Approaches for optimizing medical aid in acute ischemic stroke patients, hospitalized in UMHAT „Saint Marina` - Varna

In Bulgaria generally, treatment of acute ischemic strokes is done at the neurology wards and in smaller hospitals - in internal diseases wards, at intensive care wards in state regional hospitals; at ischemic stroke units and intensive care wards for treatment of neurological diseases at university hospitals. Between 2009 and 2013 in Varna, at the Neurology Clinic of UMHAT- St. Marina, a prospective research was carried out in view of optimizing the treatment of acute ischemic stroke (AIS) patients hospitalized at the clinic. After a stage-by-stage introduction into everyday clinical practice of innovative treatment methods, including intravenous thrombolysis and endovascular therapy of AIS patients, as well as organizational restructuring in view of optimizing the care for such patients, improvement in some of the quality indicators was observed

Contemporary surgical treatment of the osteoporotic compression fractures

SUMMARY Aim and object of the study: The vertebral compression fractures (VCF) are one of the most common complication of the osteoporosis that could be a cause for permanent and debilitating pain, restricted mobility and hence significant worsening of the quality of the life. The surgical treatment of the VCF is indicated after a failure of the conservative treatment or after established spinal instability or neurological deficit. The most commonly used surgical procedures are the percutaneous vertebroplasty with poly - methyl methacrylate(PMMA) and the transpedicular screw fixation-reconstruction. The aim of the present investigation is to summarize and elucidate the indications for the different types of spinal techniques, the potential complications and their treatment.Methods: Analyzed were 72 consecutive patients with compression spinal osteoporotic fractures treated in our clinic from January 2009 to July 2012. Of these, 38 patients (M14 / F24) with average age 66.8 years (54-80) underwent PV on 46 levels. All the fractures were without neurological deficit and classified as A1 type in Magerl. The remaining 34 patients (M5 / F29) with average age 67.3 years (56-85) underwent transpedicular screw spinal reconstruction addressing incomplete burst compression fractures in which were damaged the anterior two columns. A total of 40 levels were addressed The indications for surgery were severe pain syndrome, neurological deficit, presence of bone fragments in the spinal canal or spinal instability.Results: In our series the VCF most commonly are located in the thoracolumbar (Th11-L2) segment of the spine - 75.6%, (65/86) levels. In 7 patients 2 levels were treated in one settings, 2 patients had 3 levels treated and one patient 4 levels. Our PV subgroup showed very good outcome in 84.2% (32/38) of patients. Due to migration of the cement in the spinal canal, two patients underwent surgical decompression. The results in the spinal instrumentation subgroup are good in 82.4% (28/34) of the cases. In 6 of the instrumented cases a revision surgery had been performed, due to progressing neurological deficit and persistent pain. The surgery addressed screw pull-outs and implant mallposition/displacement.Conclusion: Our results indicate that modern surgical treatment of osteoporotic patients with symptomatic VCF presents low incidence of complications and allows for a significant reduction of pain, spinal stability, improved quality of life and prolonged active life. PV is minimally invasive procedure with a good effectiveness and uncommon complications that are clinically significant. The spinal instrumented reconstruction is indicated in case of severe multilevel VCF, spinal instability and compression of the neural structures

Work-up in a patient with embolic stroke of unknown source – clinical case

А 33-year-old man without risk factors was admitted to Cardiology Department with history of embolic stroke of unknown source (ESUS). The physical examination, laboratory tests, Holter ECG, and transthoracic echocardiography (TTE) were unremarkable. For further evaluation, he underwent transcranial contrast Doppler sonography (TCD) and transesophageal echocardiography (TEE), which showed atrial septal aneurism and patent foramen ovale (PFO) with significant right-to-left shunt. After screening for thrombophilia, the patient was scheduled for percutaneous closure of PFO. After the procedure he was discharged in a satisfactory condition with following anticoagulant therapy for a year.Conducting further clinical testing in young patients with ESUS is important for the assessment of etiology, further treatment, and secondary stroke prevention

