[Reconstruction of a metadiaphyseal bone defect after open comminuted fracture of the proximal femur using a modified Masquelet technique]

The reconstruction of segmental bone defects after surgical treatment of infected delayed unions as well as nonunions, places the highest demands on the surgical technical implementation. After treating the fracture-related infection, guaranteeing biomechanical stability is crucial for the success of the treatment. The presented case describes the successful treatment of an infected delayed union after an open metadiaphyseal comminuted fracture of the proximal femur using a modified Masquelet technique. A solid allogeneic bone graft in combination with autologous cancellous bone were inserted into a 7 cm subtrochanteric defect zone and stabilized with a combined plate and nail osteosynthesis.

Open versus minimally invasive fixation of thoracic and lumbar spine fractures in patients with ankylosing spinal diseases

Purpose

Posterior multilevel fixation of traumatic instability in ankylosing spinal disease (ASD) can be performed by open surgery (OS) or minimally invasive surgery (MIS). We investigated whether both methods differ based on the reduction results and perioperative parameters.

Methods

In this retrospective cohort study, OS and MIS groups were investigated. The bisegmental Cobb angles and dislocation angles were measured using pre- and postoperative CT images, and the initial malalignment and achieved reduction were calculated. Cut-seam time, calculated blood loss, transfusion number, fluoroscopy time, pedicle screw placement accuracy, duration of ICU stay, in-patient stay, and complications (bleeding, postoperative thrombosis and embolism, and postoperative mortality) were recorded.

Results

Seventy-five ASD patients with spine fractures (Ø 75 ± 11 years, male: 52, female: 23) (MIS: 48; OS: 27) were included in this study. The extent of reduction did not differ in the OS and MIS groups (p = 0.465; MIS:− 1 ± 3°, OS:−2 ± 6°). The residual postoperative malalignment angle was not significantly different (p = 0.283). Seventy-eight of the implanted screws (11%) showed malpositioning. No difference was found between OS and MIS (MIS, 37 [7%]; OS, 41 [16%]; p = 0.095). MIS was associated with less blood loss (OS: 1.28 ± 0.78 l, MIS: 0.71 ± 0.57 l, p = 0.001), cut-seam time (MIS: 98 ± 44 min, OS: 166 ± 69 min, p < 0.001), and hospital stay (MIS: Ø14 ± 16 d, OS: Ø38 ± 49 d, p = 0.02) than OS.

Conclusion

OS and MIS show equally limited performance in terms of the fracture reduction achieved. The MIS technique was superior to OS based on the perioperative outcome. Therefore, MIS should be preferred over OS for unstable spinal injuries, excluding C-type fractures, in ASD patients without neurological impairment.

[Surgical treatment strategy for traumatic luxation of the posterior tibial tendon : Case report and literature review]

Based on a case study, the injury pattern and surgical procedure for traumatic dislocation of the posterior tibial tendon is presented. A 32-year-old ice hockey player suffered a direct impact from a puck at the dorsomedial aspect of the inner ankle. In the course of the injury a ganglion developed due to recurrent dislocation of the posterior tibial tendon. Intraoperatively, a distracted retinaculum and a flattened retromalleolar sulcus were present. An open wedge osteotomy and suture anchor refixation of the retinaculum were performed. This procedure is described in the context of a review of the literature.

Calcium Microcrystal Formation in Recurrent Herniation Patients After Autologous Disc Cell Transplantation

Autologous disc cell transplantation (ADCT) is a cell-based therapy aiming to initiate regeneration of intervertebral disc (IVD) tissue, but little is known about potential risks. This study aims to investigate the presence of structural phenomena accompanying the transformation process after ADCT treatment in IVD disease. Structural phenomena of ADCT-treated patients (Group 1, n = 10) with recurrent disc herniation were compared to conventionally-treated patients with recurrent herniation (Group 2, n = 10) and patients with a first-time herniation (Group 3, n = 10). For ethical reasons, a control group of ADCT patients who did not have a recurrent disc herniation was not possible. Tissue samples were obtained via micro-sequestrectomy after disc herniation and analyzed by micro-computed tomography, scanning electron microscopy, energy dispersive spectroscopy, and histology in terms of calcification zones, tissue structure, cell density, cell morphology, and elemental composition. The major differentiator between sample groups was calcium microcrystal formation in all ADCT samples, not found in any of the control group samples, which may indicate disc degradation. The incorporation of mineral particles provided clear contrast between the different materials and chemical analysis of a single particle indicated the presence of magnesium-containing calcium phosphate. As IVD calcification is a primary indicator of disc degeneration, further investigation of ADCT and detailed investigations assessing each patient's Pfirrmann degeneration grade following herniation is warranted. Structural phenomena unique to ADCT herniation prompt further investigation of the therapy's mechanisms and its effect on IVD tissue. However, the impossibility of a perfect control group limits the generalizable interpretation of the results.

Neuropsychological characteristics of encephalopathy in Susac's Syndrome - Case report

Susac's Syndrome (SS) is a rare, autoimmune angiopathy characterized by hearing loss, retinal artery occlusions and encephalopathy, which is usually expressed in multifocal neurological signs and symptoms, confusion state and cognitive impairment. There have been few descriptions of neuropsychological assessment of SS. We present a case study of 29-year-old woman who developed full SS. During the post-acute stage of disease, she was admitted to neurorehabilitation ward to improve her cognitive-behavioral and motor functioning. The initial assessment revealed attention, memory and executive dysfunctions, as well as behavioral changes including impulsivity, affective dysregulation and reduced self-awareness of disease deficits. After five weeks recovery process supported by rehabilitation program, improvement was observed, although some cognitive-behavioral deficits were still present in the follow-up assessment.

[The complicated course of a femoral shaft fracture in childhood]

We report a difficult healing process after a femoral shaft fracture in childhood. We present surgical correction options of femoral shortening due to pseudarthrosis after elastic stable intramedullary nailing. First, we tried to establish distraction using an external fixator, followed by plate osteosynthesis. After material failure of plate osteosynthesis, we treated the refracture with intramedullary nailing, after which bone healing occurred.

[Impairment of oxygenation of patients in surgical intensive care : Early symptom of severe sepsis]

BACKGROUND

Sepsis and septic shock are major contributors to morbidity and mortality in intensive care patients. Early identification and adequate therapy are of utmost importance to reduce the still high mortality in patients with severe sepsis. Many of the pathophysiologic changes are nonspecific. Thus, a combination of symptoms and laboratory results are necessary to confirm the diagnosis. Impairment of the Horovitz index is identified as being a primal prognostic criterion for early diagnosis in serious progression of sepsis, after exclusion of a few differential diagnoses. Based on this fact, the prevalence of this symptom compared to other sepsis parameters is of specific interest.

