Značaj perfuzione kompjuterizovane tomografije endokranijuma u primeni intravenske trombolitičke terapije kod bolesnika sa akutnim ishemijskim moždanim udarom

UVOD: Akutni ishemijski moždani udar (AIMU) je poremećaj moždane funkcije nastao usled vaskularnih oštećenja, uzrokovane okluzijom ili embolijom krvnog suda. Za razliku od standardnog CT pregleda endokranijuma, CT perfuzija (CTP) je napredna dijagnostička procedura koja može u prvim satima od početka simptoma AIMU pružiti precizne informacije o lokalizaciji i veličini infarkta mozga, a u okviru infarkta, razlikovati srž i ishemijsku penumbru. Samim tim, CTP predstavlja svojevrsnu pomoć u selekciji pacijenata za intravensku primenu rekombinantnog tkivnog plazminogen aktivatora (rtPA). CILJ RADA: Cilj istraživanja je bio da se primenom CTP ispita koliko iznosi: optimalna veličina srži, zatim minimalni i optimalan odnos penumbre i srži infarkta pogodnih za primenu rtPA, maligni profil srži infarkta koji je nepogodan za primenu rtPA i % simptomatske hemoragije kao komplikacije nakon rtPA. MATERIJAL I METODE: Istraživanje je obavljeno u Specijalnoj bolnici „Sveti Sava“ u Beogradu kao petogodišnja retrospektivna studija. Studija je obuhvatila ukupno 130 pacijenata sa AIMU kod kojih je primenjena CTP. Eksperimentalnu grupu je sačinjavalo 100 pacijenata kojima je aplikovana rtPA, a kontrolnu grupu 30 pacijenata, koji nisu primili rtPA. Svim ispitanicima su načinjeni: standardni CT pregled glave i CT perfuzija odmah nakon prijema i kontrolni standardni CT pregled endokranijuma 24 h nakon prijema u bolnicu. Pregledi su obavljeni sa 16-slajsnom MSCT aparatu, pri čemu je pokrivenost CTP iznosila 2 cm. „Mismatch“ postoji ukoliko je perfuziona lezija na CBF mapi veća od perfuzionog deficita na CBV mapi (srţ infarkta). REZULTATI: Rezultati studije su pokazali da pacijenti oboleli od AIMU sa mismatchom manjim od 20% nisu imali koristi od primenjene rtPA, a pacijenti sa 20% i više mismatch-om su imali ili umeren ili značajan neurološki oporavak. Optimalni mismatch, kojim se postiže visoka uspešnost nakon rtPA je iznosio ˃ 101% penumbre. Pacijenti sa površinom perfuzionog deficita na CBV mapi manjom od 1175 mm2 su imali bolji neurološki oporavak, u odnosu na pacijente savećim lezijama, a samim tim su bili pogodni za primenu rtPA. Perfuzioni deficit na CBV mapi veći od 3000 mm2 (60ml) je predstavljao maligni profil infarkta, usled povećanog rizika od nastanka simptomatske hemoragije i smrtnog ishoda. Simptomatska hemoragija u eksperimentalnoj grupi je iznosila svega 3%, što predstavlja nizak procenat komplikacija nakon reperfuzione terapije. ZAKLJUČAK: CT perfuzija je urgentna i brza tehnika, koja nam daje jedinstvene informacije o AIMU, pomaže u donošenju odluke o terapijskom pristupu i može poslužiti kao surogat biomarker u predikciji kliničkog ishoda.INTRODUCTION: Acute ischemic stroke (AIS) is functional brain disorder, which is happened due to vascular damaged, caused by vessel occlusion or embolism. Unlike to noncontrast brain CT, CT perfusion (CTP) is advanced diagnostic procedure, which could give accurate information about localization and extent of AIS in the first hours of symptom onset, and also differentiate infarct cor and ischemic penumbra. Thus, CTP helps in selection patients for administration intravenous recombinant tissue plasminogen activator (rtPA) AIM: The aims of study were to estimate: the size of optimal infarct cor, minimal and optimal ratio between penumbra and infarct core which is suitable for rtPA, malignant profile of infarct core which is not suitable for rtPA and percentage of symptomatic intracerebral hemorrhage as compli-cation after rtPA using CTP. MATERIAL AND METHODS: The investigation was performed in Stroke hospital „Sveti Sava” in Belgrade as five years retrospective study. Study included 130 patients with AIS with performed CT perfusion. One hundred patients from experimental group were treated with rtPA and thirty patients from control group were not treated with rtPA. All patients underwent baseline noncontrast CT of brain, CT perfusion and control 24 hours follow-up noncontrast brain CT. Examinations were done on 16-slice MSCT and CTP covered an area of 20 mm of brain tissue. „Mismatch “was defined as a perfusion lesion (CBF lesion) larger than the core lesion (CBV). RESULTS: Results of study showed that the patients with AIS and mismatch less than 20%, had no benefit from rtPA, but patients with ≥ 20% of mismatch had good or excellent clinical outcome. Optimal mismatch, which provided favorable response after rtPA, was ˃101% of penumbra. Patients with cor perfusion lesion (CBV) less than 1175 mm2, are suitable for rtPAand had better clinical outcome, then the patients with larger lesions. Perfusion cor lesions (CBV) larger than 3000 mm2 (60ml) was malignantprofile, because of high risk of symptomatic intracerebral hemorrhage and mortality. Symptomatic hemorrhage in experimental group was only 3%, as a low percentage of complications after reperfusion therapy. CONCLUSION: CTP is emergency and rapid technique, which provides unique information about AIS, helps with clinical decision making and could be surrogate biomarker in prediction of clinical outcome