InteRhemispheric differences in clinical outcome after intravenous thrombolysis

Човешкият мозък се характеризира с функционална асиметрия, включваща междухемисферни, корови и подкорови взаимодействия. Пациентите с ИМИ в лява хемисфера и проведено тромболитично лечение (ТЛ) имат два пъти по-голяма вероятност за благоприятен клиничен изход на третия месец сравнено с дяснохемисферните инфаркти. Женският пол и левостранната локализация са предиктори на значимо подобрение на неврологичния дефицит на 24-я час след ТЛ. От друга страна асоциацията на мъжки пол и дяснохемисферна локализация на инсулта е свързана с по-голяма вероятност за благоприятен клиничен изход отколкото при жените със същата локализация. Също така дяснохемисферната локализация на инсулта при мъжете се свързва с по-добър изход отколкото при локализация налезията в лява хемисфера.The human brain is characterized by functional asymmetry including interhemispheric, cortical and subcortical interactions. Patients with acute ischemic stroke (AIS) in the left hemisphere and conducted thrombolytic therapy (IVT) have a two-fold greater likelihood of favorable clinical outcome of the third month compared with right hemispheric infarcts. Petticoats and left - sided location are predictors of significant improvement in neurological deficit 24 hours after IVT. On the other hand the association of male and right - sided location of stroke is associated with a greater likelihood of favorable clinical outcomes than women with the same location. In men it is associated with a better outcome than left-sided localization of the lesion

Surgical complications and unwated events in the modern percutaneous vertebroplasty treatment

Aim and object of the study. The modern spinal surgery accepts the percutaneous vertebroplasty (PV) with polymethylmethacrylate(PMMA) as routine procedure for treatment of painful osteoporotic, neoplastic and traumatic compression fractures in the thoracic and lumbar region of the spinal column. Although considered to be minimal invasive and safe procedure, it could be complicated with severe disabling and even life-threatening complications. The aim of the present study is to evaluate the different potential complications with their clinical presentation, diagnostics and different treatment options.Methods: The study analyzes a cohort of 56 consecutive patients (66 levels) treated with PV in our clinic for the period January 2008 - July 2012. Of them 31(55,4%) are women and 25(44,6%) are men with mean age of 61,7 (23 - 80) years. The osteoporotic and traumatic compression fractures subgroup comprises of 44 (78,6%) patients, while the patients with neoplastic fractures are 12(21,4%). All the fractures are classified as A1 Magerl`s fractures with no neurologic deficit.Results: Complications and unwanted events are registered in 9(16,1%) patients. Of them 2 experienced transient increased pain syndrome intensity, one of the patients presented with index level radiculopathy, 2 patients were diagnosed with extravertebral leakage of the cement in the spinal canal with compression of the neural structures and subsequently operated, 1 patient had cement leak in the adjacent disk, 2 patients cement leak in the paravertebral soft tissues and the paravertebral venous system and one with cement pulmonary embolism.Conclusion: PV is minimal invasive and effective procedure that is used in the treatment of the painful osteoporotic, traumatic and neoplastic compression fractures on neurologically intact patients. The clinically significant complications and unwanted events are relatively rare encounter and in the majority of the cases are treatable with conservative measures. The epidural cement migration with neural elements compression is the only one indication for surgical decompression and removal of the compressing cement

Arterial blood pressure and heart rate response in patients with acute ischemic stroke - Correlation with the severity of cardiovascular autonomic dysfunction

Background and purpose:Despite numerous studies, the mechanisms of blood pressure and heart rate regulation in cerebrovascular diseases remain not completely understood. The aim of the study was to determine the changes in blood pressure (BP) and heart rate (HR) in patients with an acute hemispheric ischemic stroke and to seek a relation to the severity of the cardiovascular autonomic dysfunction.Methods:20 healthy volunteers and 50 patients with an acute hemispheric ischemic stroke participated in the study. The values of BP and HR were registered. Cardiovascular autonomous disorders were examined with "Ewing battery" tests. Patients were divided into two groups according to the severity of the autonomous disorders.Results:Elevated BP values at admission were observed in 56% of our patients, and significantly higher values of systolic blood pressure (SBP) (p <0,001), diastolic blood pressure (DBP) (p = 0,001), and mean arterial pressure (p <0,001), as well as of the heart rate (p = 0,027) were found, compared to the control group. The most significantly increased values of the indicators were reported in patients with a stroke in the territory of the right middle cerebral artery with an involvement of the insular cortex. The results of the t-test performed, showed correlation only between the systolic blood pressure and the severity of the autonomic dysfunction, the values being significantly higher in patients with severe autonomic disorders (t = -2,14; p = 0.036).Conclusion:A variability in BP and HR with a tendency to increase was observed in patients with an acute hemispheric ischemic stroke (ICS) compared to controls, with the highest values reported in patients with ICS in the territory of right middle cerebral artery (TRMCA) with the involvement of the insular cortex (IC). A positive correlation was found between the values of systolic blood pressure (SBP) and the severity of autonomic dysfunction (AD)

