Wrist Drop: Acute Ischemic Stroke or Radial Nerve Palsy or Both

Stroke has many different symptoms, isolated hand weakness is the rarest one. Even less common are concomitant radial nerve lesions and ischemic stroke that leads to isolated hand weakness. We report a patient with sudden onset of right wrist drop mimicking radial nerve palsy, found to be due to a acute cerebral infarct and radial nerve palsy in the same time. A well-taken history of the patient's illness and thorough clinical examination can differentiate stroke from peripheral neuropathy as the cause of hand weakness. Modern neuroradiological methods such as brain MSCT or MRI can quickly and reliably indicate the etiology of a neurological disease. In every patient who presents with isolated arm weakness, and for whom we are not sure whether it is a lesion of the central or peripheral nervous system, cerebral infarction must be included as a critical differential diagnosis because it can divert attention from sometimes harmful thrombolytic therapy

NEUROFEEDBACK IN TREATING MIGRAINE HEADACHE – A PILOT STUDY

Cilj: Cilj ovog istraživanja bio je objektivizirati terapijski učinak neurofeedbacka na liječenje migrenske glavobolje u bolesnika s migrenskom glavoboljom. Metode: Kao instrument istraživanja koristio se anonimni anketni upitnik, strukturiran i modificiran za potrebe ovog istraživanja. Na kraju su uporabljena dva standardizirana testa: test za procjenu onesposobljenosti bolesnika s migrenom (MIDAS - Migraine Disability Assessment Test), te upinik o ispitivanju utjecaja glavobolje (HIT6: Headache Impact Test) koji se koristi za mjerenje utjecaja glavobolje na sposobnost obavljanja zadataka na radnom mjestu/ u školi i u socijalnim situacijama. Rezultati: Prosječan broj glavobolja tijekom jednog mjeseca kod većine ispitanika je 11 (5 do 6 puta), uz najčešće trajanje od 4 do 24 sata, kako navodi 16 ispitanika. Prosječni je intenzitet glavobolje za 10 ispitanika srednje jaka bol, a za 15 ispitanika jaka bol. Dob nije statistički značajan faktor onesposobljenosti migrenama izuzev izostanka iz škole/posla. Povezanost je utvrđena samo za parametar izostanaka s posla/škole zbog glavobolja u zadnja 3 mjeseca (dani) gdje pozitivne vrijednosti koeficijenta korelacije (ro) upućuju na zaključak da je veći broj izostanaka s posla/ škole u zadnja 3 mjeseca kod pacijenata s višim stupnjevima obrazovanja. Nakon provedene terapije utvrđena je statistički značajna razlika samo u parametrima smanjenja produktivnosti na poslu/u školi zbog glavobolja u zadnja 3 mjeseca (dani) (p=0,001). Zaključak: Testiranjem utjecaja terapije neurofeedbackom na onesposobljenost migrenama utvrđen je statistički značajan pad HIT6 rezultata, kao i pad vrijednosti svih parametara utjecaja migrena na život - MIDAS rezultati.Objective: The aim of the study was to objectify therapeutic effect of neurofeedback and to treat migraine headaches in patients with migraine. Methods: We used anonymous questionnaire, structured and modified for the purpose of this study. In the end, we used two standardized tests, i.e. the test for assessment of disability in patients with migraine (MIDAS, Migraine Disability Assessment Test) and the questionnaire testing the impact of headache (HIT6, Headache Impact Test), used to measure the impact of headaches on the ability to perform tasks at work/school and in social situations. Results: Concerning the average number of headaches per month, the majority of patients (n=11) had headache 5-6 times, usually lasting for 4 to 24 hours, as reported by 16 subjects. The average headache intensity was reported as severe pain by 10 patients and strong pain by 15 patients. Age was not a statistically significant factor for disabling migraines except for school/work absenteeism. The connection was only established for work/school absenteeism due to headaches in the last three months (days), where positive values of the correlation coefficient (ro) suggested that greater work/school absenteeism in the last three months was recorded in patients with a higher level of education. After the treatment, a statistically significant difference was only found in the reduction of work/school productivity because of headaches in the last three months (days) (p=0.001). Testing the impact of neurofeedback therapy on disability due to migraine revealed a statistically significant decrease in HIT6 results, as well as in the value of all segments of the migraine impact on life, i.e. MIDAS results

