Intracerebral Hemorrhage and Epileptic Seizures: Frequency, Localization and Seizures Types

Introduction. Among 2.8-18.7% of the patients that suffered from spontaneous intracerebral hemorrhage (ICH) develop seizures. Previous studies suggest that most important contributors to developing subsequent seizures are: volume and localization of hematoma, cortical involvement and age. Aims: To determine the occurrence of new epileptic seizures in patients with spontaneous intracerebral hemorrhage and to analyze it with respect to the patient’s age, gender, presence of premorbid risk factors, localization of the hematoma and the type of the seizures. Methods. This study is retrospective in design, with study population of 308 patients with spontaneous intracerebral hemorrhage admitted to our clinic in the period between 2008 and 2014. Analyzed premorbid risk factors for ICH are: hypertension, smoking, alcohol uptake. According to the computer tomography (CT) of brain findings the patients was divided in two groups: lobar and thalamic (deep). By the time of presents of seizures, they were classified as early (within 1 week of ICH) or late (more than 1 week after ICH). Also we analyzed the seizures type and we divided them in four groups: simple partial, partial complex, secondary generalized and tonic clonic generalized seizures. Results. Arterial hypertension was revealed in 78% of the patients with spontaneous supratentorial ICH. Epileptic seizures developed in 8.2% of analyzed patients, most of them in the first week of brain bleeding. Lobar ICH had 78.6% of the patients, with frontal localization was 44% of patients with lobar ICH, and most of them had simple partial and partial complex seizures. Conclusion. Cortical involvement, large volume of hematoma, may be a factor for provoked seizures, especially in the first days of brain bleeding.

Bilateral Serous Retinal Detachment in Preeclampsia: Case Report

Introduction. Preeclampsia presents a medical condition in pregnancy that is manifested with increased blood pressure and protein urine. Ocular involvement is rare. Retinal detachment in preeclampsia is a rare complication; it only occurs in 1-2% of severe preeclampsia but in 10% of those with eclamptic seizures. Case report. A pregnant patient G1P0 visited the outpatient clinic of the University Clinic for Ophthalmology complaining on visual disturbances. The chief complaint was blurred vision and headaches. She was in 31 week of gestation and complained that she had increased blood pressure over the last month. After initial assessment she was suspected of central serous retinal ablation (CSCR). Ocular ultrasound and posterior segment OCT (optical coherence tomography) confirmed the diagnosis. Treatment and outcome. Obstetric examination confirmed high blood (TA180/130) pressure with dipstick urine showing(+++). Unfortunately, the ultrasound showed an eutrophic pregnancy in 31 g.w. with fetus mortus inutero. The patient was administered to the intensive care unit. She had an ophthalmologic check-upat 2 weeks and one month post-partum that showed regression and visual acuity was getting better. The final check-up after 6 months revealed that retina was in place with no subretinal substantial fluid and no macular edema. Conclusion. Serous retinal detachment is a rare complication of preeclampsia. In most case it resolves spontaneously few weeks post delivery.

Iatrogenic Adrenal Failure Due to Corticosteroid-Treated Psoriasis: Pediatric Case Report

Plethora of pediatric autoimmune, dermatological, neurological and atopic disease require chronic administration of steroid medication. Long-term use of corticosterioids can result in both local (atrophy of the skin, hypertrichosis, and telangiectasia) and systemic side effects (hypothalamic-pituitary-adrenal (HPA) axis disturbance, risk of infections). We report a case of 3.5-year-old boy, who developed Cushing syndrome and secondary adrenal insufficiency after corticosteroid cream maltreatment of his psoriasis. After initial hospitalization and recovery, physiological doses of hydrocortisone were used to normalize the HPA axis. In order to prevent Cushing syndrome development, adrenal insufficiencies, and secondary infections, precaution in use of steroid therapy in early childhood must be exercised.

Epidural Anesthesia for Caesarean Section and Occurrence of Horner’s Syndrome

Recently, specifically in the last decade, at the University Clinic of Gynecology and Obstetrics, the number of patients treated with epidural analgesia for painless childbirth, which in some percentage ends in Caesarian section (35%), has increased. The increased use of the epidural anesthesia and analgesia is due to the fact that it is one of the most popular ways of childbirth today. This situation is a result of the benefits that epidural anesthesia has for the patient, which consist of allowing the pregnant woman to be conscious during childbirth and to feel and see her child coming into the world, accompanied with smaller intensity of intraoperative and postoperative pain. However, the results or the effects in practice have shown that in certain insignificant percentage patients can have negative consequences from the received analgesia (anesthesia) such as: headache, cases of durra puncture, epidural abscess or hematoma, neurological outbursts etc. But, the subject of this analysis or the aim of this study is the appearance of Horner’s syndrome, as one of the negative effects of the epidural anesthesia, which even though rarely (only in 1% of the cases) can appear as a result of the epidural anesthesia. In the case study using the historic, comparative and empirical method we will try through a specific case to determine the causes for the occurrence of the Horner’s syndrome, how it should be treated and what are the consequences for the patient.

