Metaboličke encefalopatije

Metabolic encephalopathies may be important complications of many diseases in patients treated at intensive care units. The term metabolic encephalopathies encompass a large variety of different conditions of the brain. Neurologic signs of metabolic encephalopathies, ancillary tests, differential diagnosis, etiology, pathophysiology and treatment are discussed in this review. Metabolic encephalopathies are usually multifactorial in origin and play an important role not only as diseases per se but also for monitoring the severity of decompensating organ functions during deteriorating primary diseases.Metaboličke encefalopatije su značajne komplikacije koje se javljaju u mnogih bolesnika liječenih u jedinicama intenzivnog liječenja. Termin "metaboličke encefalopatije" odnosi se na širok spektar poremećaja funkcije mozga za vrijeme teške, kritične bolesti. U ovom članku prikazani su neurološki simptomi, mogućnosti dijagnostičkih metoda, kao i etiologija, patofiziologija te terapija metaboličkih encefalopatija. Metaboličke encefalopatije su u svojoj osnovi multifaktorijalne, a prepoznavanje njihovih simptoma ima važnu ulogu u ranom otkrivanju zatajivanja organskih sustava za vrijeme pogoršavanja osnovne bolesti

Jedinica za liječenje moždanog udara - mjesto gdje bi se trebali liječiti svi bolesnici s moždanim udarom

Acute stroke is one of the leading causes of morbidity and mortality worldwide, and as the most important cause of morbidity and long-term disability imposes an enormous economic burden. Stroke units (SU) are an effective option to fight stroke. According to the European Stroke Organization, SU should provide coordinated multidisciplinary care provided by medical personnel specialized in stroke care. Helsingborg declaration from 1995 urged for organized management of acute stroke in order to reduce mortality below 200!o (SU for all stroke patients) and to achieve independency in more than 70% of 3-month stroke survivors. At the beginning of 2001, the first Croatian SU was established at Sestre milosrdnice University Hospital in Zagreb as a hospital ward with dedicated multidisciplinary stroke team consisting of neurologists specialized in the management of cerebrovascular disease, trained nurses and rehabilitation personnel, together with other professionals to enable treatment of stroke patients according to current guidelines.Moždani udar je jedan od glavnih uzroka pobola i smrtnosti u razvijenom svijetu, ali i vodeći uzrok invaliditeta. Jedinice za liječenje moždanog udara (JLMU) su dokazano učinkovit način u liječenju moždanog udara i to snižavanjem smrtnosti i zaostalog invaliditeta. Prema European Stroke Organization, JLMU bi trebale pružiti koordiniranu i multidisciplinarnu skrb s timom specijaliziranim za liječenje moždanog udara. Deklaracija iz Helsingborga 1995. godine pozvala je na organiziran pristup liječenju akutnog moždanog udara JLMU za sve bolesnike s akutnim moždanim udarom) radi snižavanja smrtnosti ispod 20% i postizanja neovisnosti kod vise od 70% bolesnika preživjelih 3 mjeseca nakon moždanog udara. Godine 2001. u okviru Klinike za neurologiju KB "Sestre milosrdnice" u Zagrebu osnovana je prva hrvatska JLMU s multidisciplinarnim timom koji se sastoji od neurologa specijaliziranih u liječenju cerebrovaskularne bolesti, primjereno obrazovanih medicinskih sestara i fizioterapeuta zajedno s drugim stručnjacima, što omogućava liječenje bolesnika s moždanim udarom prema današnjim smjernicama

The role of classic risk factors and prothrombotic factor gene mutations in ischemic stroke risk development in young and middle-aged individuals