METHOD

In a retrospective study 33 cases of serious sepsis were analysed during the patient's course of intensive care treatment focusing on oxygenation. The deterioration of oxygenation, meaning a drop in the Horovitz index below 200 mm Hg (25.7 kPa) or a decrease in paO₂ by 67.5 mm Hg (9 kPa) in spontaneously breathing patients with sepsis was the mean inclusion criteria. We compared the sequence of occurrence of known sepsis markers (e. g. PCT, WBC, CRP) with the deterioration in oxygenation to answer the question whether impairment of oxygenation could be an early symptom of severe sepsis. The Mann Whitney U‑test and a discriminant analysis were performed to verify differences of the variables investigated between surviving and deceased patients. Furthermore a regression analysis was performed to confirm the results of the discriminant analysis.

RESULTS

The mean drop in the Horovitz index was 90 ± 24 mm Hg (12 ± 3.2 kPa) within 4.5 h respectively. This was highly significant (p < 0.001). In all patients impairment of oxygenation indicated an individual onset and further progression of a serious sepsis. In more than ¾ of all cases this symptom occurred in an earlier stage than other organ dysfunctions. In 79 % of cases, patients showed an impairment of oxygenation before PCT increased on values of >2 ng/ml. In 76 % of cases impairment of oxygenation occurred earlier than all other investigated parameters. Significant differences were found between surviving and deceased patients regarding to their age as well as the timeframe from the beginning of impaired oxygenation to the onset of the effect of the administered antibiotics. These two parameters (age, time to sufficient antibiotic therapy) were confirmed by regression analysis and showing similar effect coefficients, age 1.09 and time to sufficient antibiotic therapy 1.04 respectively.

CONCLUSION

An urgent worsening of pulmonary function in patients in intensive care requires immediate differential diagnostics due to substantial therapeutic consequences. Our results confirm that impairment of pulmonary oxygenation is the first prognostic symptom of severe onset of sepsis. Consequently, we recommend that this parameter be considered in diagnostic staging. After exclusion of a few differential diagnoses impairment of oxygenation can be the very first symptom of severe sepsis. The patient's age and time to sufficient antibiotic therapy are two very important prognostic factors with respect to mortality. Early and sufficient antibiotic therapy, and in a few cases surgical intervention are of utmost importance.

[Elbow dislocation with ipsilateral proximal radial shaft fracture and radial head dislocation]

Elbow dislocation with ipsilateral proximal radial shaft fracture and dislocated radial head is a rarely described injury. In this article we present the case of a 23-year-old man with this injury. After the initial diagnostics, the radial shaft fracture was osteosynthetically fixed, whereby the anatomical positions of all parts of the elbow joint were correctly aligned and the medial collateral ligament was reconstructed. After 4.5 months the radial shaft fracture was healed with nearly complete functional recovery of the upper extremity. Thus, a good outcome can be expected when all aspects of bony and ligamentous injuries are accurately addressed.

[Aggravated reduction of the posterior malleolar fracture due to incarceration of the flexor digitorum longus tendon]

The indications for stabilization of the posterior malleolus (Volkmann triangle) while fixing ankle fractures are controversially discussed. Detailed descriptions of possible obstacles to reduction are scarce. The following case describes the difficulty of reduction of the posterior malleolus caused by interposition of the flexor digitorum longus tendon. The fracture line of the posterior malleolus passed in an atypical manner vertically to the posterior-medial tibial margin with direct contact to the anatomical pathway of the tendon. The impaction of the tendon was already present in the computed tomography (CT) scan taken preoperatively but the tendon hindering malleolar reduction was first realized during surgery after several unsuccessful attempts at repositioning.

Anatomical conditions of the posterior pelvic ring regarding bisegmental transverse sacroiliac screw fixation: a 3D morphometric study of 125 pelvic CT datasets

INTRODUCTION

Sacroiliac (SI) screws are used for osteosynthesis in unstable posterior pelvic ring injuries. In the cases of "sacral dysplasia", in which the elevated upper sacrum does not allow a secure SI screw insertion into the S1 level, the S2 segment must be used to achieve stable fixation. The bone quality of the S2 segment is thinner compared to that of the S1 vertebra and may cause biomechanical weakness. An additional SI screw insertion into the S3 level may improve stability. With respect to the anatomical conditions of the posterior pelvic ring, there have been no anatomical investigations to date regarding SI screw placement into the third sacral segment.

MATERIALS AND METHODS

CT raw datasets from 125 patients (ø59 years, ø172 cm, ø76 kg) were post-processed using Amira 5.2 software to generate 3D pelvic models. A program code implemented in C++ computed a transverse bone corridor for the first, second and third sacral segments for a typical SI screw diameter of 7.3 mm. Volume, sagittal cross-section, iliac entrance area and length of the determined screw corridors were measured. A confidence interval of 95 % was assumed (p < 0.05).

RESULTS

The fully automatic computation revealed a possible transverse insertion for one 7.3-mm screw in the third sacral segment in 30 cases (24 %). The rate (60 %) of feasible S3 screw placements in the cases of sacral dysplasia (n = 25) is significantly higher compared to that (15 %) of "normal" sacra (n = 100). With regard to the existence of transverse iliosacroiliac corridors as a function of sacral position in between the adjacent iliac bone bilaterally, a new classification of three different shape conditions can be made: caudad, intermediate minor, intermediate major, and cephalad sacrum. Gender, age, body height and body weight had no statistically significant influence on either possible screw insertion or on the calculated data of the corridors (p > 0.05).

CONCLUSION

SI screw insertion into the third sacral level deserves discussion in the cases of sacral dysplasia. Biomechanical and practical utility must be verified.

Impact of BDNF -196 G>A and BDNF -270 C>T polymorphisms on stroke rehabilitation outcome: sex and age differences

BACKGROUND

Genetic factors, including gene polymorphisms, are promising in determining stroke rehabilitation outcome. Brain-derived neurotrophic factor (BDNF) is one of the most attractive because of its role in neuroplasticity and brain repair.

OBJECTIVE

The aim of present study was to assess the role of BDNF -196 G≯A (val66met) and -270 C≯T on clinical parameters and functional outcome in patients with ischemic and hemorrhagic stroke. Additional analyses according to sex and age (≤55 and ≯55 years) were performed.

