The Impact of Revascularization in a Patient with Atypical Manifestations of Hypoperfusion

Publisher Copyright: © 2022 by the authors.Background and Objectives: Carotid revascularization is one of the most effective treatment options in patients with severe carotid artery stenosis causing hypoperfusion in basal ganglia. Atypical manifestations include hyperkinetic movements, noted as extremely rare. We report a case about a patient with 2-months-long complaints of Uncontrollable movements in his right side of the body subsided after carotid revascularization. Case presentation: A 71-year-old male was admitted to Pauls Stradins Clinical University Hospital with the main complaints of 2-months-long uncontrollable movements in his right hand and his right leg. When performing coordination tasks, slight inaccuracy was noted with the right-side extremities. Hyperkinetic movements—choreoathetosis in the right side of the patient’s face, arm, and leg—were seen. Computed tomography angiography revealed subocclusion in the proximal segment of the left internal carotid artery and 30% stenosis in the proximal segment of the right internal carotid artery. The patient was consulted by a vascular surgeon. Eversion endarterectomy of the left internal carotid artery was performed. The early postoperative period occurred without complications. The patient was discharged from the hospital 2 days after the surgery in good overall health condition. Two months later, choreoathetotic movements in his right side of the body had markedly decreased. No focal neurologic deficits were noted. Conclusions: Revascularization may be effective by eliminating emboli and stenosis, leading to hypoperfusion in watershed territories. A case of a 71-year-old male patient with the main complaints of 2-months-long uncontrollable movements in his right side of the body subsiding after carotid revascularization was demonstrated. It is vital to recognize atypical manifestations of hypoperfusion, associated with stenosis in internal carotid arteries, to early make a diagnosis, to perform an appropriate treatment, and to reduce the risk of cerebral infarction in the future, resulting in a longer high-quality life for the patient.publishersversionPeer reviewe

Carotid Artery Stenosis Correlation with Hyperhomocysteinemia in Stroke Patient Group: a Prospective Study

Introduction. Stroke is the second most common cause of death worldwide and one of the major causes of long-term disability. Carotid artery stenosis is an independent risk factor for ischemic stroke and related forms of atherosclerotic vascular disease. Aim of the Study was to examine plasma homocysteine (tHcy) levels in the stroke patient's group with significant carotid artery stenosis, to determine hyperhomocysteinemia correlation with degree of carotid artery stenosis. Materials and methods. This study was prospective and all patients (n=102) included in the study were hospitalized in Pauls Stradins Clinical University hospital in Clinic of Neurology with diagnosis of acute ischemic stroke. In the group of significant carotidal stenosis we included 48 patients with various degree of stenosis ranging from 50% to total occlusion. Evaluations of stenosis of extracranial carotid arteries were done by duplex ultrasonography method. The blood of these patients was tested for homocysteine level by ELISA (IMMULITE 2000). Results. Study did not demonstrated statistically significant difference between levels of tHcy in all groups. Mean homocysteine level was not significantly higher in the symptomatic carotid stenosis patient's group. Also there were no significant differences between levels of homocysteine in patient group with different degree of stenosis. Conclusions. We found no meaningful association between a high tHcy level and extent of carotid stenosis.publishersversionPeer reviewe

Cytomegalovirus chronic infection as a risk factor for stroke : A prospective study

Funding Information: This research was supported by European Social Fund.Stroke is the second most common cause of death in the world and a major cause of long-term disability. Chronic infection is an independent risk factor for ischemic stroke and related forms of atherosclerotic vascular disease. The aim of our study was to compare the plasma Cytomegalovirus (CMV) immunoglobulin G antibody level in a patient and control group, and to determine the association of CMV chronic infection with ischemic stroke, and with stroke subtype. The present study does not present a cogent demonstration that cytomegalovirus chronic infection is a risk factor of stroke. Further studies are necessary to clarify the effective prophylactic measures to determine other significant risk factors for stroke.publishersversionPeer reviewe

Duodenal Perforation due to Inferior Vena Cava Filter in a Multi-morbid Young Patient: First Clinical Case Report in Latvia