NEUROFEEDBACK IN TREATING MIGRAINE HEADACHE – A PILOT STUDY

Cilj: Cilj ovog istraživanja bio je objektivizirati terapijski učinak neurofeedbacka na liječenje migrenske glavobolje u bolesnika s migrenskom glavoboljom. Metode: Kao instrument istraživanja koristio se anonimni anketni upitnik, strukturiran i modificiran za potrebe ovog istraživanja. Na kraju su uporabljena dva standardizirana testa: test za procjenu onesposobljenosti bolesnika s migrenom (MIDAS - Migraine Disability Assessment Test), te upinik o ispitivanju utjecaja glavobolje (HIT6: Headache Impact Test) koji se koristi za mjerenje utjecaja glavobolje na sposobnost obavljanja zadataka na radnom mjestu/ u školi i u socijalnim situacijama. Rezultati: Prosječan broj glavobolja tijekom jednog mjeseca kod većine ispitanika je 11 (5 do 6 puta), uz najčešće trajanje od 4 do 24 sata, kako navodi 16 ispitanika. Prosječni je intenzitet glavobolje za 10 ispitanika srednje jaka bol, a za 15 ispitanika jaka bol. Dob nije statistički značajan faktor onesposobljenosti migrenama izuzev izostanka iz škole/posla. Povezanost je utvrđena samo za parametar izostanaka s posla/škole zbog glavobolja u zadnja 3 mjeseca (dani) gdje pozitivne vrijednosti koeficijenta korelacije (ro) upućuju na zaključak da je veći broj izostanaka s posla/ škole u zadnja 3 mjeseca kod pacijenata s višim stupnjevima obrazovanja. Nakon provedene terapije utvrđena je statistički značajna razlika samo u parametrima smanjenja produktivnosti na poslu/u školi zbog glavobolja u zadnja 3 mjeseca (dani) (p=0,001). Zaključak: Testiranjem utjecaja terapije neurofeedbackom na onesposobljenost migrenama utvrđen je statistički značajan pad HIT6 rezultata, kao i pad vrijednosti svih parametara utjecaja migrena na život - MIDAS rezultati.Objective: The aim of the study was to objectify therapeutic effect of neurofeedback and to treat migraine headaches in patients with migraine. Methods: We used anonymous questionnaire, structured and modified for the purpose of this study. In the end, we used two standardized tests, i.e. the test for assessment of disability in patients with migraine (MIDAS, Migraine Disability Assessment Test) and the questionnaire testing the impact of headache (HIT6, Headache Impact Test), used to measure the impact of headaches on the ability to perform tasks at work/school and in social situations. Results: Concerning the average number of headaches per month, the majority of patients (n=11) had headache 5-6 times, usually lasting for 4 to 24 hours, as reported by 16 subjects. The average headache intensity was reported as severe pain by 10 patients and strong pain by 15 patients. Age was not a statistically significant factor for disabling migraines except for school/work absenteeism. The connection was only established for work/school absenteeism due to headaches in the last three months (days), where positive values of the correlation coefficient (ro) suggested that greater work/school absenteeism in the last three months was recorded in patients with a higher level of education. After the treatment, a statistically significant difference was only found in the reduction of work/school productivity because of headaches in the last three months (days) (p=0.001). Testing the impact of neurofeedback therapy on disability due to migraine revealed a statistically significant decrease in HIT6 results, as well as in the value of all segments of the migraine impact on life, i.e. MIDAS results

SARS-CoV-2 Infection Causes Relapse of Kleine-Levin Syndrome: Case Report and Review of Literature

Recurrent episodes of hypersomnia, hypersexuality, compulsive eating, behavioral and cognitive disturbances, are the basic clinical features of Kleine-Levin syndrome (KLS). Our case report describes a patient who was diagnosed with KLS at the age of 20. With appropriate therapy, the disease had a satisfactory course until patient had a moderate form of SARS-CoV-2 infection, which led to a significant exacerbation of all symptoms. SARS-CoV-2 virus can cause almost any neurological disease, and relapse of KLS is another evidence of neurotropicity of the virus