METHODS

Three hundred thirty-eight patients (287 with ischemic and 51 with hemorrhagic stroke) were evaluated in terms of neurological deficit (National Institute of Heath Stroke Scale [NIHSS]), activities of daily living (Barthel Index [BI]), and everyday functionality (Rankin score [RS]) before and after rehabilitation. BDNF polymorphism genotyping was performed by polymerase chain reaction restriction fragment length polymorphism analysis.

RESULTS

In multivariative analysis, unfavorable outcome of stroke rehabilitation (RS ≥2) was associated with independent factors: ischemic stroke (odds ratio [OR], 2.59; 95% CI, 1.03-6.47), female gender (OR, 2.80; 95% CI, 1.39-5.64), depression (OR, 4.24; 95% CI, 1.45-12.35), falls (OR, 2.61; 95% CI, 1.16-5.87), and BDNF -196 GG polymorphism (OR, 2.18; 95% CI, 1.09-4.35). The differences of functional parameters measured with BI and RS on admission and at discharge are apparent only for comparisons between patients ≤55 and ≯55 years old carrying BDNF -196 GA+AA genotypes but not in those carrying -196 GG genotype; the differences were evident in women but not in men.

CONCLUSIONS

BDNF -196 G≯A polymorphism might affect functional outcome of stroke rehabilitation, but this hypothesis needs further verification.

Comparison of palmar fixed-angle plate fixation with K-wire fixation of distal radius fractures (AO A2, A3, C1) in elderly patients

The objective of this prospective, randomized, controlled trial was to compare the results of two operative techniques used for the treatment of unstable distal radius fractures in elderly patients classified as AO types A2, A3, and C1. Patients were treated with either fixed-angle volar plates or K-wires using a combined Kapandji and Willenegger technique. The functional results were determined after 3, 6, and 12 months. We included 40 patients aged over 65 years. Twenty-one patients were treated with plate fixation and 19 with K-wire fixation. The functional results, after 1 year, were nearly the same in both treatment groups, suggesting that either method is suitable for the treatment of unstable distal radius fractures of AO types A2, A3, and C1 in elderly patients. Sixteen of 21 patients with plate fixation and 17 of 19 patients with K-wire fixation present good results as assessed by the Castaing score. The median DASH score was three in both groups after 1 year. The patients with plate fixation were able to resume activities of daily living 4 weeks earlier. The most common complication was an intermediate post-traumatic median nerve irritation. Both methods are suitable for the treatment of elderly patients with unstable distal radius fractures of AO types A2, A3, and C1. If early functional post-operative care is important, palmar fixed-angle plate fixation is an ideal treatment approach. Otherwise, K-wire fixation is an effective, minimally invasive method with comparable clinical results.

The influence of sacral morphology on the existence of secure S1 and S2 transverse bone corridors for iliosacroiliac screw fixation

Sacroiliac (SI) screw fixation for unstable pelvic fractures stands out as the only minimally invasive method among all other ORIF procedures. A strictly transverse screw trajectory is needed for central or bilateral fracture patterns up to a complete iliosacroiliac fixation. However, secure screw insertion is aggravated by a narrow sacroiliac bone stock. This study investigates the influence of a highly variable sacral morphology to the existence of S1 and S2 transverse corridors. The analysis contained in this study is based on 125 CT datasets of intact human pelvises. First, sacral dysplasia was identified using the "lateral sacral triangle" method in a lateral 3-D semi-transparent pelvic view. Second, 3-D corridors for a 7.3mm screw in the upper two sacral levels were visualised using a proprietary IT workflow of custom-made programme scripts based on the Amira(®)-software. Shape-describing measurement variables were calculated as output variables. The results show a significant linear correlation between ratioT and the screw-limiting S1 isthmus height (Pearson coefficient of 0.84). A boundary ratio of 1.5 represented a positive predictive value of 96% for the existence of a transverse S1-corridor for at least one 7.3mm screw. In 100 out of 125 pelvises (80%), a sufficient S1 corridor existed, whereas in 124 specimens (99%), an S2 corridor was found. Statistics revealed significantly larger S1 and S2 corridors in males compared to females (p<0.05). However, no gender-related differences were observed for clinically relevant numbers of up to 3 screws in S1 and 1 screw in S2. The expanse of the S1 corridor is highly influenced by the dimensions of the dysplastic elevated upper sacrum, whereas the S2 corridor is not affected. Hence, in dysplastic pelvises, sacroiliac screw insertion should be recommended into the 2nd sacral segment. Our IT workflow for the automatic computation of 3-D corridors may assist in surgical pre-operative planning. Furthermore, the workflow could be implemented in computer-assisted surgery applications involving pelvic trauma.

[Acute compartment syndrome of the lower leg due to knee arthroscopy]

This case report describes an acute postoperative compartment syndrome of the lower leg following simple arthroscopy of the knee. The diagnostics as well as the time course of further therapeutic procedures are considered critically. Furthermore, the surgical workflow is analyzed for possible reasons. Retrospectively, an accumulation of irrigation fluid passing through a popliteal cyst into the superficial flexor compartment must be suspected. In summary, even with an optimal perioperative management the subsequent compartment syndrome due to knee arthroscopy cannot be avoided with any certainty. However, immediate causal therapy lies in the urgent dermatofasciotomy to prevent irreversible neuromuscular damage.

Cerebral amyloid angiopathy manifested as a brain tumour. Clinical and neuropathological characteristics of two cases

We present two cases (female and male patients, aged 64 and 38, respectively) of focal mass lesions mimicking a brain tumour: one with cognitive function deficit, memory troubles, behavioral changes and left hemiparesis, the other with difficulty in orientation and right hemiparesis. General physical and neurological examinations, laboratory tests and neuroimaging were used to diagnose the cases. Both of them showed nonspecific changes in the brain tissue and the brain tumour was suspected. In the first case MRI scan revealed two pathological masses in the right frontal region and hemorrhagical focus with destructions inside lesions. Second patient's MRI scan revealed a pathological mass at the interface of the left temporal and occipital regions. The neurosurgical procedure was performed. The final diagnosis was established on the basis of neuropathological examination of postoperative material. On light microscopy examination a severe cerebral amyloid angiopathy (CAA) was revealed. Amyloidoma was excluded due to the absence of amorphous material and eosynophylic masses. Tumefactive CAA is a rare condition. These two cases of focal, tumefactive, masslike lesions of diffuse cerebral amyloid angiopathy are reported because of diagnostic dilemmas. In patients with history of memory disfunction, neurological deterioration and different multiple changes observed in CT and MRI scans, such as hemorrhagic infarcts and ischemic cerebral lesions, CAA should be suspected. The imaging findings make a distinction between tumefactive CAA and brain tumours like gliomas difficult. A differential diagnosis of CAA and amyloidoma plays a significant role in a neuropathological examination.

