киретажа. Зависно од хистопатолошкиот наод ги поделивме  во 2 групи : група 1- со наод за ендометријална хиперплазија , група 2- атрофичен или ендометриум со дефициентни секреторни промени. Одредивме  индекс на телесна маса (БМИ), обезитет дефиниран со БМИ > 30 kg/m2, измеривме  крвен притисок (cut-off вредност 135/90 mmHg), обем на струк (cut-off вредност 88 см), како и податоци од анамнезата (возраст, физичка активност, тип на исхрана, пушење цигари).  Сите овие податоци беа анализирани  како етиолошки фактори во појавата на ендометријална хиперплазија. Резултати: Средна возраст на пациентките беше околу 47 години, а добиените резултати беа многу слични во двете испитувани групи. БМИ и обем на струк беа зголемени, хипертензија имаа повеќе од 60% од пациентките, но не беше утврдена статистичка значајност.  Најголем дел беа со средно образование, а живеењето во град статистички значајно го зголемува ризикот за ендометријална хиперплазија (p< 0,05). Што се однесува до животниот стил (физичка активност, калорична исхрана, пушење), резултатите покажаа дека мал дел се активни, речиси половина од нив конзумираат калорична храна и пушат, но без статистичка сигнификантност. Заклучок: Зголемената телесна тежина и покачениот крвен притисок  имаат големо влијание врз започнување и прогресија на патолошки промени на ендометриумот. Како клинички доктори секогаш треба да помислиме на хиперплазија  кај обезни и пациентки со хипертензија, кои неправилно крвават. Воедно треба и да ги едуцираме за промена на животниот стил, со цел спречување на гинеколошки и интернистички морбидитети

Cerebral Venous Sinus Thrombosis in a 19 Year Old Female With Ulcerative Colitis: Long Term Follow-up and Review From the Literature

Background: Cerebral venous sinus thrombosis is a rare complication of ulcerative colitis. Case presentation: We present a case report of a 19-year-old female patient with ulcerative colitis, who developed superior sagittal sinus thrombosis with haemorrhagic transformation. Despite the initial treatment with anticoagulant therapy, the patient became comatose, with symptomatic epileptic seizures and compromised cardiorespiratory function. She was transferred to the ICU and put on life-support for 3 weeks. She gradually improved and was discharged on low-molecular weight heparin and antiepileptic therapy. Oral anticoagulant therapy with warfarin was started 6 months later, when the subsequent D-dimers normalized. In the follow-up period, the patient experienced another series of symptomatic epileptic seizures and poorly regulated INRs. Therefore, antiepileptic and anticoagulation therapies were changed to oxcarbazepine and rivaroxaban. Conclusion: Physicians should be aware that treatment of cerebral venous sinus thrombosis with haemorrhagic transformation in a patient with ulcerative colitis is very challenging and demanding. These patients need to be closely monitored for possible complications that might arise due to the concomitant presence of both diseases and possible drug interactions