Razlike u čimbenicima rizika i ishodu između ishemijskog i hemoragijskog moždanog udara

The aim of the study was to justify the hypothesis that risk factors do not differ between ischemic and hemorrhagic stroke. This retrospective study included 1066 stroke patients. The prevalence of risk factors and hospital-based survival were compared between patients with ischemic and hemorrhagic stroke. Data were retrieved from patient records. Statistical analysis was done by use of χ-test and t-test for dependent samples. The group of hemorrhagic stroke consisted of 70 (47.9%) female and 76 (52.1%) male patients. The group of ischemic stroke included 450 (48.9%) female and 470 (51.1%) male patients. Ischemic stroke patients had a higher prevalence of hypertension (79% vs. 72%), atherosclerotic diseases (50% vs. 34%) and atrial fibrillation (15.5% vs. 4.2%), and were statistically significantly older (72.5±10.4 VS. 65.7±12.8) than those with hemorrhagic stroke, however, fatal outcome was more common in the latter (26% vs. 17%). In conclusion, data analysis pointed to differences between hemorrhagic and ischemic stroke according to both risk factors and stroke outcome.Cilj studije bio je provjeriti opravdanost hipoteze kako se čimbenici rizika ne razlikuju između ishemijskog i hemoragijskog moždanog udara. Ova retrospektivna studija uključila je 1066 bolesnika s moždanim udarom. Učestalost rizičnih čimbenika i bolničko preživljenje uspoređeni su između bolesnika s ishemijskim i hemoragijskim moždanim udarom. Podatci su izvedeni iz bolesničkih kartona. Statistička analiza je provedena pomoću χ2-testa i t-testa za zavisne uzorke. Skupina bolesnika s hemoragijskim moždanim udarom imala je 70 (47,9%) žena i 76 (52,1%) muškaraca, a skupina s ishemijskim moždanim udarom 450 (48,9%) žena i 470 (51,1%) muškaraca. Bolesnici s ishemijskim moždanim udarom imali su veću učestalost hipertenzije (79% prema 72%), aterosklerotske bolesti (50% prema 34%) i atrijske fibrilacije (15,5% prema 4,2%) i bili su statistički značajno stariji (72,5±10,4 prema 65,7±12,8) od bolesnika s hemoragijskim moždanim udarom, ali je smrtni ishod bio češći kod ovih potonjih (26% prema 17%). Dakle, analiza prikupljenih podataka ukazala je na razlike između hemoragijskog i ishemijskog moždanog udara u rizičnim čimbenicima i ishodu bolesti

CT Perfusion and Noncontrast CT in Acute Ischemic Stroke Diagnosing – Is there Influence on early Thrombolytic Therapy Outcome?

The objective of this study was to compare noncontrast computed tomography (NCCT) and computed tomography perfusion (CTP) in early diagnosis of acute ischemic stroke and to define influence of these diagnostic procedures on early outcome of thrombolytic therapy (TLTH). The study included 45 patients, 35 patients submitted to NCCT and CTP and 10 patients who underwent only NCCT, before CTP was introduced. Based on the National Institute of Health Stroke Scale (NIHSS) score we compared early outcome of patients who received TLTH after NCCT only (group 1) with the early outcome of patients who received TLTH following NCCT and CTP (group 2). Statistically significant difference was found in acute stroke diagnosing between CTP and NCCT (p=0.002). There were no statistically significant differences in TLTH early outcome between group 1 and group 2. In conclusion, CTP should be done regulary in patients presenting with acute ischemic stroke symptoms. More research needs to be done in defining exact influence of CTP implementation on the TLTH outcome

THROMBOEMBOLIC AND BLEEDING RISK ASSESSMENT IN PATIENTS WITH NON-RHEUMATIC ATRIAL FIBRILLATION USING CHA2DS2-VASC AND HAS-BLED SCORING SYSTEMS