The lateral sacral triangle--a decision support for secure transverse sacroiliac screw insertion

Sacroiliac (SI) screw fixation represents an effective method to stabilise pelvic injuries. However, to date neither reliable radiological landmarks nor effective anatomical classifications of the sacrum exist. This study investigates the influence of variability in sacral shape on secure transverse SI-screw positioning. Furthermore, consistent correlations of these anatomical conditions are analysed with respect to standard planar pelvic views. For shape analysis, 80 human computed tomography data sets were segmented with the software Amira 4.2 to obtain 3D reconstructions. We identified anatomical conditions (ACs) according to the extent of the effect on the bony screw pathway. Subsequently, the pelvis was spatially aligned using representative bone protuberances in order to create standard Matta projections. In each view, the ACs were described in terms of distance from bone landmarks. Three-dimensional shape analysis revealed the height of the pedicular isthmus (PH) as the limiting variable for secure screw insertion. The lateral and outlet views allowed an orthogonal projection of PH. In the lateral view, the ratio of the lateral sacral triangle framed by the S1 body height and width showed a high correlation to PH (p = 0.0001). A boundary ratio of 1.5 represented a reliable variable to determine whether or not a screw can be inserted (positive predictive value: 97%). In the outlet view, the distance between the S1 endplate and the SI joint top level (EJ) strongly correlated with PH (p = 0.0001). With EJ 0 mm, screw insertion was possible in all cases (100%). SI-screw insertion requires a well-planned procedure. Orientation of the sacral pedicle is of extreme relevance. A narrow sacroiliac channel and high sacral shape variability limit secure screw placement. However, no determining parameters exist, allowing accurate prediction of secure screw insertion based on X-rays or fluoroscopy. The lateral sacral triangle in the lateral view represents a simple and accurate preoperative method of support for the surgeon's decision to undertake this procedure. No additional technical effort is necessary. A boundary ratio of 1.5 predicts a sufficient bone stock for at least one 7.3 mm screw. Furthermore, the evaluation of the outlet projection can be used to assess the safety of the operation. Basically, a preoperative lateral pelvic image should be mandatory.

[Results of single stage vs. two-stage total knee arthroplasty]

BACKGROUND

The total knee arthroplasty (TKA) is a successful procedure. In cases of bilateral knee osteoarthritis, advantages of single stage TKA vs. two-stage TKA as well as the gap between the procedures in case of two-stage TKA are discussed controversially. The aim of the present study is to compare the clinical and radiographic results of single stage bilateral TKA and two-stage bilateral TKA. In cases of two-stage TKA the dependency on the gap between surgeries was determined.

MATERIAL AND METHODS

In this retrospective study 43 patients with single stage TKA and 35 patients after two-stage TKA with a maximum of 12 months between surgeries were included. Follow-up was in mean 31 ± 15 months. For clinical and radiological evaluation the Knee Society score (KSS) and Stolzalpen knee score were used. Quality of life was measured by the SF-36 score. The pain was determined using a visual analogue scale (VAS). Radiological evaluation was done by use of Knee Society roentgenographic evaluation and scoring system.

RESULTS

The overall hospital stay for patients with two-stage TKA (26 ± 5 days) was twice as long as for patients with single stage TKA (14 ± 4 days). Patients with single stage bilateral TKA had a significantly higher KSS level (186 ± 19 points) than patients after two-stage bilateral TKA (179 ± 22 points). Within the two-stage group the best range of motion was achieved by patients with a gap of 4 to 6 months between surgeries and a decreased point value was measured in patients with a gap of 10 to 12 months between TKAs. Using the VAS patients with simultaneous bilateral TKA had significantly increased pain levels during passive motion. Within the two-stage group there were no differences in VAS. The results of Stolzalpen knee score were comparable in both groups. The analysis of radiological measurements showed a significantly higher number of radiolucent lines (1 mm) in patients with single stage TKA without any clinical relevance or progress in follow-up. Patients with single stage bilateral TKA had a higher complication rate than patients with a two-stage procedure. In the single stage group 6 patients had to be revised because of fracture, dislocation, peroneal nerve palsy, patella lateralisation or loosening. In the two-stage group only one patient had to be revised due to a quadriceps tendon rupture caused by a fall at day one after surgery.

CONCLUSION

Analysis of clinical and radiological results shows only marginal differences between the two groups. In two-stage procedures functional results were best when the second surgery was done 4 to 6 months after the first procedure. Single stage TKA had a significantly higher complication rate. However, patient and surgeon should make the decision for single or two-stage bilateral TKA individually.

[Apolipoprotein E (APOE) gene polymorphism and risk and prognosis in cerebral amyloid angiopathy-related haemorrhage]

The authors present current opinions about the role of APOE (apolipoprotein E gene) genotype as a factor modifying risk, course and prognosis in haemorrhagic stroke of cerebral amyloid origin. The search for the role of genetics in haemorrhagic stroke has been ongoing for more than 15 years. One of the most frequently investigated genotypes in the context of intracerebral haemorrhages is the APOE genotype. Alleles APOE e2 and e4 have been established as risk factors for cerebral amyloid angiopathy (CAA), as well as for cerebral amyloid angiopathy-related haemorrhage (CAAH). Moreover, APOE genotype seems to determine prognosis in CAAH in terms of early mortality, as well as risk of recurrence. Current findings related to the association between different isoforms of apoE and haemorrhagic stroke due to CAA do not allow us to formulate any clinical recommendations yet.

Cellular compatibility of highly degradable bioactive ceramics for coating of metal implants

Resorbable ceramics can promote the bony integration of implants. Their rate of degradation should ideally be synchronized with bone regeneration. This study examined the effect of rapidly resorbable calcium phosphate ceramics 602020, GB14, 305020 on adherence, proliferation and morphology of human bone-derived cells (HBDC) in comparison to β-TCP. The in vitro cytotoxicity was determined by the microculture tetrazolium (MTT) assay. HBDC were grown on the materials for 3, 7, 11, 15 and 19 days and counted. Cell morphology, cell attachment, cell spreading and the cytoskeletal organization of HBDC cultivated on the substrates were investigated using laser scanning microscopy and environmental scanning electron microscopy. All substrates supported sufficient cellular growth for 19 days and showed no cytotoxicity. On each material an identical cell colonisation of well communicating, polygonal, vital cells with strong focal contacts was verified. HBDC showed numerous well defined stress fibres which give proof of well spread and strongly anchored cells. Porous surfaces encouraged the attachment and spreading of HBDC. Further investigations regarding long term biomaterial/cell interactions in vitro and in vivo are required to confirm the utility of the new biomaterials.