BACKGROUND: In young individuals, a genetically predisposing hypercoagulability and classic modifying risk factors can act synergistically on the ischemic stroke risk development. The aim of the study was to compare the prevalence of classic vascular risk factors and polymorphisms of the G20210A coagulation factor II (prothrombin), Arg506Glu coagulation factor V Leiden, C677T methylenetetrahydrofolate reductase (MTHFR), and 4G/5G plasminogen activator inhibitor-1 (PAI-1) and the impact of these gene mutations and classic vascular risk factors on the overall stroke risk in individuals aged 55 years or younger. ----- METHODS: The study included 155 stroke patients aged 55 years or younger and 150 control subjects. Stroke prevalence and odds ratio (OR) were assessed for the following parameters: G20210A prothrombin, Arg506Glu factor V Leiden, C677T MTHFR, and 4G/5G PAI-1 polymorphisms; total number of study polymorphisms in a particular subject (genetic sum); and classic vascular risk factors of hypertension, obesity, diabetes mellitus, cigarette smoking, hypercholesterolemia, hypertriglyceridemia, and elevated levels of low-density lipoprotein (LDL) cholesterol and very low-density lipoprotein cholesterol. ----- RESULTS: The prevalence of hypertension (P < .001), smoking (P < .001), decreased HDL cholesterol levels (P < .001), obesity (P = .001), elevated LDL cholesterol (P = .036), C677T MTHFR polymorphism (P < .001), and genetic sum was significantly higher in the group of stroke patients. The following parameters were found to act as independent risk factors for ischemic stroke: decreased HDL cholesterol level (P < .001; OR 4.618; 95% confidence interval [CI] 2.381-8.957); hypertension (P = .001; OR 2.839; 95% CI 1.519-5.305); obesity (P = .040; OR 2.148; 95% CI 1.036-4.457); smoking (P = .001; OR 2.502; 95% CI 1.436-4.359); and genetic sum as a continuous variable (P < .01; OR 2.307; 95% CI 1.638-3.250). ----- CONCLUSIONS: Gene mutations of the procoagulable and proatherosclerotic factors investigated exerted a synergistic action in the development of overall risk of ischemic stroke in young and middle-aged individuals

Sindrom akutnog poliradikuloneuritisa: klinička zapažanja i diferencijalna dijagnoza

Guillain-Barré syndrome (GBS) and neuroborreliosis may clinically manifest with symptoms related to acute polyradiculoneuritis. The aim and purpose of this study was analysis of clinical picture in patients with acute polyradiculoneuritis and their differential diagnosis into patients with GBS or meningoradiculoneuritis within the framework of neuroborreliosis. In this retrospective study, medical records of patients with acute polyradiculoneuritis hospitalized at University Department of Neurology, Sestre milosrdnice University Hospital Center during a 4-year period were analyzed. The study included data on 27 patients. Definitive diagnosis of GBS was made in 23 patients and of neuroborreliosis in four (14.8%) patients. Acute inflammatory demyelinating polyneuropathy was recorded in 69% of GBS patients, Miller Fisher syndrome in four patients, and acute motor axonal neuropathy and/or acute motor and sensory axonal neuropathy in three patients. Clinically, patients with neuroborreliosis manifested flaccid tetraparesis, peripheral facial nerve paresis, bulbar paresis, ocular motility disorders, and sensory symptoms of radicular pain and paresthesias. Considering the relatively high prevalence of neuroborreliosis in north-west Croatia, it is important to exclude meningoradiculoneuritis caused by Borrelia burgdorferi on differential diagnosis of GBS in these patients.Guillain-Barréov sindrom (GBS) i neuroborelioza mogu se klinički manifestirati simptomima iz okvira akutnog poliradikuloneuritisa. Cilj i svrha istraživanja bila je analiza kliničke slike bolesnika s akutnim poliradikuloneuritisom kao i njihova diferencijalna dijagnoza u bolesnike s GBS-om ili meningoradikuloneuritisom u okviru neuroborelioze. Provedeno je retrospektivno istraživanje pretraživanjem i analizom baze medicinske dokumentacije bolesnika s akutnim poliradikuloneuritisom hospitaliziranih na Klinici za neurologiju KBC “Sestre milosrdnice” u razdoblju od četiri godine. U istraživanje je bilo uključeno 27 bolesnika, definitivna dijagnoza GBS-a postavljena je u 23 bolesnika, dok je dijagnoza neuroborelioze postavljena u 4 (14,8%) bolesnika; 69% bolesnika s GBS-om imalo je akutnu upalnu demijelinizirajuću polineuropatiju, u 4 bolesnika ustanovljen je Miller-Fisherov sindrom, dok je u 3 bolesnika ustanovljena akutna motorna i/ ili senzomotorna aksonalna polineuropatija. Bolesnici s neuroboreliozom klinički su manifestirali flakcidnu teteraparezu, perifernu parezu ličnog živca, bulbarnu parezu, poremećaje bulbomotorike, a od osjetnih simptoma radikularne bolove i parestezije. S obzirom na relativno visoku učestalost neuroborelioze u bolesnika s područja sjeverozapadne Hrvatske, u diferencijalnoj dijagnozi GBS-a važno je isključiti meningoradikuloneuritis uzrokovan bakterijom Borrelia burgdorferi