Procjenjuje se da od nereumatske atrijske fibrilacije (nAF) boluje 1–2% svjetskog stanovništva. Najčešća komplikacija te aritmije jesu tromboembolijski događaji, među kojima prednjači ishemijski moždani infarkt. On je u bolesnika s nAF, u odnosu na bolesnike sa sinusnim ritmom, praćen težim kliničkim tijekom, značajno većom smrtnošću, a u preživjelih bolesnika značajno sporijim oporavkom i težim trajnim duševnim i tjelesnim oštećenjima. Primjena antikoagulantnog liječenja u bolesnika s nAF značajno smanjuje pojavnost ishemijskih moždanih infarkta, a u onih koji ga dožive tijekom njegove primjene poboljšava ishod liječenja. Stoga smjernice stručnih društava preporučuju primjenu antikoagulantnog liječenja u većine bolesnika s nAF. Istodobno, strah od krvarenja uzrokovanog antikoagulantnim liječenjem uzrok je njegova, često neopravdanog, neprimjenjivanja u bolesnika s velikim tromboembolijskim rizikom. U ovom radu prikazujemo sustave CHA2DS2-VASc i HAS-BLED, koji su preporučeni u procjeni tromboembolijskog rizika i rizika od krvarenja, prilikom odabira tromboprofilaktičkog liječenja u bolesnika s nAF.It is estimated that approximately 1–2% of the world population are affected with non-rheumatic atrial fibrillation (nAF). The most frequent complications of this arrhythmia are thromboembolic events, primarly ischemic stroke. In comparison with patients in sinus rhythm, stroke affected nAF patients have more severe clinical course and significantly higher mortality rate, and the survivors have significantly lower recovery rate and more serious permanent mental and physical impairments. The administration of anticoagulants to patients with nAF significantly reduces the incidence of stroke, while those who were stroke affected during the anticoagulant therapy show better treatment outcomes. Therefore, professional associations guidelines recommend the anticoagulant treatment for the majority of patients with nAF. The fear of bleeding caused by anticoagulants results in their frequently unjustified omission from the therapy in patients with high thromboembolic risk. This paper presents CHA2DS2-VASc- and HAS-BLED systems recommended for thromboembolic and bleeding risk assessment when deciding on thromboprophylactic therapy in patients with nAF

THROMBOPROPHYLAXIS IN PATIENTS WITH NONVALVULAR ATRIAL FIBRILLATION ADMITTED IN UNIVERSITY HOSPITAL SPLIT, CROATIA, DUE TO THE ISCHAEMIC STROKE IN RELATION TO THROMBOEMBOLIC AND BLEEDING RISK