Inflammatory cerebral amyloid angiopathy: the overlap of perivascular (PAN-like) with vasculitic (Aβ-related angiitis) form: an autopsy case

Beside advanced age, cerebral amyloid angiopathy (CAA) and hypertension (HTA) are the two most important risk factors for haemorrhagic stroke. Inflammatory changes of amyloid-laden vessels have been reported only in rare sporadic CAA cases. We present the case of a 78-year-old woman with a history of hypertension, dementia and haemorrhagic stroke of the right frontal lobe 2 years before admission. She was admitted with recurrence of symptoms of transient aphasia and central, right-side facial paresis that occurred an hour before her arrival at the hospital. In the admission unit, she was only slightly confused, with no other neurological deficits. An urgent CT scan revealed a recent haemorrhagic stroke in the left frontal lobe. In an hour her condition suddenly deteriorated. After a generalized seizure she presented with right-side hemiparesis with signs of uncal herniation and remained unconscious. A control CT scan showed a large haemorrhagic expansion that comprised the whole left brain hemisphere with 2 cm midline shift. She died about 10 hours after the onset of symptoms. At autopsy chronic inflammation of the thyroid gland, bronchopneumonia, fibrous and fatty heart degeneration and kidney haemorrhagic infarcts were documented. Amyloid deposition and systemic immune disorders in the inner organs were not demonstrated. In neuropathological examination we diagnosed inflammatory form of CAA with coexistence (the overlap) of two, perivascular and vascular, subtypes of CAA-related inflammation.

Complications of severe cerebral amyloid angiopathy in the course of dementia with Lewy bodies. A case report

A 68-year-old male who suffered from dementia, progressing for four months without Parkinson's symptoms, was admitted to the Department of Neurology because of vertigo, slight left hand paresis and positive Romberg test. During hospitalization the patient's status deteriorated. The intracerebral lobar haemorrhage, subarachnoid haemorrhage and ischaemic lesions observed on CT scans suggested the clinical diagnosis of CAA. He died after 53 days due to pneumonia. On macroscopic examination, the brain showed general cortical atrophy and ventricular dilatation. Frontal lobar haemorrhage and focal subarachnoid haemorrhage were seen on the brain autopsy. Microscopic observation demonstrated neuronal loss and microspongiosis in the hippocampus, severe neuronal loss and depigmentation in the substantia nigra pars compacta and locus coeruleus. Lewy bodies were visible in the substantia nigra and amyloid angiopathy, predominantly severe CAA according to the Vonsattel scale, in the meningeal and cortical vessels. In the presented case, the microscopic findings were typical for DLB with concomitant severe CAA. In progressive dementia, neurological deterioration, presence of lobar hemorrhagic infarcts and ischaemic lesions suggest CAA coexistent with DLB and/or AD.

Cerebral amyloid angiopathy as a cause of an extensive brain hemorrhage in adult patient with Down's syndrome - a case report

A case of 54-year old woman who deceased due to consequence of extensive brain hemorrhage is presented. The patient was admitted to our Department of Neurology due to progressive quadriparesis as a complication of the cervical spinal cord compressive myelopathy. On the third day after neurosurgical decompression of the spinal cord sudden worsening of neurological and general condition was observed, finally caused death. An autopsy study revealed an extensive brain lobar hemorrhage and a dorsal-ventral compression of the cervical spinal cord. Alzheimer's disease-type degenerative changes with concomitant CAA were seen in light microscope examination. Extensive foci of demyelination were found especially in dorsal funiculi of the cervical spinal cord. Smaller foci of demyelination were present in anterior funiculi due to the stenosis of vertebral canal.

[Cervical spine osteoblastoma in children: Selective diagnostics as the basis for effective surgical management]

Expansively growing cervical spine osteoblastomas are rare but can cause severe neurological damage as a result of their anatomical relationship to nerve structures. Also, cerebral vessels, especially the vertebral artery in its transvertebral position, are often covered by tumor tissue. In complete resection of the tumor, it is sometimes possible to retain the affected vessel. In addition to conventional radiographic diagnostics, computed tomography, and magnetic resonance imaging, angiography and Doppler sonography of the intracranial arteries executed in parallel can provide evidence of the dimension of the neurological deficit to be expected during resection. This case report describes the staged diagnostic procedure and successful complete resection, retaining the affected vertebral artery, of an osteoblastoma of the 5th cervical body with massive intraspinal expansion in an 11-year-old child.

Small cerebral vessel disease in familial amyloid and non-amyloid angiopathies: FAD-PS-1 (P117L) mutation and CADASIL. Immunohistochemical and ultrastructural studies

Three patients (of two unrelated Polish families) with early-adult onset dementia were subjects of the study. Two cases, previously diagnosed as familial Alzheimer's disease (FAD) with cerebral amyloid angiopathy (CAA), were confirmed by genetic and neuropathological studies, and one case of CADASIL was ultrastructurally confirmed by the presence of vascular granular osmiophilic material. Now the brain autopsy material has been reinvestigated using immunohistochemical (IHC) markers for vascular smooth muscle cells, paying special attention to collagen markers for extracellular matrix components and ultrastructural microvascular changes. In both diseases, IHC examination showed a reduction or loss of expression of smooth muscle actin (SMA) in tunica media of the cerebral arterioles. Fibrous thickening of the wall of the small meningeal arteries, intracerebral arterioles and numerous capillaries, with amyloid or granular deposits, drew our attention. In these vessels, marked expression of fibrillar collagen type III as well as strong immunoreactivity of the basement membrane (BM) component collagen type IV were found. The most damage was observed in the FAD/CAA double-barrel vessel wall and in some CADASIL arterioles changed by fibrinoid necrosis. The fibrous changes of the small vessels were more distinct in CADASIL t han in FAD/CAA. In FAD,electronmicroscopic examination revealed both amyloid and collagen fibres within the thickened BM of capillaries and the small arterioles. Clusters of collagen fibres between lamellae of BM, frequently in a pericyte position,were observed,and some were seen in the degenerated pericytes as well. Typical changes of the pericytes were accumulation of lipofuscin-like material and their degeneration. The mitochondria of the pericytes and of the endothelium were rare and swollen, with damaged and reduced cristae. The VSMCs of the arteriolar walls exhibited degenerative changes with atrophy of the cellular organelles. The fibrous,collagen-richCADASILsmallcerebralvessels,despite the weakness of the vessel wall due to reduction of VSMCs, appeared to be stronger than in FAD/CAA. These findings may suggest an accelerated process of transformation of the small cerebral vessels in which early onset of VSMCs loss is a predominant feature of the vascular changes in both presented diseases.

