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Clinical Neuroscience

NOVEMBER 20, 2015

[A rare complication of a rare disease; stroke due to relapsing polychondritis]

KILIC COBAN Eda, XANMEMMEDOV Elimir, COLAK Melek, SOYSAL Aysun

[Relapsing polychondritis (RP) is an episodic and progressive inflammatory disease of cartilaginous structures. Its diagnosis is based primarily on clinical features such as laboratory parameters, biopsy. Neurological complications occur in 3% of the cases and are classified as an important cause of death. The cranial nerve disorders are most common but hemiplegia, ataxia, myelitis, polyneuritis, seizures, confusion, hallucination and headache can also happen. The aetiology of central nervous system involvement is still unknown. Moreover stroke has rarely reported in these patients. The diagnosis of stroke is challenging because of its rarity among these patients. Perhaps vasculitis is the common underlying mechanism. Also meningitis and encephalitis can occur during the course of RP. A 44 year-old woman was admitted with uncontemplated left hemiparesis, redness, swelling, and tenderness of the metacarpophalangeal and interphalangeal joints of the right hand and the cartilaginous portion. White blood cell count, C-reactive protein and the erythrocyte sedimentation rate were elevated. Vasculitis biomarkers were normal in our patient. Carotid and vertebral artery doppler ultrasonography, cranial and cervical MR Angiography were normal. Echocardiography showed a mild mitral valve prolapse and regurgitation. Our patient had the history of auricular polychondritis but she had not been diagnosed. Hemiparesis was her first neurological manifestation that led her to doctors for diagnosis. Our patient fulfilled the criteria of RP so no biopsy was needed. She was treated with oral prednisolone (80 mg/day) and aspirin (300 mg/day) and now she is on 10 mg prednisolone and 150 mg azathioprine. Two months later her physical and neurological symptoms returned to normal.]

Lege Artis Medicinae

NOVEMBER 15, 2019

[Vascular biomarkers ]

BENCZÚR Béla

[While risk scores are invaluable tools for adapted preventive strategies, a significant gap exists between predicted and actual event rates. Additional tools to further refine the risk stratification of patients at an individual level are biomarkers. A surrogate endpoint is a biomarker that is intended as a substitute for and being realized earlier than a clinical hard endpoint. In order to be suitable as a surrogate endpoint of cardiovascular events, a biomarker should meet several well-defined criteria. It has been proposed that a plenty of potential vascular biomarkers would have a role in primary and secondary cardiovascular prevention. Most of the biomarkers examined fit within the concept of early vascular aging. The only biomarkers that fulfill most of the criteria and, therefore, are close to being considered a clinical surrogate endpoint are carotid ultrasonography, ankle-brachial index and carotid-femoral pulse wave velocity. ]

Clinical Neuroscience

JULY 30, 2019

Effects of CHADS2 score, echocardiographic and haematologic parameters on stroke severity and prognosis in patients with stroke due to nonvalvular atrial fibrillation