ABSTRACT Introduction: The inferior vena cava filter is known to be a safe and effective method for preventing fatal pulmonary artery thromboembolism. We report a case report of inferior vena cava filter perforation on duodenum in a multimorbid young patient undergoing full midline laparotomy and cavotomy. Case presentation: A 37-year-old male was admitted to a tertiary university hospital following recurrent episodes of epistaxis. In 2008, the patient developed traumatic subarachnoid haemorrhage with a following decompressive trepanation and bilateral pulmonary artery thromboembolism. An inferior vena cava filter was implanted. In 2021, due to suspected duodenal perforation, an urgent fibrogastroscopy was performed, revealing duodenal perforation caused by the inferior vena cava filter and aortic pseudoaneurysm. Vena cava filter evacuation was indicated; to date, no such operation has been performed in Latvia. The early postoperative period occurred without any complications. The patient was discharged 15 days after the surgical treatment in good overall health. Results: This was a clinical case report about a 37-year-old multimorbid patient with positive anamnesis of traumatic subarachnoid haemorrhage following decompressive trepanation and bilateral pulmonary artery thromboembolism and inferior vena cava filter implantation due to absolute contraindications to anticoagulant therapy. Conclusion: Inferior vena cava filters are generally safe but can cause clinically significant complications. The case of 37-year-old multimorbid patient with the main complaints of pain around the left ear and recurrent nose bleeds was discussed. On fibrogastroscopy, duodenal perforation caused by the inferior vena cava filter and aortic pseudoaneurysm were seen. Full midline laparotomy and cavotomy was performed. The patient was discharged in good overall health. Detailed assessment of the radiological findings, fibrogastroscopic studies and the novel treatment of a complicated disease occurring for the first time in Latvia proved successful for both patient recovery and outcome. Keywords: Cavotomy; Laparotomy; Multimorbidity; Inferior vena cava filter; Duodenal perforationpublishersversionPeer reviewe

CARDIOEMBOLIC STROKE IN LATVIA : PREVENTION AND LONG-TERM OUTCOME

NTRODUCTION:Untreated non-valvular atrial fibrillation is one of major causes of stroke. The goalof the study was to evaluate the use of antithrombotic medication stroke prevention and assess long-term stroke outcome.METHODS:This study involved 531 cardio embolicstroke patients of thePaul’sStradins Clinical University Hospital, Riga, Latvia,in 2014. After dischargethe patients or their relatives were interviewed by phone after 30, 90, 180, and 365 days. Standardized questions were asked about the patients’abilities and use of prescribed secondary prevention medication. Theresults were compared between patient groups, assigned according to prescribed medications. RESULTS:Of all the patients included in the study,8.9% were using oral anticoagulants before stroke onset. One year after discharge,1.44% of patients were not using any preventivemedication, 23.56%were using antiplatelet agents, 43.27% warfarin,and 31.73% target-specificoralanticoagulants. The one-year mortality ratewas 40.7%. The mortality rate was significantly higher in the patient group using no secondary preventivemedication or antiplatelet agents compared to the patient group that used oral anticoagulants. CONCLUSION:Cardio embolicstroke primary and secondary prevention in Latvia islacking. The study outcomes suggest that action is neededto increase the use of oral anticoagulants in primary stroke prevention in patients with atrial fibrillation. Poor function outcomes, dementia,and patients’incompliance limits the use of oral anticoagulants in secondary preventionpublishersversionPeer reviewe

Is Anticoagulation Necessary for Severely Disabled Cardioembolic Stroke Survivors?