Assessment of cerebral vasoreactivity by transcranial color Doppler and breath retention test in patients after SARS-COV-2 virus infection

Uvod: Od početka pandemije virusa SARS-CoV-2 bilo je jasno da je virus izrazito neurotropan. Neurološke manifestacije mogu se kretati od nespecifičnih simptoma kao što su vrtoglavica, glavobolja i smetnje mirisa do teških oblika neurološke disfunkcije. Neke neurološke komplikacije mogu se javiti čak i nakon blagih oblika respiratornih bolesti. Cilj ove studije bio je procijeniti cerebrovaskularnu reaktivnost u bolesnika s nespecifičnim neurološkim simptomima nakon SARS-CoV-2 infekcije. Metode: Za 25 bolesnika (mušarci N=16, žene N=9), u dobi od 33 do 62 godine, koji su imali nespecifične neurološke simptome 36 dana nakon preboljele blage infekcije SARSCoV-2 virusom i 180 dana nakon početka SARS-COV-2 infekcije, kao i 25 zdravih ispitanika u kontrolnoj skupini, ispitivali smo vazoreaktivnost moždanih krvnih žila pomoću transkranijskog doplera kodiranog bojom i testom zadržavanja daha. Mjerili smo vršnu sistoličku brzinu (PSV, eng. Peak Systolic Velocity), krajnju dijastoličku brzinu (EDV, eng. End-Diastolic Velocity ) i srednju brzinu (MV, eng.Mean flow Velocity), indeks otpora (RI, eng.Resistance Index) i indeks pulsatilnosti (PI, eng.Pulsatility Index) srednje moždane arterije (MCA, eng. Middle Cerebral Artery). Rezultati: 36 dana nakon početka SARS-CoV-2 infekcije pronađene su statistički značajno niže brzine protoka kroz srednju moždanu arteriju u mirovanju [razlika aritmetičkih sredina iznosi za PSV 12,5 (T=4,5, p<0.001), za EDV 4,6 (T=3,2, p=0.002), za MV 9,2 (T=4,4, p<0,001), za RI 0,03 (T=3,1, p=0,003)], niže maksimalne brzine na kraju razdoblja zadržavanja daha (2,4 puta za PSV, za EDV 1,4 puta niže i 1,2 puta niže za MV) i niži indeks zadržavanja daha (BHI) (0,554 vs. p<0,001)) u odnosu na kontrolnu skupinu zdravih ispitanika. Nakon 180 dana od početka SARS-CoV-2 infekcije nema značajnih promjena ispitivanih parametara za PSV (t=1,1, p=0,065), EDV (t=0,21; p=0,837), MV(t=1,6; p=0,118), PI(t=1,1; p=0,286) nakon testa zadržavanja daha ni u fazi mirovanja za PSV (t=1,5; p=0,156), RI (t =1,9; p=0,07), i MV (t=1,4, p=0,066) dok su vrijednosti EDV (t=4,9; p<0,001) i PI (t=2,4; p=0,028) bile više. Zaključci: Smanjenje brzina protoka kroz srednju moždanu arteriju ukazuju na oslabljenu moždanu vazoreaktivnost u skupini ispitanika nakon infekcije SARS-CoV-2 virusom s obzirom na kontrolnu skupinu i sugeriraju oštećenje vaskularnog endotela virusom SARS-CoV-2. Nakon 180 dana od početka infekcije nije došlo do oporavka moždane vazoreaktivnosti kod ispitanika nakon SARS-CoV-2 infekcije.Background: From the beginning of the SARS-CoV-2 virus pandemic, it was clear that the virus was highly neurotropic. Neurological manifestations can range from non-specific symptoms such as dizziness, headache and odor disturbances to severe forms of neurological dysfunction. Some neurological complications can occur even after mild forms of respiratory diseases. The aim of this study was to assess cerebrovascular reactivity in patients with nonspecific neurological symptoms after SARS-CoV-2 infection. Methods: For 25 patients (men N=16, women N=9), aged 33 to 62 years, who had nonspecific neurological symptoms 36 days after mild SARS-CoV-2 virus infection and 180 days after the onset of SARS-COV-2 infections, as well as 25 healthy subjects in the control group, we examined cerebrovascular vasoreactivity using color-coded transcranial Doppler and breath retention test. We measured peak systolic velocity (PSV), end-diastolic velocity (EDV) and mean velocity (MV), resistance index (RI). ) and the Pulsatility Index (PI) of the Middle Cerebral Artery (MCA). Results: 36 days after the onset of SARS-CoV-2 infection, statistically significantly lower resting cerebral artery flow rates were found [the difference in arithmetic means is for PSV 12.5 (T=4,5, p<0,001), for EDV 4,6 (T=3.2, p=0.002), for MV 9,2 (T=4.4, p <0,001), for RI 0,03 (T=3,1, p=0.003)], lower maximum velocities at the end of the breath holding period (2,4 times) for PSV, for EDV 1,4 times lower and 1,2 times lower for MV) and lower breath retention index (BHI) (0,554 vs. p <0,001)) compared to the control group of healthy subjects 180 days after the onset of SARS -CoV-2 infection there are no significant changes in the examined parameters for PSV (t=1.1, p=0,065), EDV (t=0.21; p=0,837), MV (t=1,6; p=0,118), PI (t=1,1; p=0,286) after the breath hold test and in rest period for PSV (t=1,5; p=0,156), RI (t=1,9; p=0,07), and MV (t=1,4, p=0,066) while the values of EDV (t=4,9; p<0,001) and PI (t =2,4; p=0,028) during rest period were higher. Conclusions: Decreased flow rates through the middle cerebral artery indicate poor cerebral vasoreactivity in the group of subjects after SARS-CoV-2 virus infection relative to the control group and suggest vascular endothelial damage by the SARS-CoV-2 virus. After 180 days from the onset of infection, there was no recovery of cerebral vasoreactivity in subjects after SARS-CoV-2 infection