AYNACI Ozer, TEKATAS Aslan, AYNACI Gülden, KEHAYA Sezgin, UTKU Ufuk

Introduction - The aim of this study is to evaluate utility of CHADS2 score to estimate stroke severity and prognosis in patients with ischemic stroke due to non-valvular atrial fibrillation (AF) in addition to evaluate effects of hematologic and echocardiographic findings on stroke severity and prognosis. Methods - This prospective study included 156 ischemic stroke cases due to non-valvular AF in neurology ward of Trakya University Medical School between March 2013-March 2015. National Institute of Health Stroke (NIHS) score was used to evaluate severity of stroke at admission. Carotid and vertebral Doppler ultrasonography findings, brain computed tomography (CT) and magnetic resonance imaging (MRI) of the cases were evaluated. Left atrial diameter and ejection fraction (EF) values were measured. CHADS2 score was calculated. Modified Rankin Scale was used to rate the degree of dependence. Effects of age and sex of the patients, presence of diabetes mellitus (DM), Congestive Heart Failure (CHF), Cerebrovascular Disease (CVD) and C-reactive protein (CRP) levels on CHADS2, NIHS, and mRS were evaluated. Results - In patients with age ≥75, mean NIHS score was 3.3 points and mean mRS score was 1.02 points higher, than in patient below 75 years of age. Compared with the mild risk group, cases in the high risk group had older age, higher serum D-dimer, fibrinogen and CRP levels and lower EF. A positive relation was detected between stroke severity and Hemorrhagic Transformation (HT), previous CVD history, and presence of CHF. A significant association was found between increased stroke severity and Early Neurological Deterioration (END) development. Older age, higher serum fibrinogen, D-dimer, CRP and lower EF values were associated with poor prognosis. History of CVD and presence of CHF were associated with poor prognosis. END development was found to be associated with poor prognosis. In the high-risk group, 30.3% (n = 33) had END. Among those in the high-risk group according to the CHADS2 score, END development rate was found to be significantly higher than in the moderate risk group (p <0.05). There was a strong positive correlation between CHADS2 and NIHS scores. mRS score increased with increasing CHADS2 score and there was a strong correlation between them. Effect of stroke severity on prognosis was assessed and a positive correlation was found between NIHS score and mRS value. Discussion - Our study demonstrated the importance of CHADS2 score, haemostatic activation and echocardiographic findings to assess stroke severity and prognosis. Knowing factors which affect stroke severity and prognosis in patients with ischemic stroke may be directive to decide primary prevention and stroke management.

Clinical Neuroscience

MAY 30, 2019

Population-based stroke screening days in the 12th district of Budapest in 2011 and 2016 - What have and what have not changed?

FOLYOVICH András, BOTOS Nóra, BALOGH Erzsébet, BAKOS Mária, HERTELENDY Anna, BÉRES-MOLNÁR Anna Katalin

Introduction - Population-based screening is an option to identify persons at high risk for stroke. However it is associated with rather high expenses, necessitating the selection of effective methods that take local characteristics into account. The 12th district of Budapest has a long tradition of population-based screening for frequent and preventable diseases. The Szent János Hospital hosts an annual stroke screening day. In the present study, previously published data from the 2011 screening were compared with those obtained in 2016, looking for changes and tendencies throughout the examined period. Subjects and methods - The screening day was conducted in a generally similar way in 2011 and 2016. Similarly to the previous event, the program was organized on a Saturday, the call for the event was spread by the local newspaper. The crew composition was the same. As regards the components of the screening (currently including general history taking, risk status assessment, blood pressure measurement, BMI assessment, cholesterol and blood glucose tests, carotid duplex ultrasonography, and ophthalmological examination), the only difference was the absence of cardiologic examination (it was conducted on an independent day). The anonymous data sheet was the same. Results - The number of participants in the 2016 event was 33, to provide more comfortable conditions. The female predominance was slightly less pronounced but was still present in 2016 (60.6% vs. 72.9%). The mean age became substantially higher (71.2 y vs. 62.9 y). The ratios of participants with higher level of education (97% vs. 94%) and those who are married were still remarkable. The most frequent risk factors were the same; however the ratio of participants with hypertension, ‘other heart disease’, and diabetes increased, whereas that of with hyperlipidemia and obesity decreased. The incidence of atrial fibrillation was unaltered. None of the participants in 2016 admitted smoking (previously this ratio was 20.8%) or drinking heavily. The findings of the carotid ultrasonography revealed a more favorable vascular status. Ophthalmological assessments (predominantly hypertensive alterations on fundoscopy) revealed that the pathological vs. physiological ratio switched to 1:2 from 2:1. The final evaluation of the screening program likewise demonstrated an improved overall state of health of the population. Conclusions - We observed a more favorable stroke risk status of the population in 2016. Whether it is indeed a tendency unknown at present. The role of the local media in calling for screening is still decisive, and the cohesive power of the family is important.