[Post-lobectomy bronchopleural fistula -- a challenge for postoperative intensive care]

Bronchopleural fistula (BPF) and bronchial stump insufficiency (BSI) after lobectomies and pneumonectomies are dreaded complications with incidences of up to 12 % and a mortality rate of up to 51 %. Apart from the basic illness causes include complications like aspiration-pneumonia and ARDS, formation of empyema as well as histories of sepsis. Corticoid treatments, old age, diabetes mellitus, previous irradiation as well as post-operative mechanical ventilation (barotrauma) are often counted among contributing causes. Suturing the bronchus and reinforcement by tissue are still the methods of choice, but they are often counter-indicated in high-risk patients. Endoscopic treatments with partial lung occlusions, e. g. by insertion of spongiosa, coils, and/or fibrin glue have been described. However, they require the respective area to be probable. With only one third the rate of success is quite unsatisfactory. The retro-graded instillation of inflammatory-selerotizing substances, like doxycycline, via a chest tube leads to a pleurodesis caused by adhesion of the remaining lung parenchyma to the thoracic wall and a reduction in size of the residual pleural space. In an 82-year old female patient a BPF of the second upper lobe bronchus was detected after a middle lobe resection for abscess and post-radiation ulcer following a mastectomy for carcinoma. The leakage was detected on bronchoscopy by retro-graded instillation via the chest tube of methylene-blue solution into the thoracic cavity. After administering the water-soluble contrast agent amidotrizoic acid in a similar manner a CT confirmed the diagnosis. As the bronchial segment concerned could not be entered selectively, preservation of the right lung lobe's residual ventilation by endoscopic-occlusion procedures was ruled out. Employing a strictly conservative therapy (spontaneous ventilation, retro-graded doxycycline instillations) complete healing with a fully ventilated lower lobe could be achieved over a period of 78 days. BPF as well as residual intro-thoracic cavities after lobectomies pose a serious problem. Using methylene blue for a retro-graded demonstration of BPF during bronchoscopy presents a feasible and cost-efficient diagnostic method. A strictly applied conservative therapy including short-time low-pressure artificial respiration as well as obliteration by fibrous tissue of the thoracic cavity using doxycycline is a feasible procedure for inoperable high-risk patients.

["Malignant" middle cerebral artery territory infarction]

The pathology, clinical course, outcome, diagnosis, treatment and prognosis of dramatic malignant middle cerebral artery territory infarction were presented. About 10% of stroke patients suffer from malignant middle cerebral artery territory infarction, mainly due to brain edema and herniation. This syndrome causes high mortality. The newest conservative and surgical treatment was presented.

[Changes in lipoprotein (a) [Lp(a)] level after an ischemic stroke]

The aim of the work was to recognize whether often observed high levels of apolipoprotein (a) [Lp(a)] in patients shortly after an ischemic stroke are a result of the acute phase reaction. In 13 patients Lp(a) was determined within the first 24 hours after the stroke onset, after the next 7 days and after three months i.e. when it could be considered that Lp(a) level was the same as before onset of the disease. In 17 patients only two determinations were performed. Another acute phase indicator: C-reactive protein (CRP), as well as serum lipids were also determined. CRP level was increased in the first determination and increased further after 7 days. After three months it returned to low values. High density lipoprotein (HDL) cholesterol which demonstrates a negative acute phase response changed in the opposite way. No similar fluctuations of Lp(a) level were observed. It can be concluded that during the investigated period Lp(a) had no properties of the acute phase reactant.

Variation in the management of acute physiological parameters after ischaemic stroke: a European perspective

Studies have shown significant variation in stroke case fatality across Europe. These variations suggest the need to explore whether differences in physiological support in acute stroke exist across Europe. Data were collected in four European centres over 6 months. These included clinical status and management of acute physiology (hydration, oxygenation, nutrition, hypertension, hyperglycaemia and temperature in the first week of ischaemic stroke) and survival at 3 months. Differences in acute supportive care between centres were adjusted for case mix. Patients admitted to centres in London (n = 106), Dijon (n = 95), Erlangen (n = 91) and Warsaw (n = 72) were studied. There were significant differences in incontinence, dysphasia, dysphagia, conscious level, pyrexia, hyperglycaemia and comorbidity between centres. After adjusting for case mix, there were significant differences in intravenous fluid use (P = 0.04), enteral feeding (P = 0.003), initiation of new antihypertensive therapy (P = 0.0006) and insulin therapy (P = 0.004) between centres, with the London centre having the lowest uptake of interventions. Three-month case fatality rates varied from 10 to 28%. This pilot study shows significant variation in acute physiological support in acute stroke across four European centres, which remains unexplained by case mix. Further research is required to link variation in acute care with stroke outcome, to identify which interventions appear to be the most effective.

[Atrial fibrillation and carotid artery disease in ischemic stroke patients]

Ischemic strokes occurring in patients with non-rheumatic atrial fibrillation (AF) are due to a variety mechanisms, and not necessarily to cardiogenic embolism. The aim of the study was to determine the role and prevalence of carotid artery disease in stroke patients with AF, as well as its influence on the stroke prognosis. 513 consecutive patients with ischemic stroke participated in the study. The diagnosis was based on the clinical examination, brain CT and Doppler ultrasonography. Risk factors and clinical data were collected prospectively according to the Stroke Data Bank NIH protocol. AF was diagnosed in 166 (32.4%) patients. Carotid artery stenosis > 45% was present in 104 (20.3%). AF and co-existing carotid stenosis was found in 27 (5.3%) cases. There were 16.2% patients with carotid stenosis in the group with AF. In all groups 87 patients died (30-day mortality rate: 17%). The highest mortality rate was noted in the group with co-existing AF and carotid artery stenosis (25.9%), followed by the groups with AF only (21.6%) and no changes (15.9%), with the lowest mortality in the group with only vascular changes, i.e. stenosis or occlusion (9.1%). The carotid stenosis group differed significantly both from patients with co-existing AF and carotid stenosis (p > 0.01) and from those with AF only (p < 0.05).

High early case fatality after ischaemic stroke in Poland: exploration of possible explanations in the International Stroke Trial

PURPOSE

To determine why Polish patients included in the International Stroke Trial (IST) had a higher early case fatality than patients from other countries.