A Case of Kleine-Levin Syndrome: Diagnostic and Therapeutic Challenge

Kleine-Levin syndrome (KLS) is a rare sleep disorder mainly affecting teenage boys in which the main features are intermittent hypersomnolence, behavioral and cognitive disturbances, hyperphagia, and in some cases hyper sexuality. Etiology is unknown, and there is no specific clinical or imaging test for this syndrome even though the illness has well-defined clinical features. Also, there is no effective treatment for KLS. KLS is self-limited, so the prognosis for these patients is not so bad. This study presents our case report and comprehensive workout that led to diagnosis which is primarily clinical. Our patient is a 20-year-old man referred to our clinic because of sleeping problems. At the age of 14, he presented with complaints of the excessive duration of sleep, increased appetite, excessive daytime sleepiness, loss of interest in social activities during attendance of high school and hallucinations. The excessive diagnostic procedure does not find pathological. Kleine-Levin syndrome (KLS) is a rare sleep disorder of unknown etiology which diagnosis is clinical and diagnostic workup is mainly to exclude other similar conditions. There is no specific therapy, but the disease is self-limited and with good prognosis

Assessment of cerebral vasoreactivity by transcranial color Doppler and breath retention test in patients after SARS-COV-2 virus infection

Uvod: Od početka pandemije virusa SARS-CoV-2 bilo je jasno da je virus izrazito neurotropan. Neurološke manifestacije mogu se kretati od nespecifičnih simptoma kao što su vrtoglavica, glavobolja i smetnje mirisa do teških oblika neurološke disfunkcije. Neke neurološke komplikacije mogu se javiti čak i nakon blagih oblika respiratornih bolesti. Cilj ove studije bio je procijeniti cerebrovaskularnu reaktivnost u bolesnika s nespecifičnim neurološkim simptomima nakon SARS-CoV-2 infekcije. Metode: Za 25 bolesnika (mušarci N=16, žene N=9), u dobi od 33 do 62 godine, koji su imali nespecifične neurološke simptome 36 dana nakon preboljele blage infekcije SARSCoV-2 virusom i 180 dana nakon početka SARS-COV-2 infekcije, kao i 25 zdravih ispitanika u kontrolnoj skupini, ispitivali smo vazoreaktivnost moždanih krvnih žila pomoću transkranijskog doplera kodiranog bojom i testom zadržavanja daha. Mjerili smo vršnu sistoličku brzinu (PSV, eng. Peak Systolic Velocity), krajnju dijastoličku brzinu (EDV, eng. End-Diastolic Velocity ) i srednju brzinu (MV, eng.Mean flow Velocity), indeks otpora (RI, eng.Resistance Index) i indeks pulsatilnosti (PI, eng.Pulsatility Index) srednje moždane arterije (MCA, eng. Middle Cerebral Artery). Rezultati: 36 dana nakon početka SARS-CoV-2 infekcije pronađene su statistički značajno niže brzine protoka kroz srednju moždanu arteriju u mirovanju [razlika aritmetičkih sredina iznosi za PSV 12,5 (T=4,5, p<0.001), za EDV 4,6 (T=3,2, p=0.002), za MV 9,2 (T=4,4, p<0,001), za RI 0,03 (T=3,1, p=0,003)], niže maksimalne brzine na kraju razdoblja zadržavanja daha (2,4 puta za PSV, za EDV 1,4 puta niže i 1,2 puta niže za MV) i niži indeks zadržavanja daha (BHI) (0,554 vs. p<0,001)) u odnosu na kontrolnu skupinu