Cilj rada bio je procijeniti usklađenost propisivanja tromboproilakse u bolesnika s nevalvularnom atrijskom ibrilacijom (nAF) prigodom prijma na liječenje zbog ishemijskog moždanog infarkta sa smjernicama Europskog kardiološkog društva za tromboproilaksu u bolesnika s nAF. U presječno retrospektivno istraživanje je uključeno 327 bolesnika [143 (44 %) muškaraca] s nAF, liječenih zbog ishemijskog moždanog infarkta. Tromboembolijski (TE) rizik procijenjen je sustavom CHA2DS2-VASc, a rizik krvarenja sustavom HAS-BLED. Prije doživljenog ishemijskog moždanog infarkta 98,2 % bolesnika pripadalo je skupini velikog tromboembolijskog rizika. Od tog broja tromboproilaksu je primjenjivalo samo 179 (55 %) bolesnika: 65,5 % bolesnika primjenjivalo je acetilsalicilnu kiselinu, 30,5 % varfarin, a 4 % klopidogrel. Raniji tromboembolijski incident nezavisno je korelirao s primjenom (OR 2,5; 95% CI 1,4-4,5; p=0,003), a neregulirana arterijska hipertenzija s neprimjenjivanjem (OR 0,47; 95% CI 0,25-0,88; p=0,019) varfarina. Od 55 bolesnika koji su ishemijski moždani infarkt doživjeli unatoč primjeni varfarina, u 83,7 % bolesnika vrijednosti protrombinskog indeksa prilikom prijama su bile niže od terapijskih.Autori zaključuju da tromboproilaksa u bolesnika s nAF hospitaliziranih zbog ishemijskog moždanog infarkta nije bila sukladna njihovom tromboembolijskom riziku i trenutnim smjernicama Europskog kardiološkog društva.Aim of the study was to assess the concordance of the thromboprophylactic treatment in patients with nonvalvular atrial ibrillation (nAF) at the time of admission due to ischemic stroke with clinical guidelines of the European Society of Cardiology. Methods: In the cross-sectional study were included 327 patients [143 (44%) males] treated because of ischemic stroke associated with nAF. The index of the thromboembolic risk (TE) has been established by the CHA2DS2-VASc score, whereas the bleeding risk has been assessed by the HAS-BLED score. Results: Before the ischemic stroke, 98.2% of patients belonged to the group of high TE risk. Among these patients only 179 (55%) were received thromboprophylaxis: 67.5% patients acetylsalicylic acid, 30.5% warfarin, and 4% clopidogrel. Previous ischemic stroke was independently correlated with warfarin administration (OR 2.5; 95% CI 1.4-4.5; p=0.003), while poorly controlled arterial hypertension was independently correlated with warfarin non-administration (OR 0.47; 95% CI 0.25-0.88; p=0.019). The 83.7% of 55 patients, who experienced ischemic stroke during anticoagulant treatment, had an INR values lower than therapeutic. Conclusion: Thromboprophylaxis among the patients with nAF admitted because of ischemic stroke did not correlate with their TE risk and contemporary guidelines of the European Society of Cardiology

Dehiscence of a valved aortic conduit as a delayed complication of the blunt chest trauma

65-godišnji muškarac s dakronskim tubularnim graftom uzlazne aorte i mehaničkim aortalnim zaliskom („kompozitni graft“), zaprimljen je na Neurološki odjel zbog tranzitorne ishemijske atake. Sedam mjeseci prije ove hospitalizacije, doživio je prometnu ezgodu s tupom povredom prsišta. Radiografijom prsnoga koša i ranstorakalnim ehokardiografskim pregledom učinjenim neposredno po nezgodi, nisu zabilježene patološke promjene. Prilikom prijama, bolesnik je bio bez simptoma, stabilnih hemodinamskih parametara. Unatoč tome, ehokardiografskim pregledom je zabilježena hiscencija kompozitnog grafta aorte u području proksimalne anastomoze s posljedičnim nastankom pseudoaneurizme u prostoru između aortne stijenke i dakronskog grafta. Pseudoaneurizma je slobodno municirala s izlaznim traktom lijeve klijetke. Bolesnik je žurno upućen na kardiokirurški zahvat. Nažalost, umro je naglom smrću, tijekom pripreme za operativni zahvat. Prikazani slučaj upućuje na to da je, zbog odgođenog nastajanja pseudoaneurizme i dehiscencije dakronskog grafta, ehokardiografsko praćenje poželjno u svih olesnika, prethodno podvrgnutih „rekonstrukciji po Bentallu“, tijekom nekoliko mjeseci nakon tupe povrede prsišta.A 65-year old man with bileaflet mechanical aortic prosthesis and a Dacron tubular aortic graft was admitted at the Department of Neurology due to transient ischemic attack. Seven months before admission, he had suffered a car accident with blunt thoracic trauma. A chest X-ray and transthoracic echocardiogram performed at the time of the accident reported no abnormalities. At admission, he was presented as a asymptomatic, hemodynamically stable patient. However, echocardiography showed dehiscence of the valved aortic conduit from the native aortic annulus at the proximal anastomosis site, and free communication between the left ventricular outflow tract and the periconduit cavity. The patient was referred to a cardiac surgeon. Unfortunately, he experienced sudden death before the scheduled operation. Our case suggests that, because of delayed development of pseudoaneurysm and conduit dehiscence, echocardiography follow-up is recommended in patients after Bentall reconstruction within several months after the blunt chest trauma