Tromboliza kod akutnog ishemijskog moždanog udara - naša iskustva kao dio pristupa SITS-MOST

Thrombolysis with intravenous recombinant tissue plasminogen activator (rt-PA) is the first evidence based treatment for acute ischemic stroke, which aims to reduce the cerebrovascular lesion. At University Department of Neurology, Sestre milosrdnice University Hospital, Zagreb, thrombolytic therapy with intravenous rt-PA (alteplase) (Actrlyse®) for acute ischemic stroke was introduced in 2004. We present our results referring to demographic, time logistics and clinical outcome data as part of SITS-MOST (Safe Implementation of Thrombolysis in Stroke - MOnitoring STudy) and compare them with the results from other centers in Croatia and all other participating centers. Up to now, 56patients (61% of male and 39% of female, average age 67 years) have been treated at our department with intravenous rt-PA (0.9 mg/kg body weight, maximum 90 mg), with 10% of the dose given asabolus followed by 60-minute infusion. Our experiences with thrombolytic therapy with intravenous rt-PA (alteplase) (Aculyse®) for acute ischemic stroke confirm the safety and the efficacy of this therapy.Tromboliza intravenskim rekombiniranim aktivatorom tkivnog plazminogena (rt-PA) je prvi dokazani učinkoviti način liječenja akutnog ishemijskog moždanog udara u svrhu smanjenja cerebrovaskularnog oštećenja. U Klinici za neurologiju Kliničke bolnice "Sestre milosrdnice", Zagreb, trombolitička terapija intravenskim rt-PA-om (alteplase) (Actilyse®) u bolesnika s akutnim ishemijskim moždanim udarom započela je 2004. godine. Predstavljamo naše dosadašnje rezultate, koji se odnose na demografske, vremenske i podatke o kliničkom ishodu bolesnika, prikupljene u sklopu SITS-MOST (Safe Implementation of Thrombolysis in Stroke - MOnitoring STudy) istraživanja. u svrhu usporedbe rezultata dobivenih u našem centru s rezultatima iz drugih centara Hrvatske i svijeta. Do sada je u našem centru trombolizom intravenskim rt-PA-om (0,9 mg/kg tjelesne težine, do maksimalno 90 mg). 10% doze primijenjene u bolusu, 90% doze u infuziju u trajanju od 60 minuta, liječeno 56 bolesnika (61% muškarci, 39% žene, prosječne životne dobi 67 godina). Naša iskustva u trombolitičkoj terapiji (alteplase) (Acrdyse®) u bolesnika sa akutnim ishemijskim moždanim udarom potvrđuju učinkovitost i sigurnost takvog načina liječenja