zdravih ispitanika. Nakon 180 dana od početka SARS-CoV-2 infekcije nema značajnih promjena ispitivanih parametara za PSV (t=1,1, p=0,065), EDV (t=0,21; p=0,837), MV(t=1,6; p=0,118), PI(t=1,1; p=0,286) nakon testa zadržavanja daha ni u fazi mirovanja za PSV (t=1,5; p=0,156), RI (t =1,9; p=0,07), i MV (t=1,4, p=0,066) dok su vrijednosti EDV (t=4,9; p<0,001) i PI (t=2,4; p=0,028) bile više. Zaključci: Smanjenje brzina protoka kroz srednju moždanu arteriju ukazuju na oslabljenu moždanu vazoreaktivnost u skupini ispitanika nakon infekcije SARS-CoV-2 virusom s obzirom na kontrolnu skupinu i sugeriraju oštećenje vaskularnog endotela virusom SARS-CoV-2. Nakon 180 dana od početka infekcije nije došlo do oporavka moždane vazoreaktivnosti kod ispitanika nakon SARS-CoV-2 infekcije.Background: From the beginning of the SARS-CoV-2 virus pandemic, it was clear that the virus was highly neurotropic. Neurological manifestations can range from non-specific symptoms such as dizziness, headache and odor disturbances to severe forms of neurological dysfunction. Some neurological complications can occur even after mild forms of respiratory diseases. The aim of this study was to assess cerebrovascular reactivity in patients with nonspecific neurological symptoms after SARS-CoV-2 infection. Methods: For 25 patients (men N=16, women N=9), aged 33 to 62 years, who had nonspecific neurological symptoms 36 days after mild SARS-CoV-2 virus infection and 180 days after the onset of SARS-COV-2 infections, as well as 25 healthy subjects in the control group, we examined cerebrovascular vasoreactivity using color-coded transcranial Doppler and breath retention test. We measured peak systolic velocity (PSV), end-diastolic velocity (EDV) and mean velocity (MV), resistance index (RI). ) and the Pulsatility Index (PI) of the Middle Cerebral Artery (MCA). Results: 36 days after the onset of SARS-CoV-2 infection, statistically significantly lower resting cerebral artery flow rates were found [the difference in arithmetic means is for PSV 12.5 (T=4,5, p<0,001), for EDV 4,6 (T=3.2, p=0.002), for MV 9,2 (T=4.4, p <0,001), for RI 0,03 (T=3,1, p=0.003)], lower maximum velocities at the end of the breath holding period (2,4 times) for PSV, for EDV 1,4 times lower and 1,2 times lower for MV) and lower breath retention index (BHI) (0,554 vs. p <0,001)) compared to the control group of healthy subjects 180 days after the onset of SARS -CoV-2 infection there are no significant changes in the examined parameters for PSV (t=1.1, p=0,065), EDV (t=0.21; p=0,837), MV (t=1,6; p=0,118), PI (t=1,1; p=0,286) after the breath hold test and in rest period for PSV (t=1,5; p=0,156), RI (t=1,9; p=0,07), and MV (t=1,4, p=0,066) while the values of EDV (t=4,9; p<0,001) and PI (t =2,4; p=0,028) during rest period were higher. Conclusions: Decreased flow rates through the middle cerebral artery indicate poor cerebral vasoreactivity in the group of subjects after SARS-CoV-2 virus infection relative to the control group and suggest vascular endothelial damage by the SARS-CoV-2 virus. After 180 days from the onset of infection, there was no recovery of cerebral vasoreactivity in subjects after SARS-CoV-2 infection