Gastrointestinal Lymphoma in Tertiary Gastroenterology Center: Epidemiological, Clinical and Endoscopic Features

Introduction. Within the heterogeneous group of extra-nodal lymphoma, the gastrointestinal tract is the most frequently involved extranodal site accounting for 30-50% of all extranodal cases. Gastrointestinal involvement most oftenoccurs secondarily, while the primary gastrointestinal lymphomasare relatively rare accounting for 30%-45% of all extranodal lymphomas and 0.9% of all gastrointestinal tumors. Within the gastrointestinal tract, lymphoma can arise in any region but the stomach is the most commonly involved organ being affected in 50-70% of all the gastrointestinal lymphomas, followed by the small intestine and ileocecal region. The aim of the study was to analyze and present data regarding the endoscopic aspects and clinical presentation of patients with gastrointestinal lymphoma. Methods. We retrospectively reviewed the medical records of patients with primary or secondary gastrointestinal lymphoma diagnosed at our Clinic over a fifteen-year period (January 1, 1999 to December 31, 2013). We analyzed the demographic data, clinical presentation, anatomic distribution, endoscopic aspect of the lesion, extension of the neoplastic process and occurrence of different histological subtypes. Results. We discovered 18 patients with gastrointestinal lymphoma (7 males and 11 females). Fourteen patients (77.7%) were considered primary, while 4 patients (22.2%) were considered secondary gastrointestinal lymphoma. The stomach was affected in 14 cases (11 primary and 3 secondary), there were 2 duodenal lymphomas, 1 lymphoma of the terminal ileum and 1 peritoneal lymphoma. In most patients (10) massive and diffuse gastrointestinal infiltration was diagnosed, 5 patients had ulcerated lesions in the stomach and 3 patients presented with polyploid mass. Six patients presented with upper gastrointestinal bleeding, 1 patient with biliary tract obstructtion, one patient with protein losing enteropathy, malabsorptionand consecutive bowel perforation and one patient presented only with ascites and pleural effusion. All the malignant lymphomas were Non-Hodgkin type and among them we registered only one T-cell lymphoma. Being diagnosed in 6 patients (33.33%), diffuse large B-cell lymphoma was the most prevalent histological type. The lymphoma was limited to the gastrointestinal tract in 6 patients, 7 patients had regional nodal involvement, in 2 patients there was an intra-abdominal spread and in 3 patients there was an extra-abdominal dissemination. Most patients received chemotherapy and only 2 patients were treated surgically. Two patients had rapidly progressive clinical course and lethal outcome shortly after the diagnosis was established and before chemotherapy was administered. Conclusion. The gastrointestinal lymphoma has a variable clinical presentation and endoscopic aspect that often makes the diagnosis challenging. Substantial level of diagnostic awareness and comprehensive clinical approach are necessary in order to establish the correct diagnosis, provide appropriate treatment and prolong survival.

Patient-Controlled Analgesia (PCA) with Remifentanil Versus Intermittent Epidural Boluses for Labor Analgesia

Introduction. Remifentanil is becoming more and more popular for labor analgesia as an alternative for neuro-axial anesthesia. In this study we compared the severity of pain, patient satisfaction and side effects between two different types of labor analgesia. Methods. Eightyprimiparous patients ASA I or II, atterm pregnancy, were included in the study and divided in two groups. The first group (35 patients) received intravenous remifentanil on patient control pump in bolus doses. The second group (45 patients) received intermittent epidural boluses with highly diluted local anesthetic and opioid (Bupivacain and Fentanil). We analyzed oxygen saturation (SpO2), respiration rate, heart rate, blood pressure, sedation, nausea and vomiting as well as patient pain scores and satisfaction scores through 2 different VAS. Results. Mean SpO2 was significantly lower in the PCA remifentanil group 96.2%±1.6 versus 98.2±1.2 in the epidural group. Respiratory depression (RR<9 or SpO2 <90%) was not found in both groups. Sedation scores were significantly higher in the PCA remifentanil group, P<0.05. Incidence of nausea and vomiting was similar between the two groups, without significant difference. PCA remifentanil was inferior to epidural analgesia with respect to pain scores at all time points, but without significant difference in patient satisfaction between the two groups. Conclusion. Intravenous patient-controlled analgesia with remifentanil provides satisfactory level of labor analgesia, with lower SpO2 and more sedation. It could be an excellent alternative to epidural analgesia but continuous monitoring and oxygen supply is mandatory.

