Lege Artis Medicinae

[Carotid artery auscultation]

MAGYAR M. Tünde, EUN-MI Nam, CSIBA László, RITTER A. Martin, BERND E. Ringelstein, DIRK W. Droste

AUGUST 20, 2003

Lege Artis Medicinae - 2003;13(06)

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[Diagnosis and therapy of insect sting allergy]

BÁNKÚTI Beáta

[Over the past 20 years great progress has been made in understanding the pathogenesis, diagnosis and treatment of allergic reactions caused by insect stings. The incidence of insect sting allergy in a general population is about 0.4- 3% but anaphylaxis to Hymenoptera venom can be fatal. The diagnosis of venom allergy is based on the history suggesting an allergic reaction and on the demonstration of the persistence of specific IgE antibody either by skin tests or RAST. Patients who had a severe allergic reaction and has positive venom skin test or RAST result should be advised to receive venom immunotherapy (VIT). The risk for subsequent life-threatening systemic sting reactions can be significantly reduced with VIT. VIT should be continued for at least 3 to 5 years and provides about 90 % protection from insect sting anaphylaxis.]

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[The connection between gastroesophageal reflux disease and obstructive sleep apnoea]

DEMETER Pál, VÁRDI Visy Katalin

[Clinical knowledge on the gastroesophageal reflux disease has been increased with the subject of extragastrointestinal complications in the last decade. Because of cardiological, pulmonological, laryngeal and dental complications, an interdisciplinary approach is required. The non-cardiac chest pain, bronchial asthma, chronic bronchitis, chronic caugh, posterior laryngitis and acidic damage of dental enamel are the most important complications. Authors study a less common connection between the gastroesophageal reflux disease and obstructive sleep apnoea. Sleeping can be considered as a risk factor of the reflux event by itself, because of the decrease of primary peristalsis, producing of saliva, and acidic and volume clearance of oesophagus as well. During obstructive sleep apnoea negative intrathoracic pressure increases extremely, resulting in increased transdiaphragmatic gradient of pressure as well. In addition, the powerful movement of diaphragm twitches the lower oesophageal sphincter through the phrenoesophageal ligament. These two mechanism practically promotes the reflux event in patients with obstructive sleep apnea. The new challenge for the gastroenterologists is to further research this new connection, to play more active role in the complex therapy, and to have a new diagnostic approach of serious gastroesophageal reflux disease.]

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Background: This overview provides a summary of the applications of transcranial Doppler (TCD) in ischemic stroke. Results: A fast-track neurovascular ultrasound protocol has been developed for detecting occlusion or stenosis. The technique is more reliable in the carotid area than in the posterior circulation. By monitoring the pulsatility index the in­crea­sed intracranial pressure can be diagnosed. TIBI score was developed for grading residual flow. TCD has been shown to accurately predict complete or any recanalization. Regarding recanalization, TCD has a sensitivity of 92%, a specificity of 88%, a positive predictive value of 96%, a negative predictive value of 78% and an overall accuracy of 91%, respectively. Sonothrombolysis seemed to be a promising application but randomized controlled trials have shown that it does not improve clinical outcome. TCD examination can detect microembolic signals (MES) which are associated with an increased risk of stroke. Micro­em­boli were detected in symptomatic and asymptomatic carotid artery stenosis and during carotid endarterectomy. The number of microemboli can be decreased by antithrombotic therapy. Contrast en­chan­ced examination and Valsalva maneuver with continuous TCD monitoring can accurately screen for right-to-left shunt.

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[Treatment options for enormous carotid thrombus as a complication of SARS-CoV-2 infection]

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[In SARS-CoV-2 positive patients with corresponding neurological symptoms the presence of carotid bifurcation macrothrombus should always be considered. Hypercoagulopathy caused by viral endotheliitis, systemic inflammation and cytokine storm play an important role in its development. Here we present two patients treated with different treatment strategies because of carotid bifurcation macrothrombus as a complication of SARS-CoV-2 infection. In both cases, the soft macrothrombus was eliminated and the patients’ neurological condition were improved. Intravenous thrombolysis, acute carotid stenting with embolic filter protection device and mechanical thrombectomy with aspiration are effective treatments.]