NEUROLOGICAL MANIFESTATIONS OF POST-COVID-19 SYNDROME

Uvod: Krajem 2019. otkrivena je nova bolest nazvana COVID-19. Bolest je uzrokovana novim koronavirusom SARS-CoV-2. Ubrzo je Svjetska zdravstvena organizacija (SZO) proglasila pandemiju. Osim dišnih simptoma uočeno je da se bolest može očitovati i neurološkom simptomatologijom te da se tijekom i nakon liječenja COVID-19 mogu javiti neurološke komplikacije. Nakon preboljenja COVID-19, neovisno o težini kliničke slike, dio bolesnika žali se na zaostale neurološke simptome. U tim slučajevima govorimo o post-COVID-19 sindromu. Za simptome koji se javljaju tjednima ili mjesecima nakon COVID-19 simptoma u literaturi su korišteni različiti termini kao što su npr. od "dugi-COVID", "post–COVID sindrom", "posljedice SARSCoV-2 infekcije". Simptomi podrazumijevaju različita očitovanja organskih sustava koji se jave i/ili traju dulje od 4 tjedna. Cilj: Napraviti pregled trenutnih znanstvenih činjenica povezano sa sindromom post-COVID-19. Metode: Pretražili smo bazu podataka MEDLINE s ključnim riječima: post-COVID-19, neurološka očitovanja i dugi COVID-19 u vremenu od 2020. godine. Rezultati: Prema podatcima koje smo prikupili postoje četiri stadija COVID-19. Akutni COVID-19 podrazumijeva simptome i znakove bolesti koji traju do 4 tjedna. Produljeni simptomatski COVID-19 podrazumijeva simptome i znakove koji traju od 4 do12 tjedana. Post-COVID-19 sindrom podrazumijeva simptome i znakove koji se jave nakon akutne bolesti te traju dulje od 12 tjedana, a nisu objašnjeni drugom dijagnozom. Sindrom post-COVID-19 podrazumijeva znakove i simptome koji se pojavljuju tijekom ili nakon COVID-19 te traju dulje od 12 tjedana, a nisu objašnjeni drugom dijagnozom. Simptomi se mogu preklapati i varirati u intenzitetu. Dugi COVID podrazumijeva COVID-19 i sindrom post-COVID-19. Što se neuroloških post-COVID-19 očitovanja tiče, kod bolesnika su najčešće prisutni slabost i umor, mialgija, smetnje raspoloženja i smetnje spavanja. Također, u literaturi se navode i trajna glavobolja, smetnje koncentracije koje su nazvane moždanom maglom (od engl. brain fog), parestezije, poremećaj ili gubitak okusa, poremećaj ili gubitak mirisa te smetnje autonomnog živčanog sustava. Postoji nekoliko pretpostavljenih načina kojima virus dođe do središnjeg živčanog sustava: njušni, dišni i probavni. Središnji živčani sustav može biti oštećen izravno i neizravno. Moždana magla i smetnje pamćenja objašnjeni su središnjom i respiratornom hipoksijom te proupalnim odgovorom organizma. U slučaju sumnje na sindrom post-COVID-19 pri postavljanju dijagnoze uvijek treba uzeti u obzir i ostale moguće dijagnoze. U mnogim slučajevima potrebno je učiniti magnetsku rezonanciju (MR) mozga i vratne kralježnice. Ponekad je potrebno u dijagnosticiranje bolesti uključiti i ostale specijaliste. Zaključak: Sindrom post-COVID-19 može se očitovati nizom neuroloških poremećaja kao što su kognitivni simptomi, nesanica i promjene raspoloženja, disautonomija, smetnje mirisa i okusa, sindrom postintenzivne skrbi.Introduction: At the end of 2019, a new disease named COVID-19 was discovered. The disease is caused by the new coronavirus SARS-CoV-2. A global pandemic was soon declared by the World Health Organization (WHO). The disease mostly presents by respiratory simptoms. It can also be presented by neurological symptoms and neurological complications may occur during and after treatment of COVID-19. Regardless of COVID-19 symptoms, some patients complain of persistent symptoms. In such cases, we talk of so-called post-COVID-19 syndrome. Various terms have been used in the literature for the spectrum of symptoms that occur weeks or months after COVID-19 symptoms, such as "long-COVID", "post-COVID syndrome", "consequences of SARS-CoV-2 infection". Symptoms include various manifestations of organ systems that occur and/or last longer than 4 weeks. Aim: Our aim was to analyze scientifi c papers on the topic of post-COVID-19 syndrome. We also wanted to describe the proposed pathophysiological mechanisms of post-COVID-19 syndrome and highlight the possible diagnostic algorithm. Methods: We searched the MEDLINE database using the following key features:„postCOVID-19“, „neurological manifestations“ and „long-COVID-19“ back to the year 2020. Results: Accoding to our fi ndings, there are several stages of COVID-19. Acute COVID-19 includes acute disease that lasts for 4 weeks. Ongoing symptomatic COVID-19 includes symptoms that last for 4 to 12 weeks. Post-COVID-19 syndrome involves signs and symptoms that occur during or after COVID-19 infection, last for more than 12 weeks, and cannot be explained by another diagnosis. Symptoms can affect different organ systems and may overlap and fl uctuate in intensity. The term „long COVID-19“ describes ongoing symptomatic COVID-19 and post-COVID-19 syndrome. Neurological manifestations of post-COVID-19 syndrome include weakness and fatigue, myalgia, mood disorders, and sleep disturbances. Persistent headaches, impaired concentration ("brain fog"), paresthesias, dysgeusia, hyposmia and disorders of the autonomic nervous system have also been reported in the literature. There are several proposed routes for SARS-CoV-2 to reach the central nervosu system: olfactory, hematogenous and gastointestinal. The central nervous system can be damaged directly and indirectly. "Brain fog" and memory diffi culties are explained by central and respiratory hypoxia (especially), as well as proinfl ammatory body response. In case of post-COVID-19 neurolgical symptoms, there always have to be a diagnostic approach that considers and searches for alternative diagnosis in the patient context. Basic laboratory workup with possible later extension has to be done. Also, proper neuroimaging methods, mostly brain and/or spine magnetic resonance imaging, should be performed. In some cases, a multidisciplinary approach may be required. Conclusion: We have made a review of neurological postCOVID-19 symptoms and their pathophysiological mechanism with the initial care proposed. We would also like to note that there still are numerous data on the topic that will certainly be revealed with time