Background and Objectives: Oral anticoagulants are the hallmark of cardioembolic stroke prevention, but they are frequently underused, especially in elderly patients and patients with paroxysmal atrial fibrillation. In our paper, we analyzed the long-term outcome of severely disabled cardioembolic stroke survivors depending on the prescribed antithrombotic secondary prevention medication. Materials and Methods: In our study, we retrospectively collected data for ischemic stroke (IS) patients treated in P. Stradins Clinical University hospital, Riga, Latvia, from 2014 until 2017. Patients’ clinical data were collected using local stroke registry, including patients’ demographic data, vascular risk factors, clinical findings, and laboratory results. Severely disabled stroke survivors were followed up by phone at 30/90/180/365 days after discharge. Patients’ functional outcomes were assessed using the adapted version of The Rankin Focused Assessment–Ambulation. The collected data were compared in 4 groups according to prescribed secondary prevention medication. Results: A total of 682 (91.42%) patients were followed up and included in data analysis. The median age of patients was 80 (IQR = 75–85) years. Of these patients, 231 (31%) were males and 515 (69%) were females. One-year probability of survival of patients not taking any preventive medication was 53% (IQR = 29–76), while in patients taking antiplatelet agents it was 57% (IQR = 37–78), 78% (IQR = 68–88) of patients on Vitamin K antagonists (VKA) and 81% (IQR = 72–90) in patients on direct oral anticoagulants (DOACs). One year after discharge 73 (31%) had mRS 0–2, 50 (20.9%), 29 (12.1%) were still severely disabled, and 87 (36.4%) had died. Conclusions: Anticoagulant use in secondary prevention predicts better functional outcome and higher survival rate in patients with severe cardioembolic stroke due to non-valvular atrial fibrillation (NVAF), therefore severe neurological deficit must not be a reason of restriction of anticoagulatioPeer reviewe

Problems of Cardioembolic Stroke Primary and Secondary Prevention in the Latvian Population

Publisher Copyright: © 2015 by Kristaps Jurjns.Atrial fibrillation is one of major risk factors of cerebral infarction. The use of oral anticoagulants is the only evidence-based method of reducing the risk of cardioembolic accidents. The guidelines of oral anticoagulant admission and usage have been available since 2012. The results of this study show that of 550 stroke patients that were admitted to Pauls Stradiņš Clinical University Hospital, Riga, Latvia, from 1 January 2014 until 1 July 2014, atrial fibrillation was diagnosed in 247 (45%) cases, and of these patients, only 8.5% used oral anticoagulants before the onset of stroke. Six months after discharge of 111 (44.9%) stroke survivors, five (4.5%) used no secondary prevention medication, 27 (24.3%) used antiplatelet agents, 54 (48.6%) warfarin, and 25 (22.5%) used target specific oral anticoagulants (TSOACs). The mortality rate was significantly higher in the patient group that used no secondary prevention medication or antiplatelet agents compared to the patient group that used oral anticoagulants. The use of oral anticoagulants for primary stroke prevention in Latvia is insufficient. The mortality of cardioembolic stroke in 180 days is very high-40.4%. Secondary prevention is essential to prevent recurrent cardioembolic accidents.publishersversionPeer reviewe

S 100 proteīns un neironu specifiskā endolāze kā cerebrālā infarkta diagnostiskie un prognostiskie biomarķieri. Promocijas darba kopsavilkums