METHODS

Of 19,435 patients randomised to IST, 17,370 had CT or autopsy-confirmed ischaemic stroke. We compared the baseline clinical state and 14-day case fatality of patients randomised in Polish centres with those from all other IST countries. We examined: age, gender, presence of atrial fibrillation (AF), conscious level, neurological deficit, cause of death and aspirin use in the 3 days before stroke.

RESULTS

In Poland, the 14-day case fatality rate was significantly higher than in other IST countries (13% vs. 9.6%; odds ratio, OR, 1.5, 95% confidence interval, CI, 1.2-1.9). In Poland, a significantly higher proportion of deaths was attributed to coronary heart disease (2.5% vs. 0.7%) and pulmonary embolism (1.0% vs. 0.4%). Polish patients had higher percentage of AF and drowsiness, but were younger. When these factors were adjusted for, Polish patients still had approximately a 57% higher risk of death within 14 days compared with other countries. A logistic regression analysis revealed that an increased risk of death within 14 days in Poland compared to other IST patients was present among patients younger than 75 years (OR 1.7; 95% CI 1.3-2.4), females (OR 1.8; 95% CI 1.3-2.5), patients who were alert at onset (OR 2.4; 95% CI 1.7-3.4), with partial anterior circulation syndrome (PACS) (OR 2.0; 95% CI 1.4-2.8) or lacunar syndrome (LACS) (OR 2.4; 95% CI 1.1-5.0) and without AF (OR 1.8; 95% CI 1.3-2.4). Polish patients were less likely to have been on aspirin before their stroke than other countries (7.6% vs. 20.8%).

CONCLUSION

The 14-day case fatality was significantly higher in Poland than in other countries in IST. Part of the increase was due to greater stroke severity in the Polish patients. However, differences persisted even after adjustment for baseline stroke severity. Several factors may have contributed the excess: poor attention to treatment of cardiovascular disease, less attention to treatment of secondary complications of stroke and some other--as yet unidentified--factor specific to Poland.

[Lateral medullary infraction due to left atrial myxoma--a case report]

A case of 53 year old women with Wallenberg syndrome due to atrial myxoma is reported. She was operated. Atrial myxoma on 7 x 8 cm was removed. After few months she can walk independently, she needs only a little help in everyday activities.

[Prognostic factors in the acute phase of haemorrhagic stroke]

The aim of the study was establishing which parameters play a significant prognostic role in acute haemorrhagic stroke in its acute phases (during 30 days from stroke onset). The material included 110 patients with haemorrhagic stroke (HS) treated in the years 1997-1999 at the II Neurology Department, Institute of Psychiatry and Neurology in Warsaw or at the Neurology Department, Hospital in Piła. The analysis of risk factors, fitness before stroke and on the first day of the disease was based on history data. On the first day of the disease the assessment included state of consciousness, brain stem signs, vomiting, stroke type on the basis of clinical condition (according to Oxford classification, OCSP), blood pressure, body temperature measurements, intensity of neurological signs according to Scandinavian scale (SSS). In the blood glucose level, fibrinogen, leucocyte count and ESR were determined. In the first week consciousness state, blood pressure and miction were checked repeatedly. It was found that serious consciousness disturbances, stroke type TACS, POCS and severe not classified stroke, presence of brain stem involvement, low SSS score, high body temperature, high leucocyte count and glucose level were more frequent in patients who died within 30 days after stroke onset. Prognostically important were also instability of blood pressure and urinary incontinence in the first week. All clinical observation and laboratory analyses of prognostic importance in the acute phase of HS can be done in typical hospital settings.

Advanced atherosclerosis of the aortic arch is uncommon in ischemic stroke: an autopsy study

Aortic and carotid atherosclerosis are known risk factors for stroke. The aim of the study was to determine the frequency of atherosclerotic lesions in the aorta and carotid arteries in subjects dying of ischemic and hemorrhagic stroke and to determine whether aortic atherosclerosis was associated with any specific ischemic stroke subtype. Autopsies were performed in 207 patients who died during hospitalization for stroke from 1993 to 1997. Subjects ranged in age from 37 to 98 years, mean 74.45 years (SD +/- 11.84). There were 132 women and 75 men. Stroke was hemorrhagic in 66 and ischemic in 141. Advanced atherosclerotic lesions were less frequent in the aortic arch (1.9%) than in the thoracic aorta (51.7%), abdominal aorta (60.4%), or carotid arteries (23.7%). Moderate atherosclerotic lesions in the aortic arch were observed more frequently in ischemic (75.2%) than hemorrhagic stroke (56.1%, p=0.026). Advanced or moderate atherosclerotic lesions in any part of the aorta did not predict ischemic stroke subtype. Advanced atherosclerosis of the carotids was more common in ischemic stroke (28.4%) than hemorrhagic stroke (13.6%, p < 0.05). Advanced atherosclerosis of the carotids was more common in stroke due to atherothrombosis (51.4%) than in stroke due to cardiac embolism (22.1%) or stroke of unknown etiology (5.6%). The low frequency of advanced atherosclerotic lesions of the aortic arch suggests that this disease process is not a common mechanism of stroke.

Factor V Leiden, prothrombin gene G20210A variant, and methylenetetrahydrofolate reductase C677T genotype in young adults with ischemic stroke

Ischemic stroke in young adults is a well-known disease, but despite extensive clinical and laboratory investigations, its etiology remains unclear in approximately half of the cases. We examined the prevalence of factor V Leiden, the prothrombin G20210A genotype, and the C677T mutation in the methylenetetrahydrofolate reductase (MTHFR) gene in 100 patients (51 males and 49 females) who survived an ischemic stroke without a cardiac embolic source at an age < or = 45 years, and in 238 healthy control subjects from the same geographic area. The patients were selected for study only if the diagnosis of stroke was documented by computed tomography scan or nuclear magnetic resonance (NMR) of the brain, or both. Heterozygosity for the FV Leiden mutation was found in 3 patients (3.0%) and in 10 control subjects (4.2%). Two patients (2.0%) and five control subjects (2.1%) were heterozygous for the prothrombin G20210A mutation. The frequencies of the MTHFR 677TT, CT, and CC genotypes in the patient group were 12%, 37%, and 51%, respectively, and were not significantly different from those in control subjects (11%, 40%, and 49%, respectively). In conclusion, our results indicate that FV Leiden mutation, prothrombin G20210A genotype, and homozygosity for the C677T mutation in the MTHFR gene are not associated with an increased risk for ischemic stroke in young adults.