Impact of diabetes mellitus and admission hyperglycemia on outcomes after intravenous thrombolysis in acute ischemic stroke patients

Diabetes mellitus (DM) is a major risk factor for stroke, which is associated with unfavorable outcomeafter acute ischemic stroke (AIS) and disability. The potential harmful effect of DM, and the role and importance of blood glucose(BG) at admission are currently unclear for clinical outcome after АIS. Aim of this study is to look for correlations between the presence of DM and theinitial level of BG and the clinical outcome after an intravenous thrombolysis (IVT) in patients with acute AIS.Material and methods. IVT with Astylise has been conducted to 170 patients with AIS for the period 09.2011- 09.2015, from which 20% (n = 34) are with DM, 80% without DM (n = 136). According to the values of the BG at admission they have been divided into three groups: I group- (n = 34) 8,1 mmol/l.Results With mRs (0-2) at 3 months are 60.2% of patients without DM and 40% respectively, p= 0,05(OR-1,5, 95% CI 0,91-2,49). With mRs (0-1) are 35% and 24% respectively (p= 0.196). The probability of this outcome is 1.47 times higher in those without DM (OR 1,47, 95% CI: 0,7-3,09). Mortality about the third month is 20% in patients with DM and 8.8% in those without DM, p 0.05); With mRs (0-1) are respectively 38.2%, 32.3% and 30.8% (p> 0.05). Mortality is 15.4% in the III group compared to 9.2% in the II and 8.8% in the I (p> 0.05). With mRs(3-5) are 38.4% of the III group and 26.5% in the I (p> 0.05).Conclusion. Patients with DM have significantly higher mortality and lack of favorable functional outcome at third monthcompared to those without DM, which can not be explained by the presence of ICH. The initial HG not significantly associated with unfavorable clinical outcome, but she quickly identify patients with an increased risk of such an outcome in which blood sugar levels should be closely monitored

Autonomic cardiovascular disorders in stroke - electrocardiographic changes and risk of sudden cardiac death

Нарушенията на кардиоваскуларните автономни функции са често срещани при мозъчно-съдова болест, имат голямо клинично значение и са най-отчетливо проявени в острата фаза на инсулта. При пациенти с мозъчен инсулт се наблюдават електрокардиографски промени; повишава се честотата на ритъмните нарушения на сърцето, плазмените нива на катехоламините и сърдечните ензими. Вариабилността на сърдечната честота (ВСЧ) предсказва в по-голяма степен ранната, внезапна смъртност.Disturbances of cardiovascular autonomic function are common in patients with cerebrovascular disease (CVDs), have great clinical importance and are most clearly manifested in the acute phase of stroke. In patients experienced stroke are observed electrocardiographic (ECG) changes, increased frequency of heart rhythm disorders, plasma catecholamine levels and cardiac enzymes. Heart rate variability (HRV) shows higher risk of sudden cardiac death

Quality indicators in the treatment of acute ischemic stroke

Cerebrovascular diseases are a global medical and social issue because of the high morbidity, disability and mortality they cause. WHO announces 15 million new ischemic strokes per year globally, with 5 million associated deaths and 5 million patients left permanently disabled. Thrombolysis (TL) with tissue plasminogen activator (rt-PA) is currently an approved differentiated pharmacotherapeutic treatment of ischemic stroke (IS) in its acute phase. There is irrefutable evidence of better health results and efficient clinical management of ischemic strokes within an integrated therapeutic approach as a key factor for improving the functional outcome in stroke patients. Quality is one of the most widely discussed issues in the theory and practice of disease management. Strict compliance with the standards for ischemic stroke treatment is an indicator of high quality patient management