Assessment of cerebral vasoreactivity by transcranial color Doppler and breath retention test in patients after SARS-COV-2 virus infection

Uvod: Od početka pandemije virusa SARS-CoV-2 bilo je jasno da je virus izrazito neurotropan. Neurološke manifestacije mogu se kretati od nespecifičnih simptoma kao što su vrtoglavica, glavobolja i smetnje mirisa do teških oblika neurološke disfunkcije. Neke neurološke komplikacije mogu se javiti čak i nakon blagih oblika respiratornih bolesti. Cilj ove studije bio je procijeniti cerebrovaskularnu reaktivnost u bolesnika s nespecifičnim neurološkim simptomima nakon SARS-CoV-2 infekcije. Metode: Za 25 bolesnika (mušarci N=16, žene N=9), u dobi od 33 do 62 godine, koji su imali nespecifične neurološke simptome 36 dana nakon preboljele blage infekcije SARSCoV-2 virusom i 180 dana nakon početka SARS-COV-2 infekcije, kao i 25 zdravih ispitanika u kontrolnoj skupini, ispitivali smo vazoreaktivnost moždanih krvnih žila pomoću transkranijskog doplera kodiranog bojom i testom zadržavanja daha. Mjerili smo vršnu sistoličku brzinu (PSV, eng. Peak Systolic Velocity), krajnju dijastoličku brzinu (EDV, eng. End-Diastolic Velocity ) i srednju brzinu (MV, eng.Mean flow Velocity), indeks otpora (RI, eng.Resistance Index) i indeks pulsatilnosti (PI, eng.Pulsatility Index) srednje moždane arterije (MCA, eng. Middle Cerebral Artery). Rezultati: 36 dana nakon početka SARS-CoV-2 infekcije pronađene su statistički značajno niže brzine protoka kroz srednju moždanu arteriju u mirovanju [razlika aritmetičkih sredina iznosi za PSV 12,5 (T=4,5, p<0.001), za EDV 4,6 (T=3,2, p=0.002), za MV 9,2 (T=4,4, p<0,001), za RI 0,03 (T=3,1, p=0,003)], niže maksimalne brzine na kraju razdoblja zadržavanja daha (2,4 puta za PSV, za EDV 1,4 puta niže i 1,2 puta niže za MV) i niži indeks zadržavanja daha (BHI) (0,554 vs. p<0,001)) u odnosu na kontrolnu skupinu zdravih ispitanika. Nakon 180 dana od početka SARS-CoV-2 infekcije nema značajnih promjena ispitivanih parametara za PSV (t=1,1, p=0,065), EDV (t=0,21; p=0,837), MV(t=1,6; p=0,118), PI(t=1,1; p=0,286) nakon testa zadržavanja daha ni u fazi mirovanja za PSV (t=1,5; p=0,156), RI (t =1,9; p=0,07), i MV (t=1,4, p=0,066) dok su vrijednosti EDV (t=4,9; p<0,001) i PI (t=2,4; p=0,028) bile više. Zaključci: Smanjenje brzina protoka kroz srednju moždanu arteriju ukazuju na oslabljenu moždanu vazoreaktivnost u skupini ispitanika nakon infekcije SARS-CoV-2 virusom s obzirom na kontrolnu skupinu i sugeriraju oštećenje vaskularnog endotela virusom SARS-CoV-2. Nakon 180 dana od početka infekcije nije došlo do oporavka moždane vazoreaktivnosti kod ispitanika nakon SARS-CoV-2 infekcije.Background: From the beginning of the SARS-CoV-2 virus pandemic, it was clear that the virus was highly neurotropic. Neurological manifestations can range from non-specific symptoms such as dizziness, headache and odor disturbances to severe forms of neurological dysfunction. Some neurological complications can occur even after mild forms of respiratory diseases. The aim of this study was to assess cerebrovascular reactivity in patients with nonspecific neurological symptoms after SARS-CoV-2 infection. Methods: For 25 patients (men N=16, women N=9), aged 33 to 62 years, who had nonspecific neurological symptoms 36 days after mild SARS-CoV-2 virus infection and 180 days after the onset of SARS-COV-2 infections, as well as 25 healthy subjects in the control group, we examined cerebrovascular vasoreactivity using color-coded transcranial Doppler and breath retention test. We measured peak systolic velocity (PSV), end-diastolic velocity (EDV) and mean velocity (MV), resistance index (RI). ) and the Pulsatility Index (PI) of the Middle Cerebral Artery (MCA). Results: 36 days after the onset of SARS-CoV-2 infection, statistically significantly lower resting cerebral artery flow rates were found [the difference in arithmetic means is for PSV 12.5 (T=4,5, p<0,001), for EDV 4,6 (T=3.2, p=0.002), for MV 9,2 (T=4.4, p <0,001), for RI 0,03 (T=3,1, p=0.003)], lower maximum velocities at the end of the breath holding period (2,4 times) for PSV, for EDV 1,4 times lower and 1,2 times lower for MV) and lower breath retention index (BHI) (0,554 vs. p <0,001)) compared to the control group of healthy subjects 180 days after the onset of SARS -CoV-2 infection there are no significant changes in the examined parameters for PSV (t=1.1, p=0,065), EDV (t=0.21; p=0,837), MV (t=1,6; p=0,118), PI (t=1,1; p=0,286) after the breath hold test and in rest period for PSV (t=1,5; p=0,156), RI (t=1,9; p=0,07), and MV (t=1,4, p=0,066) while the values of EDV (t=4,9; p<0,001) and PI (t =2,4; p=0,028) during rest period were higher. Conclusions: Decreased flow rates through the middle cerebral artery indicate poor cerebral vasoreactivity in the group of subjects after SARS-CoV-2 virus infection relative to the control group and suggest vascular endothelial damage by the SARS-CoV-2 virus. After 180 days from the onset of infection, there was no recovery of cerebral vasoreactivity in subjects after SARS-CoV-2 infection