Značaj perfuzione kompjuterizovane tomografije endokranijuma u primeni intravenske trombolitičke terapije kod bolesnika sa akutnim ishemijskim moždanim udarom

UVOD: Akutni ishemijski moždani udar (AIMU) je poremećaj moždane funkcije nastao usled vaskularnih oštećenja, uzrokovane okluzijom ili embolijom krvnog suda. Za razliku od standardnog CT pregleda endokranijuma, CT perfuzija (CTP) je napredna dijagnostička procedura koja može u prvim satima od početka simptoma AIMU pružiti precizne informacije o lokalizaciji i veličini infarkta mozga, a u okviru infarkta, razlikovati srž i ishemijsku penumbru. Samim tim, CTP predstavlja svojevrsnu pomoć u selekciji pacijenata za intravensku primenu rekombinantnog tkivnog plazminogen aktivatora (rtPA). CILJ RADA: Cilj istraživanja je bio da se primenom CTP ispita koliko iznosi: optimalna veličina srži, zatim minimalni i optimalan odnos penumbre i srži infarkta pogodnih za primenu rtPA, maligni profil srži infarkta koji je nepogodan za primenu rtPA i % simptomatske hemoragije kao komplikacije nakon rtPA. MATERIJAL I METODE: Istraživanje je obavljeno u Specijalnoj bolnici „Sveti Sava“ u Beogradu kao petogodišnja retrospektivna studija. Studija je obuhvatila ukupno 130 pacijenata sa AIMU kod kojih je primenjena CTP. Eksperimentalnu grupu je sačinjavalo 100 pacijenata kojima je aplikovana rtPA, a kontrolnu grupu 30 pacijenata, koji nisu primili rtPA. Svim ispitanicima su načinjeni: standardni CT pregled glave i CT perfuzija odmah nakon prijema i kontrolni standardni CT pregled endokranijuma 24 h nakon prijema u bolnicu. Pregledi su obavljeni sa 16-slajsnom MSCT aparatu, pri čemu je pokrivenost CTP iznosila 2 cm. „Mismatch“ postoji ukoliko je perfuziona lezija na CBF mapi veća od perfuzionog deficita na CBV mapi (srţ infarkta). REZULTATI: Rezultati studije su pokazali da pacijenti oboleli od AIMU sa mismatchom manjim od 20% nisu imali koristi od primenjene rtPA, a pacijenti sa 20% i više mismatch-om su imali ili umeren ili značajan neurološki oporavak. Optimalni mismatch, kojim se postiže visoka uspešnost nakon rtPA je iznosio ˃ 101% penumbre. Pacijenti sa površinom perfuzionog deficita na CBV mapi manjom od 1175 mm2 su imali bolji neurološki oporavak, u odnosu na pacijente savećim lezijama, a samim tim su bili pogodni za primenu rtPA. Perfuzioni deficit na CBV mapi veći od 3000 mm2 (60ml) je predstavljao maligni profil infarkta, usled povećanog rizika od nastanka simptomatske hemoragije i smrtnog ishoda. Simptomatska hemoragija u eksperimentalnoj grupi je iznosila svega 3%, što predstavlja nizak procenat komplikacija nakon reperfuzione terapije. ZAKLJUČAK: CT perfuzija je urgentna i brza tehnika, koja nam daje jedinstvene informacije o AIMU, pomaže u donošenju odluke o terapijskom pristupu i može poslužiti kao surogat biomarker u predikciji kliničkog ishoda.INTRODUCTION: Acute ischemic stroke (AIS) is functional brain disorder, which is happened due to vascular damaged, caused by vessel occlusion or embolism. Unlike to noncontrast brain CT, CT perfusion (CTP) is advanced diagnostic procedure, which could give accurate information about localization and extent of AIS in the first hours of symptom onset, and also differentiate infarct cor and ischemic penumbra. Thus, CTP helps in selection patients for administration intravenous recombinant tissue plasminogen activator (rtPA) AIM: The aims of study were to estimate: the size of optimal infarct cor, minimal and optimal ratio between penumbra and infarct core which is suitable for rtPA, malignant profile of infarct core which is not suitable for rtPA and percentage of symptomatic intracerebral hemorrhage as compli-cation after rtPA using CTP. MATERIAL AND METHODS: The investigation was performed in Stroke hospital „Sveti Sava” in Belgrade as five years retrospective study. Study included 130 patients with AIS with performed CT perfusion. One hundred patients from experimental group were treated with rtPA and thirty patients from control group were not treated with rtPA. All patients underwent baseline noncontrast CT of brain, CT perfusion and control 24 hours follow-up noncontrast brain CT. Examinations were done on 16-slice MSCT and CTP covered an area of 20 mm of brain tissue. „Mismatch “was defined as a perfusion lesion (CBF lesion) larger than the core lesion (CBV). RESULTS: Results of study showed that the patients with AIS and mismatch less than 20%, had no benefit from rtPA, but patients with ≥ 20% of mismatch had good or excellent clinical outcome. Optimal mismatch, which provided favorable response after rtPA, was ˃101% of penumbra. Patients with cor perfusion lesion (CBV) less than 1175 mm2, are suitable for rtPAand had better clinical outcome, then the patients with larger lesions. Perfusion cor lesions (CBV) larger than 3000 mm2 (60ml) was malignantprofile, because of high risk of symptomatic intracerebral hemorrhage and mortality. Symptomatic hemorrhage in experimental group was only 3%, as a low percentage of complications after reperfusion therapy. CONCLUSION: CTP is emergency and rapid technique, which provides unique information about AIS, helps with clinical decision making and could be surrogate biomarker in prediction of clinical outcome