Hypertension and nephrology

SEPTEMBER 10, 2017

[Thought about renovascular hypertension by a special case report]

GAJDÁN Nikolett, LÉGRÁDY Péter, BAJCSI Dóra, MORVAY Zita, NAGY Endre, LETOHA Annamária, KYPROS Constantinou, FEJES Imola, SONKODI Sándor, ÁBRAHÁM György

[Renovascular hypertension is a well-known form of secunder hypertension. Two thirds of cases are caused by atherosclerotic plaque and one third are caused by fibromuscular dysplasia. The prevalence of it is less than 1%. Digital subtraction angiography is considered the goldstandard diagnostic method. The 58-year old female patient was hospitalized with resistant hypertension. Duplex ultrasonography showed fibromuscular stenosis the in left renal artery. Percutaneous transluminal angioplasty and stenting were performed. Her blood pressure normalized. The patient did not attend the control examinations. Next time in 2001, she was referred to our emergency department with increased blood pressure of 210/140 mmHg. Following control ultrasonography angiography showed total occlusion of the left renal artery and significant stenosis of the right renal artery. Left nephrectomy was necessary due to shrunken kidney and dilatation and stenting of the right renal artery. The blood pressure normalized again. Since 2004 until 2014 despite of the regular visits, we detected in stent restenosis of the right renal artery almost in each year. Even so, renal function was preserved all the time. In autumn of 2014, the patient suffered severe stroke, and few months later at the age of 74 she died. There are many open questions to discus concerning the right treatment of renovascular hypertension yet. Even so by performing 12 intravascular interventions we could ensure her acceptable quality of life for 16 years.]

Journal of Nursing Theory and Practice

FEBRUARY 28, 2016

[Care of the fistula, advantages of the monitoring and the surveillance with thermodilution technique]

GREGUSCHIK Judit, RIKKER Csaba, LUKÁCSI Attila, MOGYORÓSI Róza

[Introduction: The best choice of vascular access for haemodialysis patients is the native arteriovenous fistula (AVF). Therefore, monitoring and surveillance of vascular accesses has a high priority. Aim of the research: The aim of our study was to evaluate the AVF surveillance protocol of our dialysis clinic. Research and sampling methods: We began AVF monitoring and surveillance in our dialysis clinic in February 2003. Until May 2015 we evaluated the data of 307 patients. Results: Besides the regular physical investigation of fistulas we performed measurements of vascular access flow (Qa) with thermodilution technique. In cases of suspected stenosis we performed Colour Doppler Ultrasonography and/or fistulography. Stenosis was verified in 154 cases at 344 patients. Percutan transluminal angioplasty was performed in 241 cases at 127 patients. Creation of a new fistula was necessary only in 24 cases at 21 patients. Within the last three years the percentage of patients treated via AVF has risen from 75% to 84%. Conclusions: Regular monitoring and surveillance of vascular accesses and the timely correction of its complications are able to reduce thrombosis of fistulas and the necessity of using central venous catheters. ]

Clinical Neuroscience

JANUARY 25, 2013

[The significance of high-resolution ultrasonography in the diagnosis of peripheral nerve disorders]

SCHEIDL Erika, JOSEF Böhm, FARBAKY Zsófia, DEBRECZENI Róbert, BERECZKI Dániel, ARÁNYI Zsuzsanna

[High resolution ultrasonography is an emerging technique for the investigation of peripheral nerves and is increasingly used worldwide in the diagnosis of peripheral nerve disorders, however, until now it is not widespread in Hungary. According to the literature this method is especially useful in entrapment neuropathies, traumatic peripheral nerve injuries, tumors of the peripheral nerves and sonographically guided interventions. Ultrasonography allows precise morphological analysis and quantitative measurements of the nerves providing useful complementary information to electrodiagnostic data. In entrapment neuropathies ultrasound shows nerve swelling mainly proximal to the sites of compression and a focal change of echotexture. On longitudinal scan, an abrupt caliber change and spindle-like swelling of the compressed nerve segment can be seen. Evaluation of the anatomical background and visualisation of the postoperative and posttraumatic changes provide useful information for planning of the therapy. Ultrasound may be of significant help in localizing the pathological nerve segment when it is at an electrophysiologically inaccessible site or when substantial secondary axonal loss precludes precise electrophysiological localization and it might even show pathological changes when nerve conduction studies are normal. Contrary to electrophysiological investigation ultrasonography might discover neurotmesis in the akute phase of traumatic nerve injuries indicating the necessity of surgical intervention. We provide a summary of the main indications and further application areas of this method.]