ANTICOAGULANT THERAPY IN PATIENTS WITH PERMANENT ATRIAL FIBRILLATION – EVIDENCE BASED MEDICINE AND CLINICAL PRACTICE

Cilj istraživanja bio je procijeniti usklađenost propisivanja tromboprofilaktičkog liječenja u bolesnika s permanentnom atrijskom fibrilacijom (pAF) s kliničkim smjernicama Europskoga kardiološkog društva. U prospektivno presječno istraživanje susljedno su uključena 674 bolesnika (59% muškaraca) otpuštenih s kardiološkog odjela s dijagnozom pAF. Težina tromboembolijskog (TE) rizika procijenjena je CHA2DS2-VASc-sustavom, a rizik od krvarenja HAS-BLED-sustavom. U skupinu velikog TE rizika klasificirano je 578 (86%), umjerenog 57 (8%), a malog 39 (6%) bolesnika. Tromboprofilaksa je primijenjena u 601 (89%) bolesnika: varfarin u 310 (46%), acetilsalicilna kiselina u 258 (38%), a klopidogrel u 33 (5%). Varfarin je propisan u 47% bolesnika velikog, 49% bolesnika umjerenog te u 26% bolesnika malog TE rizika (P=0,03), a acetilsalicilna kiselina u 39% bolesnika malog, 39% bolesnika umjerenog i 38% bolesnika velikog TE rizika (P=0,998). Acetilsalicilna kiselina (P<0,001) i varfarin (P=0,007) bili su značajno češće korišteni u skupini bolesnika s velikim rizikom od krvarenja, u kojoj je zabilježena jednaka učestalost propisivanja varfarina i acetilsalicilne kiseline (53% prema 47%; P=0,416). Dob ³75 godina bila je nezavisni prediktor neprimjenjivanja (OR 1,7; 95% CI 1,2–2,4; P=0,003), a anamneza moždanog infarkta primjenjivanja varfarina (OR 0,47; 95% CI 0,29–0,76;P=0,002). Prilikom propisivanja tromboprofilaktičkog liječenja bolesnicima s pAF liječnici se ne pridržavaju preporučenih smjernica. Unatoč nepostojanju kontraindikacija značajan udio bolesnika s velikim TE rizikom nije dobio varfarin. Istodobno, varfarin je propisivan bolesnicima s malim TE rizikom čime su nepotrebno izloženi neželjenim učincima antikoagulantnog liječenja.Objective of study was to assess the concordance of the tromboprophylactic treatment in patients with permanent atrial fibrillation (pAF) with guidelines of the European Society of Cardiology. Prospective cross-sectional study consecutivelly included 674 patients (400 Š59%Ć male) discharged from cardiology department with the diagnosis pAF. The thromboembolic risk (TE) has been established according to CHA2DS2-VASc score, whereas the bleeding risk has been assessed according to HAS-BLED score. 578 (86%) belonged to the group of high, 57 (8%) to the group of moderate, and 39 (6%) patients to the group of low TE risk. 601 (89%) patients received thromboprophylaxis: 310 (46%) warfarin, 258 (38%) acetylsalicylic acid, and 33 (5%) patients clopidogrel. Warfarin has been prescribed to 47% of patients with high, 49% of patients with moderate and to 26% of patients with low TE risk (P=0.03). Acetylsalicylic acid (ASA) has equally been prescribed to patients of all TE risk groups: low, moderate and high (39% vs. 39% vs. 38%; P=0.998). ASA (P<0.001) and warfarin (P=0.007) have been used more frequently in the group of patients with high bleeding risk, in which the same incidence of warfarin and ASA administration has been registered (53% vs. 47%; P=0.416). Age ³75 has been an independent predictor of non-administration (OR 1.7; 95% CI 1.2–2.4; P=0.003), whereas the history of stroke was for warfarin administration (OR 0.47; 95% CI 0.29–0.76; P=0.002). In prescribing thromboprophylaxis to patients with pAF, cardiologists do not observe the recommended clinical guidelines. Despite nonexistence of contraindications, a significant number of patients with high TE risk has not been administered warfarin. At the same time, warfarin has been administered to the patients with low TE risk, exposing them unnecessarily to the undesired effect of anticoagulant treatment