Promotion work was done at Rīga Stradiņš University, Neurology and Neurosurgery Departments of P.Stradins Clinical University Hospital, Neurology Clinic. Defence: on 18th February 2013 at 17.00 of Riga Stradiņš University Fundamental Sciences open meeting of Promotion Council in Riga, Dzirciema street 16, Hippocrate auditorium.The promotion work is addressing one of the most topical current neurological problems – diagnostics of cerebral infarction in its acute phase. Cerebral infarction is the most common cerebrovascular pathology and one of the main mortality, demence and disability causes worldwide. Treatment of cerebral infarction is known to progress nowadays and the modern treatment methods – intravenous thrombolysis, intrarterial thrombolysis and thrombectomy – are the most effective therapeutic possibilities, despite it, the risk of possible complications is still high. Correctly chosen specific cerebal infarction therapy for the patient can reduce the development of possible complication risk after the manipulation, therefore extra diagnostic methods are needed. Biomarkers are one of the additional diagnostic possibilities in cerebral infarction cases. Biomarkers which are specific for cerebral tissue lesions, can relieve the assessment of ischemic damage in patients in an acute cerebral infarction phase, when imaging diagnostics, especially computer tomography possibilities are not great. Prognosing cerebral infarction size, one can more precisely plan the patient’s treatment, envisaging the prognosis of the disease and the effectivity of the method applied at the very beginning of the disease, reducing the development of the complication risk. Up to now several studies have been described in scientific literature, investigating the relationship of biomarkers with cerebral tissue ischemic damage, demonstrating various degree sensitivity, specificity and prognostic value, and concluding, that there is lack of a longer time observation data, therefore further studies are needed. The aim of the study was to assess S100 protein and neuron specific enolase (NSE) as cerebral infarction diagnostic and prognostic biomarkers, drawing conclusions on the usefulness of their application in daily practice. In the prospective study there were analyzed the data on 336 patients with cerebral infarction and 168 control group patients who had undergone treatment at P.Stradins State University Hospital, Neurology clinic in the period from October 2008 till March 2011. All studied patients with cerebral infarction were stated S100 and NSE level in blood by 24 hours since the onset of cerebral infarction symptoms. Laboratory tests were done at the accredited and certified laboratory of the Clinical Immunology Centre. Patients’ radiological imaging diagnostic examinations were done at Radiology Institute. For the statistical analysis of the study data a specialized programme – SPSS 15 for Windows, SPSS, Chicago, IL was used. As a result of the work, the patients with cerebral infarction were found S100 protein and NSE level being higher in comparison to the control group, as well as finding S100 protein level in serum also correlating with cerebral infarction size which could be considered the prognostic factor in the hemorrhagic transformation development. In patients with cerebral infarction S100 protein correlates with the effectivity of thrombolytic and thrombectomy therapy and the incidence of the development of hemorrhagic complications. Comparing the studies described in the literature, our study results in relation to biomarker level changes in acute cerebral infarction cases are similar to the before described, however, one cannot find the literature data on the biomarker correlation to the effectivity of thrombectomy, thus, there are no studies to compare to our acquired data. As a result of work, practical recommendations were developed, in which S100 protein level determination can be recommended as a diagnostic and prognostic indicator, especially in clinics where there are not available sensitive radiological investigation methods for patients with cerebral infarction in an acute disease phase.Promotion work has been done with the financial support of European Social Fund project "Support to doctoral students in acquiring the study programme and getting a scientific degree at Rīga Stradiņš University