Lege Artis Medicinae

FEBRUARY 21, 2004

[LARGE VESSEL MANIFESTATION OF GIANTCELL ARTERITIS]

KOLOSSVÁRY Endre, PINTÉR Hajnalka, ERÉNYI Éva, KOLLÁR Attila, FARKAS Katalin, KISS István, HARCOS Péter, SIMON Károly

[The diagnosis of giant-cell arteritis is a real challenge for clinicians. There are several reasons for the difficulties in establishing the diagnosis. This disease is associated to rare conditions, therefore most physicians lack clinical experience. This condition shows very heterogeneous manifestation, the intensity of the symptoms vary in time. Early diagnosis is of great importance in order to prevent ischemic complications. Among these complications one should emphasise the role of anterior ischemic optic neuropathy that may result in abrupt blindness. In this case report, we show a rare socalled large vessel manifestation of giant-cell arteritis. This form of the disease needs different approach in diagnosis where color duplex ultrasonography may have distinguished importance. The final verification of the diagnosis is based on histology. However the lack of all histological criteria do not exclude the presence of giant-cell arteritis.]

Hungarian Radiology

DECEMBER 21, 2009

[Cervical space occupying lesions: diagnosis at sonoelastography]

UJLAKI Mátyás, MAGYAR Péter, KARLINGER Kinga

[Among cervical (neck) region tumours, the thyroid lesions and the metastatic lymph nodes are the most detectable with conventional B-mode ultrasonography (US). The use of MRI and CT scans are limited because of the cost, and in case of CT, the radiation. With the introduction and constant development of sonoelastography, we have in our hands a new imaging procedure which is cheap, fast and harmless, yet giving more information to the examiner than conventional US. The elastographic examination of thyroid lesions is a more explored area than the elastographic visualisation of cervical lymph nodes. The ‘off-line’ elastography showed the highest accuracy allowing to calculate and analyse the strain index of cervical lymph nodes - strain index > 1.5 (85% sensitivity, 98% specificity) - but the ‘off-line’ processing of US elastograms is still too time consuming to be used in busy clinical settings. During the examinations of the thyroid gland both real-time and off-line processed strain imaging were used. An Italian team made a great leap forward as they standardized the degree of distorsion under the application of the external force. Then using the Ueno and Itoh elasticity score they achieved remarkable accuracy with real-time sonoelastography (P <0.0001). On the other hand only those organs are suitable for the US elastography characterization which can be slightly compressed, consequently the examination of a lesion with calcified shell cannot give useful information. Near to the pulsating arteries substantial amounts of decorrelation noise may appear and the examiner has to pay attention what structures are in the ROI box since the sonoelastography method assumes computations relative to the average strain inside the box. To detect a follicular carcinoma in the thyroid gland remains a big challenge. Despite of the limitations most researchers agree on the fact that sonoelastography is a perfect tool to use in addition to the conventional US examination. B-mode US combined with sonoelastography raised the accuracy in differentiation in all cases. With this modality it is also possible to deduce the number of cases when healthy lymph nodes or tissue peaces are taken for biopsy during FNAB.]

Lege Artis Medicinae

DECEMBER 20, 2005

[PENILE VEIN THROMBOSIS AT YOUNG AGE]

KOVÁCS GÁBOR, GASZTONYI Beáta, BATTYÁNY István, NAGY Ágnes, BUZOGÁNY István, KASSAI Miklós, HUNYADY Béla, LOSONCZY Hajna

[INTRODUCTION - Mondor’s disease is an uncommon disorder occuring mostly in middleaged women and characterized by superficial thrombophlebitis classically involving the thoraco- epigastric veins. Rarely, cases have been reported in atypical sites (upper arms, abdomen, groin and penis). CASE REPORT - This is the first case being published in the Hungarian literature. The young male patient's complaints were caused by penile vein thrombosis which was demonstrated on physical examination and Doppler ultrasonography. Since hereditary thrombophilia and malignancy has been ruled out, we assume that local trauma and venous stasis caused by previous abdominal surgery have been the etiological factors of the disease. CONCLUSION - We give a review of the literature and would like to draw the attention to this rare type of thrombosis, its risk factors and the difficulties of the therapy.]