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Simultaneous subdural, subarachnoideal and intracerebral haemorrhage after rupture of a peripheral middle cerebral artery aneurysm

BÉRES-MOLNÁR Anna Katalin, FOLYOVICH András, SZLOBODA Péter, SZENDREY-KISS Zsolt, BERECZKI Dániel, BAKOS Mária, VÁRALLYAY György, SZABÓ Huba, NYÁRI István

The cause of intracerebral, subarachnoid and subdural haemorrhage is different, and the simultaneous appearance in the same case is extremely rare. We describe the case of a patient with a ruptured aneurysm on the distal segment of the middle cerebral artery, with a concomitant subdural and intracerebral haemorrhage, and a subsequent secondary brainstem (Duret) haemorrhage. The 59-year-old woman had hypertension and diabetes in her medical history. She experienced anomic aphasia and left-sided headache starting one day before admission. She had no trauma. A few minutes after admission she suddenly became comatose, her breathing became superficial. Non-contrast CT revealed left sided fronto-parietal subdural and subarachnoid and intracerebral haemorrhage, and bleeding was also observed in the right pontine region. The patient had leucocytosis and hyperglycemia but normal hemostasis. After the subdural haemorrhage had been evacuated, the patient was transferred to intensive care unit. Sepsis developed. Echocardiography did not detect endocarditis. Neurological status, vigilance gradually improved. The rehabilitation process was interrupted by epileptic status. Control CT and CT angiography proved an aneurysm in the peripheral part of the left middle cerebral artery, which was later clipped. Histolo­gical examination excluded mycotic etiology of the aneu­rysm and “normal aneurysm wall” was described. The brain stem haemorrhage – Duret bleeding – was presumably caused by a sudden increase in intracranial pressure due to the supratentorial space occupying process and consequential trans-tentorial herniation. This case is a rarity, as the patient not only survived, but lives an active life with some residual symptoms.

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[Systemic thrombolysis and endovascular intervention in postpartum stroke]

BERECZKI Dániel Jr., NÉMETH Beatrix, MAY Zsolt, SZAKÁCS ZOLTÁN, GUBUCZ István, SZIKORA István, SZILÁGYI Géza

[Introduction - There are no previously published cases about intravenously applied recombinant tissue plasminogen activator in acute ischemic stroke during puerperium. Case presentation - We report a 40-year-old woman with postpartum acute ischemic stroke caused by multiple cervical artery dissections treated by systemic thrombolysis and endovascular intervention. Discussion - There are only limited data regarding thrombolytic treatment in acute stroke during pregnancy and puerperium. Current acute stroke treatment guidelines - while considering pregnancy as a relative exclusion criterion - do not deal with the postpartum state. Conclusion - As the condition is rare, randomized controlled trials are not feasible, therefore further reports on similar cases could eventually help us suggest guidelines or at least propose recommendations for the acute thrombolytic treatment of strokes occurring in pregnancy and puerperium.]

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Evaluation of ischemic stroke patients with systemic cancer

UFUK Emre, TASKIN Gunes, IREM Pinar, FURUZAN Kokturk, ESENGUL Liman, ORHAN Yağiz

Purpose - In cancer patients, an ischemic stroke can be seen as both a direct effect of cancer and a complication of treatment. This condition can negatively affect the follow-up and treatment of these patients. For this research, we aimed to evaluate the clinical features, stroke types and etiological features of ischemic stroke patients with histories of cancer or found to have cancer during the aetiological investigation. Materials and methods - We retrospectively evaluated 100 patients (57 males, 43 females) who were hospitalized with acute stroke and determined to have the presence of cancer or a cancer history during the aetiological investigation between 2011 and 2016. All the demographic features, stroke types and localizations, National Institutes of Health Stroke Scale (NIHSS) scores, Rankin Scale scores, durations of cancer and cancer treatments were recorded. Results - The mean age of the patients was 67.07 ± 10.9 years old, the median NIHSS score was 5, and the median Rankin Scale score was 4. While 79% of patients had ischemic stroke risk factors, 21% did not. Atherosclerotic stroke was the most common stroke type (49%, n=49) and cryptogenic strokes were detected in 21% (n=21). In addition, 63% of the patients had chronic cancer (later than 6 months), 31% of the patients had recent cancer histories (less than 6 months), and 29% of the patients had metastases. Among all the malignancies, lung cancer (n=23), gastrointestinal cancer (n=20) and gynaecological-breast cancer (n=16) were the three most common. Moreover, 37% of the patients underwent chemotherapy, 29% underwent radiotherapy, and 88% of the patients had Carotid/Vertebral Doppler USG abnormalities. Conclusion - Similar to what is stated in the literature, an atherosclerotic stroke was the most common type of stroke in the cancer patients. Stroke risk factors were not detected in 21% of the patients, and in the majority of the patients, atherosclerotic changes in the carotid artery were observed in the Doppler examinations. In the aetiology and prognosis of ischemic stroke, it is important to keep in mind the existence of cancer in addition to the classical stroke risk factors.