S 100 Protein and Neuron Specific Enolase as Diagnostic and Prognostic Biomarkers of Cerebral Infarction. Summary of the Doctoral Thesis

Promocijas darbs izstrādāts Rīgas Stradiņa universitātes Neiroloģijas un neiroķirurģijas katedras klīniskajā bāzē – VSIA Paula Stradiņa Klīniskās universitātes slimnīcas Neiroloģijas klīnikā. Aizstāvēšana: 2013. gada 18. februārī plkst. 17.00 Rīgas Stradiņa universitātes Teorētiskās medicīnas promocijas padomes atklātā sēdē Rīgā, Dzirciema ielā 16, Hipokrāta auditorijā.Promocijas darbs ir veltīts vienai no aktuālākajām mūsdienu neiroloģijas problēmām – cerebrāla infarkta diagnostikai akūtā periodā. Cerebrāls infarkts ir visbiežāk sastopamā cerebrovaskulārā patoloģija un ir viens no galvenajiem mirstības, demences un invaliditātes cēloņiem pasaulē. Zināms, ka cerebrāla infarkta ārstēšana šodien strauji progresē, un mūsdienīgas ārstēšanas metodes – intravenozā trombolīze, intraarteriāla trombolīze un trombektomija – ir visefektīvākās ārstēšanas iespējas, tomēr iespējamo komplikāciju attīstības risks ir augsts. Pacientam pareizi izvēlēta specifiska cerebrāla infarkta terapija samazinās iespējamo komplikāciju attīstības risku pēc manipulācijas, tādēļ ir nepieciešamas papildu diagnostiskās metodes. Biomarķieri ir viena no papildu diagnostikas iespējām cerebrāla infarkta gadījumā. Biomarķieri, kas ir specifiski smadzeņu audu bojājumam, var atvieglot išēmiskā bojājuma novērtēšanu pacientiem akūtā cerebrāla infarkta fāzē, kad attēldiagnostikas, īpaši datortomogrāfijas, iespējas nav lielas. Prognozējot cerebrāla infarkta plašumu, ir iespējams precīzāk plānot pacienta ārstēšanu, paredzot slimības prognozi un pielietojamo terapijas metodes efektivitāti jau slimības sākumā, mazinot terapijas komplikāciju attīstības risku. Līdz šim literatūrā aprakstīti vairāki pētījumi, kuros tiek pētīti biomarķieri saistībā ar smadzeņu audu išēmisku bojājumu – tie demonstrē dažādu jutību, specifiskumu un prognostisko vērtību, secinot, ka trūkst ilgāku laika novērojumu datu un ir nepieciešami turpmāki pētījumi. Pētījuma mērķis bija izvērtēt S100 proteīnu un neironu specifisko enolāzi (NSE) kā cerebrāla infarkta diagnostiskus un prognostiskus biomarķierus, izdarot secinājumus par to pielietošanas lietderību ikdienas praksē. Prospektīvā pētījumā tika analizēti dati 336 pacientiem ar cerebrālu infarktu un 168 kontroles grupas pacientiem, kas ārstējušies VAS P. Stradiņa Klīniskās universitātes slimnīcas Neiroloģijas klīnikā periodā no 2008. gada oktobra līdz 2011. gada martam.Visiem pētījuma pacientiem ar cerebrālu infarktu noteica S100 proteīna un NSE līmeni asinīs līdz 24 stundām kopš cerebrāla infarkta simptomu sākuma. Laboratoriskās analīzes veiktas akreditētā un sertificētā Klīniskās imunoloģijas centra laboratorijā. Pacientu radioloģiskās attēldiagnostikas izmeklējumi veikti Radioloģijas institūtā. Pētījuma statistiskās analīzes datu aprēķiniem izmantota specializēta programmatūra – SPSS 15 for Windows, SPSS, Chicago, IL. Darba rezultātā noskaidrots, ka pacientiem ar cerebrālu infarktu S100 proteīna un NSE līmenis ir augstāks, salīdzinot ar kontroles grupu, kā arī S100 proteīna līmenis serumā korelē ar pacientu funkcionālo stāvokli, cerebrāla infarkta plašumu, un var tikt uzskatīts par hemorāģiskas transformācijas veidošanās prognostiski lietderīgu faktoru. Pacientiem ar cerebrālu infarktu S100 proteīns korelē ar trombolītiskās un trombektomijas terapiju efektivitāti, hemorāģisko komplikāciju attīstības biežumu. Salīdzinot ar literatūrā apskatītajiem pētījumiem, mūsu pētījuma rezultāti saistībā ar biomarķieru līmeņa izmaiņām akūta cerebrāla infarkta gadījumā ir līdzīgi iepriekš aprakstītajiem, tomēr literatūrā nav pieejami pētījumi par biomarķieru saistību ar trombektomijas efektivitāti – tādejādi nav pētījumu, ar kuriem salīdzināt mūsu pētījumā iegūtos datus. Darba rezultātā tika izstrādātas praktiskās rekomendācijas, kurās S100 proteīna līmeņa noteikšanu var rekomendēt kā diagnostisko un prognostisko rādītāju, īpaši klīnikās, kur nav peejamas jutīgas radioloģiskās izmeklēšanas metodes pacientiem ar cerebrālu infarktu akūtajā slimības periodā.Promocijas darbs veikts ar Eiropas Sociālā fonda projekta "Atbalsts doktorantiem studiju programmas apguvei un zinātniskā grāda ieguvei Rīgas Stradiņa universitātē" finansiālu atbalst

S 100 Protein and Neuron Specific Enolase as Diagnostic and Prognostic Biomarkers of Cerebral Infarction. Doctoral Thesis