Modern design of built-in cabinets

Rad ne sadrži sažetak

Modern design of built-in cabinets

Rad ne sadrži sažetak

Prevention and treatment of postdural puncture headache with peroral thepohyline

Lumbalna punkcija (LP) uobičajena je neurološka procedura koja se rabi u dijagnostičke i u terapijske svrhe. Postpunkcijska glavobolja (PPG) razmjerno je česta popratna pojava lumbalne punkcije čija se incidencija kreće u rasponu od 30% do 50% kod dijagnostičkih ili terapijskih lumbalnih punkcija, dok se tijekom provođenja epiduralne anestezije ukoliko se dogodi „incidentalni“ ubod dure učestalost povećava do 80%. Upravo tako velika učestalost tog problema u svakodnevnoj kliničkoj neurološkoj praksi opravdava težnju brojnih kliničkih studija posvećenih prevenciji PPG-a, ili smanjenju njezina intenziteta. Češće navođeni pripravci s potencijalnim učinkom na učestalost i intenzite PPG su lijekovi iz skupine metilksantina, posebice teofilin. Teofilin bi se kao lijek s dobro poznatim farmakodinamskim i farmakokinetskim svojstvima te predvidivim nuspojavama mogao vrlo jednostavno primjenjivati u prevenciji i/ili liječenju PPG-a, a s obzirom na jednostavnost primijene tog lijeka PPG bi bilo moguće liječiti i u izvanbolničkim uvjetima. Hipotetski, teofilin kompetitivnom neselektivnom inhibicijom fosfodiesteraze, neselektivnim antagonističkim djelovanjem na adenozinske receptore te interferiranjem s unosom kalcija u sarkoplazmatsku mrežicu smanjuje kompenzatornu venodilataciju. Osim toga, teofilin stimuliranjem natrijsko-kalijske pumpe uzrokuje povećano stvaranje likvora. Prikazanim mehanizmima teofilin djeluje na dva osnovna prihvaćena patofiziološka mehanizma nastanka PPG-a, što bi trebalo rezultirati rjeđom pojavom i slabijim intenzitetom PPG-a. Provedeno je dvostruko slijepo randomizirano istraživanje u skupini hospitaliziranih pacijenata u kojih je postavljena indikacija za dijagnostičku lumbalnu punkciju (LP) zbog sumnja na demijelinizacijsku bolest središnjeg ili perifernog živčanog sustava. Ispitivana je populacija oba spola (27 žena i 12 muškaraca) u dobi od 18 do 50 godina. Ispitanici su, nakon potpisivanja informiranog pristanka, randomizirani u dvije skupine. Njih 17 je (44%) primalo placebo,a 22 (56%) su peroralno primala 300 mg teofilina u obliku tablete s produljenim oslobađanjem dvaput na dan tijekom pet dana uzastopno. Ispitanici su četiri puta dnevno , počevši od prvog dana 30 minuta prije LP-a , procjenjivali intenzitet eventualne glavobolje prema vizualno-analognoj ljestvici (VAS-u). Osim toga, ispitanici su bilježili eventualnu pojavu mučnine, i to prema VAS-u te prema upitniku Oweral nausea index ( ONI). Osim što je prvog dana praćenja zabilježena statistički značajna razlika u učestalosti glavobolje između dviju ispitnih skupina, tijekom daljnjeg praćenja nije zamijećena statistički značajna razlika između tih skupina. U objema je ispitivanim skupinama uočena razlika u intenzitetu glavobolje petog dana u odnosu prema drugom, trećem i četvrtom danu praćenja. To opažanje s jedne strane tumačimo mogućim spontanim povlačenjem simptoma, što se i inače opaža u nekih bolesnika, no u velikog dijela ispitanika smanjenje intenziteta PPG-a povezujemo s činjenicom da je protokol istraživanja dopuštao uzimanje nesteroidnih analgetika ako bude potrebno. Nije uvrđena statistički značajna razlika u broju ispitanika s mučninom s obzirom na primijenjenu terapiju mjereno prema VAS ljestvici, a ni statistički značajna razlika u broju ispitanika s mučninom s obzirom na primijenjenu terapiju mjereno prema ONI ljestvici. U ispitanika koji su osjećali mučninu nije utvrđena statistički