Warfarin-Induced Skin Necrosis in Patients With Low Protein C Levels

Warfarin-induced skin necrosis (WISN) is a rare complication of anticoagulant therapy associated with a high incidence of  morbidity and mortality requiring immediate drug cessation. At particular risk are those with various thrombophilic abnormalities, especially when warfarinisation is undertaken rapidly with large loading doses of warfarin. Cutaneous findings include petechiae that progress to ecchymosis and hemorrhagic bullae. With the increasing number of patients anticoagulated as out-patients for thromboprophylaxis, we are concerned that the incidence of skin necrosis may increase. We present a case of WISN with low protein C level. He was a 50-year-old male who came to our department because of acute infarction in irrigation area of the superior cerebellar artery. He had intermittent atrial fibrillation and was started on anticoagulant therapy.  After few day of therapy, he developed skin necrosis, and his level of protein C was low. Warfarin-induced skin necrosis is a rare but serious complication that can be prevented by routine screening for protein C, protein S or antithrombin deficiencies or for the presence of antiphospholipid antibodies before beginning warfarin therapy

Internal Watershed Infarction as an Imaging and Clinical Challenge: a Case Report

We presented the case of a patient with internal watershed infarction with a nonspecific clinical presentation including hemiplegia, hemisensory deficit, and speech disturbance. Neuroimaging and ultrasound diagnostic procedure are important tools for diagnosis of these rare ischemic events that count for about 6% of all strokes.  Specific therapy is mandatory for the diagnosis of watershed infarction and different from the therapeutical measures than can be taken for embolic and atherothrombotic strokes. Our patient was a 69-year-old, right-handed Caucasian woman who presented to our facility with acute right side weakness and speech disturbance. He had hypothyroidism, permanent atrial fibrillation, diabetes mellitus and she was hypotensive. She reported dizziness few days before the accident. Imaging studies revealed internal watershed infarction. Therapeutic procedures were taken to restore low cerebral blood flow. Internal watershed infarction is rare (less than 10% of all strokes) but well recognized a clinical feature of stroke. Specific pathophysiology generally is connected with hypoperfusion and hemodynamic mechanisms. Specific therapy is mandatory for these conditions