Sporadični oblik Creutzfeldt-Jakobove bolesti u bolesnice s ispadima nekonvulzivnog epileptičnog statusa: prikaz slučaja

Creutzfeldt-Jakob disease is the most common form of human prion diseases. A 57-year-old woman was transferred to our Department from a local hospital, where she had been treated for two weeks due to consciousness disorders and convulsive epileptic attacks that progressed to refractory status epilepticus. Electroencephalography showed diffuse spike-wave complex discharges and development of nonconvulsive status epilepticus. The causes of metabolic encephalopathy and paraneoplastic syndrome were ruled out. A combination of clinical features and findings of diagnostic procedures including electroencephalography, biomarkers in the cerebrospinal fluid and magnetic resonance imaging suggested with great probability that the patient was affected with sporadic Creutzfeldt-Jakob disease.Creutzfeldt-Jakobova bolest je najčešći oblik prionske bolesti u ljudi. Prikazuje se slučaj bolesnice koja je prevezena u našu Kliniku iz manje bolnice, gdje je bila liječena dva tjedna zbog poremećaja stanja svijesti i konvulzivnih epileptičnih napadaja koji su progredirali do epileptičnog statusa koji je bio refraktoran na primijenjenu terapiju. Elektroencefalografija je prikazala difuzna izbijanja kompleksa šiljak-val i razvoj nekonvulzivnog epileptičnog statusa. Koristeći kombinaciju kliničkih značajka i nalaza dijagnostičkih pretraga uključujući elektroencefalografiju, biomarkere u cerebrospinalnoj tekućini i nalaze magnetske rezonance zaključeno je s velikom vjerojatnošću da se radi o sporadičnom obliku Creutzfeldt-Jakobove bolesti