značajna razlika u njezinu intenzitetu mjereno prema VAS ljestvici, a ni prema ONI ljestvici s obzirom na primijenjenu terapiju. Rezultati prikazanog istraživanja ne potvrđuju tezu o učinkovitosti peroralno primijenjenog teofilina u prevenciji pojave PPG-a ni tezu o njegovoj učinkovitosti u liječenju postojećeg PPG-a i prateće mučnine.Lumbar puncture (LP) is a common neurological procedure used for the diagnostic and therapeutic purposes. Postdural puncture headache (PDPH) is a relatively common side effect of lumbar puncture with an incidence ranging from 30% to 50% in the case of a diagnostic or therapeutic lumbar puncture. However, if “incidental” dural jab happens, the incidence rises to 80% during epidural anesthesia . A high frequency of this problem in clinical neurology justifies numerous clinical studies devoted to prevention of PDPH or reduction of its intensity. One of the frequently investigated drugs is theophylline, a drug from the group of methylxanthines. Theophylline is a drug with well-known pharmacodynamic and pharmacokinetic properties, including its side effects, so it could be easily applied in the prevention and / or treatment of PDPH. Since it is very easy to apply theophylline orally, it can be used for PDPH treatment in outpatient facilities. Our research was conducted with a group of patients hospitalized in the Department of Neurology, Split University Hospital during the period from 1st May of 2011 untill 31st March of 2012. The indication for performing diagnostic LP was suspected demyelinating disease of the central or peripheral nervous system. There have been investigated subjects of both genders (27 females and 12 males) aged 18-50. Subjects were randomized into two groups. 17 (44%) patients were receiving placebo, whereas 22 (56%) were receiving orally 300 mg of theophylline as the extended release tablets twice a day for five consecutive days. Neither the patients nor the doctors who were prescribing the drug (or placebo), as well as researchers who have noted the results of the poll were aware of randomization until the end of the study. Using visual analog scale (VAS) in the range 0-10, subjects have been estimating its headache intensity four times a day - starting from 30 minutes before LP – for the following five days. Furthermore, subjects noted the potential occurrence of nausea using VAS and the "Oweral nausea index" questionnaire (ONI). The statistically significant difference between these groups, with regard to the headache frequency, was found only for the first day of treatment. During the follow-up, there were no statistically significant differences between the same groups. In both groups, there was a difference in a headache intensity on the fifth day compared to the second, third and the fourth day. This could be due to the spontaneous withdrawal decreased intensity of PDPH associated with the intake of nonsteroid antiinflamatory drugs, which were allowed by the protocol. Statistically significant difference was not found in the number of subjects with nausea with regard to applied therapy as indicated by VAS.Anyway, there was a significant difference found in the number of subjects with nausea with regard to applied therapy as indicated by the ONI scale. In subject who reported nausea, there was no significant difference in its intensity indicated by VAS or ONI scale with regards to applied therapy. The results do not confirm the hypothesis that orally administered theophylline is effective in prevention of PDPH. Also, the research does not verify the effectiveness of the thesis in treating existing PDPH and accompanying nausea