Reactive Stroma in Prostatic Carcinoma and Correlation with Tumor Grade and Tumor Stage

Introduction. Reactive stroma co-evolves with prostatic carcinoma. The aim of this study is to establish stromal changes in the prostatic cancer tissue and to quantify those changes. Methods. Samples from 70 patients treated with radical prostatectomy due to prostatic cancer were used for this analysis. Stromal changes in prostatic cancer tissue were analyzed using histochemical stain Trichrome Masson and immunohistochemical stains Vimentin and Desmin and those changes were compared to the stromal composition in the surrounding benign prostatic hyperplasia. These changes were quantified as following: for the histochemical stain Trichrome Masson we measured the intensity of the stain and for the immunohistochemical stains Vimentin and Desmin we used the “stromal index” that combines the frequency and intensity of the signal. We correlated the received data between each parameters and with tumor grade and tumor stage using the Spearman rank correlation test. Results. There was significant correlation between Trichrome Masson staining intensity and tumor grade (R=0,27 p=0,023) and tumor stage (R=0,24 p=0,049), between Vimentin expression and tumor grade (R=0,35 p=0,003) and tumor stage (R=0,28 p=0,019) and between Desmin expression and tumor grade (R=−0,25 p=0,035). Conclusion. Analyses of the stromal composition and the expression of stromal markers in prostatic carcinoma and their quantification could serve as an additional tool in evaluation of tumor aggressiveness and tumor extension.

Cerebral Oxygenation Non Invasive Monitoring in Traumatic Brain Injury - A Pilot Study

Introduction. Cerebral oxymetry obtained with Near Infrared Spectroscopy (NIRS) provides noninvasive monitoring of microvasculature in the brain allowing for early recognition and preventive treatment of impaired cerebral oxygenation in traumatic brain injuries. Optimizing cerebral oxygenation is advocated to improve outcome in traumatic brain injured (TBI) hence the goal of this study was to determine the benefit of non invasive monitoring of cerebral oxygenation. Methods. Noninvasive monitoring was conducted in fifteen patients with traumatic brain injury. The values and changes in cerebral oxymetry were analyzed and compared with others tracked parameters: Glasgow Coma Scale on admission to determine the severity of traumatic brain injuries, systolic arterial blood pressure, mean arterial blood pressure, pulse oxymetry, and regular laboratory test. Regional cerebral oxygenation was measured using cerebral oxymetar INVOS 5100 Somanetics®. Results. According to obtained data, we noticed that any change in hemodynamic profile directly influenced the regional cerebral oxygen saturation. Higher changes in values of 15 % and more from basal ones correlate with unfavorable outcome as neurologic sequels. Decreased values of rSO2 in our study were rectified with several simple interventions. In our cases parameter which was most prominent cause for disturbed rSO2 was decreased mean arterial blood pressure. Conclusion. Stable hemodynamic profile leads to optimized cerebral oxygenation. Monitoring the regional oxygen saturation influenced by several factors is important step for forehanded detection of adverse secondary brain injuries. NIRS technology as monitoring system has potential to have diagnostic value and enable right therapeutic decisions and consequently better prognosis in TBI. Continued study of the benefits of cerebral oxygen monitoring is warranted.

Tethered Cord Syndrome in Children – Report of Two Cases

Tethered spinal cord syndrome is a neurological disorder caused by tissue attachments that limit the movement of the spinal cord within the spinal column. Attachments may occur congenitally at the base of the spinal cord (medullary cone) or they may develop near the site of an injury to the spinal cord. These attachments cause an abnormal stretching of the spinal cord. The course of the disorder is progressive. We present two patients that were diagnosed at age of three months and three years, respectively. Final diagnosis was made by magnetic resonance imaging, and both patients were referred to University Clinic of Neurosurgery for further treatment. Our aim is to illustrate the advantages of the early diagnostics of this progressive condition, to present diagnostic methods that are age-dependent and to illustrate the early clinical indicators for its existence.

Case Report of Feminizing Genital Reconstruction in a Female with Congenital Adrenal Hyperplasia

Introduction. Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders of adrenal steroidogenesis. In approximately 90-95% of the CAH cases, it is a deficiency of the enzyme steroid 21-hydroxylase. The degree of enzyme insufficiency determines the severity of the disease. In the simple virilizing type of CAH dominant symptoms are virilization in girls and precocious puberty in boys. Virilizing type of CAH is the most common etiology of ambiguous genitalia in women. There are several options for surgical reconstruction of such anomalies, which must always be optimized to the patient’s anatomy, to achieve a good esthetic and functional result. Detailed presentation of the case. The paper presents the case of a 36-year old woman with delayed pediatric diagnosis of simple virilizing type of CAH, due to deficiency of 21-hydroxylase, pronounced phenotypic virilization, clitoromegaly, hyperpigmentation of the external genitalia, vaginal hypoplasia and existence of low confluence of the urethra with the vagina in so called low type of urogenital sinus andbilateral micromastia, also called mammary hypoplasia. The patient underwent augmention mammoplasty, clitoroplasty, reduction of clitoral hood and proximal labioplasty. Discussion. CAH is a continuum of disorders, affecting patients throughout the life. Feminizing genitoplasty includes three parts: clitoroplasty, labioplasty and vaginoplasty. Clitorectomy in modern times is unacceptable option. Conclusion. Surgical management and reconstruction in women with simple virilizing type CAH and ambiguous genitalia remains still controversial and emotionally laden area in reconstructive surgical activity and requires a team approach.