[Brain stem syndrome after cervical chiropractic manipulations]

This is a case report of a 41-year old man who had ischaemic lesion in the pons following chiropractic manipulation. He had brainstem syndrome with right hemiparesis. He improved. After 4 a year follow-up he is in a very good condition.

[Headache concurrent with the onset of ischemic stroke]

The aim of the study was to assess the occurrence of headache in acute ischaemic stroke and its association with type, aetiology and localization of stroke. 342 patients with stroke were analysed. Their average age was 70.8 +/- 13.1. Headache was observed in 17.8% stroke patients. There was no correlation between headache and size of ischaemic lesion in CT. Headache was observed in 43.1% of patients with small foci localized in deep structure, and in 33.3% of large cortical-subcortical foci. The analysis between the frequency of headache and type of stroke according OCSP classification revealed that headache occurred statistically significant more frequent in POCI.

[Atherosclerotic changes in the aorta of patients with ischemic and hemorrhagic stroke]

Clinico-pathological analysis of 207 patients dying after stroke was performed. The occurrence of atherosclerotic lesions in the aortic arch, thoracic and abdominal parts of aorta were compared in patients dying of ischaemic and haemorrhagic stroke. Advanced atherosclerotic lesions in the arch of aorta were rare in patients with ischaemic and haemorrhagic stroke. Moderate atherosclerotic lesions in the aortic arch were observed more frequently in ischaemic than in haemorrhagic stroke. Advanced atherosclerotic lesions in thoracic and abdominal part of aorta occurred with the same frequency in ischaemic and haemorrhagic stroke.

[Determination of lipoprotein (a) [Lp(a)] in patients with ischemic stroke. Preliminary communication]

The aim of this work was the determination of apolipoprotein(a) [Lp(a)] in the patients three months after the onset of ischaemic stroke. A group of 56 patients was investigated. Stroke was diagnosed as caused by atherosclerotic changes in main cerebral arteries in 32 patients and in 11 by changes in cervical arteries. In 13 persons a lacunar stroke was recognised. The mean Lp(a) level and the median value were significantly higher in the group of patients after stroke as compared with 45 controls. A more frequent occurrence of Lp(a) level over 30 mg/dl considered as pathological was observed more often in the patients. No correlation was seen between Lp(a) and the resistance of LDL to oxidation nor between Lp(a) and the amount of products of LDL oxidation in vitro.

Cumulative industrial trauma as an etiology of seven common disorders in the foot and ankle: what is the evidence?

The concept of cumulative industrial trauma as an etiology of orthopaedic disease has recently generated considerable attention in both the medical and legal communities. To clarify the current state of knowledge about the issue as applied to the foot and ankle, we critically reviewed the literature on the etiology of seven foot and ankle disorders commonly involved in compensation litigation in the practice of the senior author: hallux valgus, interdigital neuroma, tarsal tunnel syndrome, lesser toe deformity, heel pain, adult acquired flatfoot, and foot and ankle osteoarthritis. Koch's postulates were appropriately modified and used as a logistic framework to analyze the potential for cumulative industrial trauma to cause foot pathology. In none of the disorders analyzed could cumulative industrial trauma reasonably satisfy even one of Koch's three postulates. We conclude there is currently no unequivocal literature support upon which to invoke cumulative industrial trauma as a clear etiology of these disorders of the adult foot and ankle. The superb evolutionary adaptation of the human foot to prolonged ambulation and the absence of industrial demands that significantly differ from this task likely account for this dramatically reduced vulnerability of the foot to industrial repetitive motion disorders compared to the upper extremity.

[Venous infarcts]

Venous infarcts are uncommon and frequently misdiagnosed as arterial infarcts, intracerebral haemorrhages or tumours on CT. Cerebral venous thrombosis is a condition with large variety of causes. However, in 20 to 35% of causes, no cause is found. The clinical features depend on the location of venous thrombosis. Clinical signs are mainly headache, hemiparesis, cranial nerves paresis, epilepsy, TIA. The question about the proper way of treatment and duration of treatment remains open.

[Comparison of neurological status in patients treated in a stroke unit with those treated in classical care model]

140 patients with stroke (69 men and 71 women) aged 71.7 +/- 12.4 treated in the general neurology were compared with 102 patients (46 men, 56 women) aged 71.5 +/- 11.2 treated in the stroke unit during the period 1.11.95 to 31.10.97. Neurological status and state of environmental dependency during the discharge time were similar in both groups, but the state of motor performance was significantly better in the group of patients treated in the stroke unit. In the stroke unit collaboration between nurses and rehabilitants makes it possible to increase the time of rehabilitation and to introduce the elements of exercises which can be done by patients under control of nurse.

Heart disease contributes to high stroke mortality in Poland

CONTEXT

The case-fatality rate for ischemic stroke in Poland are 3 times higher than in the United States. The reason for this difference is uncertain.

OBJECTIVE

To explore whether cardiac comorbidity contributes to high case-fatality rates for ischemic stroke in Poland.

DESIGN

Prospective collection of data on ischemic stroke by using a structured data collection instrument.

SETTING

A regional neurological hospital in Warsaw.

INTERVENTION

Standard medical care was provided to all ischemic stroke patients.

OUTCOME MEASURE

Survival at 30 days, stroke lesion size and location by computerized tomographic scan, stroke syndrome.

RESULTS

252 patients with ischemic stroke were registered. Overall 30-day case-fatality rate was significantly higher in the group of patients with atrial fibrillation (AF) (28.6% v 13.9%) and congestive heart failure (CHF) (29.1% v 12.7%) than in those without these comorbidities. In patients with either AF or CHF, ischemic lesions seen on computed tomography (CT) scans were more likely to be very large (occupying more than 1 lobe) and were more likely to involve both superficial and deep structures of the brain. Large hemispheric syndromes were more likely in patients with AF (38.5% v 18.5%) and CHF (33.8% v 18.9%) than in those without these comorbidities.

CONCLUSIONS

Strokes caused by CHF or AF tend to be larger and are more likely to lead to death. The high prevalence of cardiac disease may be one cause of high stroke mortality in Poland.

[Clinical autosomal dominating arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL)]

CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy) is a diffuse disease of small arteries, predominating in the brain. It starts during mid-adulthood and is characterized by recurrent ischaemic events (transient or permanent), attacks of migraine with aura, severe mood disorders, subcortical dementia and at MRI white periventricular leukoencephalopathy. CADASIL is an autosomal dominant disease. The gene Notch3 on which the mutation was detected is located on chromosome 19. There is so far no specific treatment and death occurs after a mean of twenty years.