Promocijas darbs izstrādāts Rīgas Stradiņa universitātes Neiroloģijas un neiroķirurģijas katedras klīniskajā bāzē – VSIA Paula Stradiņa Klīniskās universitātes slimnīcas Neiroloģijas klīnikā. Aizstāvēšana: 2013. gada 18. februārī plkst. 17.00 Rīgas Stradiņa universitātes Teorētiskās medicīnas promocijas padomes atklātā sēdē Rīgā, Dzirciema ielā 16, Hipokrāta auditorijā.Promocijas darbs ir veltīts vienai no aktuālākajām mūsdienu neiroloģijas problēmām – cerebrāla infarkta diagnostikai akūtā periodā. Cerebrāls infarkts ir visbiežāk sastopamā cerebrovaskulārā patoloģija un ir viens no galvenajiem mirstības, demences un invaliditātes cēloņiem pasaulē. Zināms, ka cerebrāla infarkta ārstēšana šodien strauji progresē, un mūsdienīgas ārstēšanas metodes – intravenozā trombolīze, intraarteriāla trombolīze un trombektomija – ir visefektīvākās ārstēšanas iespējas, tomēr iespējamo komplikāciju attīstības risks ir augsts. Pacientam pareizi izvēlēta specifiska cerebrāla infarkta terapija samazinās iespējamo komplikāciju attīstības risku pēc manipulācijas, tādēļ ir nepieciešamas papildu diagnostiskās metodes. Biomarķieri ir viena no papildu diagnostikas iespējām cerebrāla infarkta gadījumā. Biomarķieri, kas ir specifiski smadzeņu audu bojājumam, var atvieglot išēmiskā bojājuma novērtēšanu pacientiem akūtā cerebrāla infarkta fāzē, kad attēldiagnostikas, īpaši datortomogrāfijas, iespējas nav lielas. Prognozējot cerebrāla infarkta plašumu, ir iespējams precīzāk plānot pacienta ārstēšanu, paredzot slimības prognozi un pielietojamo terapijas metodes efektivitāti jau slimības sākumā, mazinot terapijas komplikāciju attīstības risku. Līdz šim literatūrā aprakstīti vairāki pētījumi, kuros tiek pētīti biomarķieri saistībā ar smadzeņu audu išēmisku bojājumu – tie demonstrē dažādu jutību, specifiskumu un prognostisko vērtību, secinot, ka trūkst ilgāku laika novērojumu datu un ir nepieciešami turpmāki pētījumi. Pētījuma mērķis bija izvērtēt S100 proteīnu un neironu specifisko enolāzi (NSE) kā cerebrāla infarkta diagnostiskus un prognostiskus biomarķierus, izdarot secinājumus par to pielietošanas lietderību ikdienas praksē. Prospektīvā pētījumā tika analizēti dati 336 pacientiem ar cerebrālu infarktu un 168 kontroles grupas pacientiem, kas ārstējušies VAS P. Stradiņa Klīniskās universitātes slimnīcas Neiroloģijas klīnikā periodā no 2008. gada oktobra līdz 2011. gada martam.Visiem pētījuma pacientiem ar cerebrālu infarktu noteica S100 proteīna un NSE līmeni asinīs līdz 24 stundām kopš cerebrāla infarkta simptomu sākuma. Laboratoriskās analīzes veiktas akreditētā un sertificētā Klīniskās imunoloģijas centra laboratorijā. Pacientu radioloģiskās attēldiagnostikas izmeklējumi veikti Radioloģijas institūtā. Pētījuma statistiskās analīzes datu aprēķiniem izmantota specializēta programmatūra – SPSS 15 for Windows, SPSS, Chicago, IL. Darba rezultātā noskaidrots, ka pacientiem ar cerebrālu infarktu S100 proteīna un NSE līmenis ir augstāks, salīdzinot ar kontroles grupu, kā arī S100 proteīna līmenis serumā korelē ar pacientu funkcionālo stāvokli, cerebrāla infarkta plašumu, un var tikt uzskatīts par hemorāģiskas transformācijas veidošanās prognostiski lietderīgu faktoru. Pacientiem ar cerebrālu infarktu S100 proteīns korelē ar trombolītiskās un trombektomijas terapiju efektivitāti, hemorāģisko komplikāciju attīstības biežumu. Salīdzinot ar literatūrā apskatītajiem pētījumiem, mūsu pētījuma rezultāti saistībā ar biomarķieru līmeņa izmaiņām akūta cerebrāla infarkta gadījumā ir līdzīgi iepriekš aprakstītajiem, tomēr literatūrā nav pieejami pētījumi par biomarķieru saistību ar trombektomijas efektivitāti – tādejādi nav pētījumu, ar kuriem salīdzināt mūsu pētījumā iegūtos datus. Darba rezultātā tika izstrādātas praktiskās rekomendācijas, kurās S100 proteīna līmeņa noteikšanu var rekomendēt kā diagnostisko un prognostisko rādītāju, īpaši klīnikās, kur nav peejamas jutīgas radioloģiskās izmeklēšanas metodes pacientiem ar cerebrālu infarktu akūtajā slimības periodā.Promocijas darbs veikts ar ESF projekta „Atbalsts doktorantiem studiju programmas apguvei un zinātniskā grāda ieguvei Rīgas Stradiņa universitātē” atbalst