Posterior reversible encephalopathy syndrome: A case report

Posterior reversible encephalopathy syndrome (PRES) is characterized by the following symptoms: seizures, impaired consciousness and/or vision, vomiting, nausea, and focal neurological signs. Diagnostic imaging includes examination by magnetic resonance (MR) and computed tomography (CT), where brain edema is visualized bi-laterally and symmetrically, predominantly posteriorly, parietally, and occipitally. Case report. We presented a 73-year-old patient with the years-long medical history of hipertension and renal insufficiency, who developed PRES with the symptomatology of the rear cranium. CT and MR verified changes in the white matter involving all lobes on both sides of the brain. After a two-week treatment (antihypertensive, hypolipemic and rehydration therapy) clinical improvement with no complications occurred, with complete resolution of changes in the white matter observed on CT and MR. Conclusion. PRES is a reversible syndrome in which the symptoms withdraw after several days to several weeks if early diagnosis is made and appropriate treatment started without delay

Hypoplasia of the ipsilateral internal jugular vein is associated with worse outcome in acute anterior circulation stroke

Background/Aim. Disruption of cerebral venous blood drainage leads to cerebral venous congestion, an increase in intracranial pressure and decrease of the cerebral perfusion pressure. The exact role of the cerebral venous circulation in acute stroke is not yet known. The main blood drainage from the brain and the superficial parts of the face and neck is drained by a paired internal jugular vein (IJV). Congenital anomalies of IJV may disrupt the blood collection from the brain, which leads to congestion of the cerebral venous circulation. The aim of our study was to determine the association between the hypoplastic ipsilateral IJV and clinical outcome of patients with acute ischemic anterior circulation stroke. Methods. This prospective case series study involved the patients with the anterior circulation stroke and ultrasonographic criteria for unilateral hypoplasia of the ipsilateral IJV. Data from the 74 consecutive patients with acute anterior circulation stroke admitted to the Special Hospital for Cerebrovascular Diseases “Sveti Sava”, Belgrade, from September 2015 to January 2016 were included. Ultrasonography of IJV diameter and the collection of the hemodynamic data were performed in all patients. Neurological deficits on admission were evaluated using the National Institutes of Health Stroke Scale (NIHSS) score. The clinical outcome was assessed using the modified Rankin Scale (mRS) score (from 0 to 6) at 30 days or at discharge, whichever occurred sooner. Good and poor outcomes were defined as an mRS score of 0–2 and 3–6, respectively. Results. Ipsilateral hypoplastic IJV was diagnosed in 13 (17.6%) patients with anterior circulation stroke. In this group, 9 stroke patients (69.2%) had mRS ≥ 3. Of the remaining 4 patients with mRS ≤ 2, three had bilateral hypoplasia of IJV and one patient had smaller diameter of the IJV, but did not fulfill the ultrasonographic criteria for hypoplastic venous anomaly. Conclusions. In our case, a series of the patients with anterior circulation stroke with ultrasonographic criteria for unilateral hypoplasia of the ipsilateral IJV (on stroke side) have worse clinical outcome compared with the patients with bilateral hypoplasia