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Aim Etiology of ischemic stroke (IS) is multifactorial and includes interaction of genetic and environmental factors. Different genes, their polymorphisms, host susceptibility, and inflammation processes play a role in IS development. The aim of this study was to evaluate the effect of PPAR - γ and IL - 6 gene variants on IS onset. Material and methods A total of 301 subjects (144 males, 157 females) participated in the study, 114 patients with IS and 187 healthy controls. Results Statistically significant predictors of IS were male gender (OR 7.13, 95% CI 2.92–17.39, p < 0.001), hypertension (OR 7.82. 95% CI 2.53–24.19, p < 0.001), lowered HDL cholesterol (OR 8.20, 95% CI 2.41–27.94, p = 0.001), elevated C-reactive protein (OR 5.26, 95% CI 1.92–14.41) and IL - 6 − 174 GC (OR 2.44 95% CI 1.01–5.91, p = 0.0048) genotype. Males, compared to females, had 7 times higher odds for stroke. IL6 − 174G/C genotype increased the odds for IS for 2.4 times. PPARγ was not statistically significantly associated with stroke. Conclusion We can point to the IL - 6 − 174G > C polymorphisms as candidate gene marker and risk factor for the prediction of ischemic stroke. [ABSTRACT FROM AUTHOR]

Aim: In order to gain insight into the current prevailing practices regarding the limitation of life-sustaining treatment in intensive care units (ICUs) in Croatia, we assessed the frequency of limitation and provision of certain treatment modalities, as well as the associated patient and ICU-related factors., Methods: A multicenter retrospective cross-sectional study was conducted in 17 ICUs in Croatia. We reviewed the medical records of patients deceased in 2017 and extracted data on demographic, clinical, and health care variables. A logistic regression analysis was conducted to determine the associations between these variables and treatment modalities., Results: The study enrolled 1095 patients (55% male; mean age 69.9±13.7). Analgesia and sedation were discontinued before the patient's death in 23% and 34% of the cases, respectively. Patients older than 71 years were less often mechanically ventilated (P<0.001), and less frequently received inotropes and vasoactive therapy (P=0.002) than younger patients. Patients hospitalized in the ICU for less than 7 days less frequently had discontinuation of mechanical ventilation and inotropes and vasoactive therapy than patients hospitalized for 8 days and longer (P<0.001). Logistic regression analysis showed that ICU type was a crucial determinant, with multidisciplinary and surgical ICUs being associated with higher odds of intubation, mechanical ventilation, vasoactive and inotropic therapy, analgesia, and sedation., Conclusion: Older patients and those diagnosed with stroke and intracranial hemorrhage received fewer therapeutic modalities. All the observed treatment modalities were more frequently discontinued in patients who were hospitalized in the ICU for a prolonged time.

Ischemic stroke is one of the leading causes of death and permanent disability in the world. Rapid diagnosis and intervention are crucial for reducing its consequences on individuals and societies. Therefore, identifying reliable biomarkers for early detection, prognostics, and therapy can facilitate the early prediction and prevention of stroke. Metabolomics has been shown as a promising tool for biomarker discovery since many post-ischemic metabolites can be found in the plasma or serum of the patient. In this research, we performed a comparative targeted metabolomic analysis of stroke thrombi, stroke patient serums, and healthy control serums in order to determine the alteration in the patients' metabolomes, which might serve as biomarkers for early prediction or stroke prevention. The most statistically altered metabolites characterized in the patient serums compared with the control serums were glutamate and serotonin, followed by phospholipids and triacylglycerols. In stroke thrombi compared with the patients' serums, the most significantly altered metabolites were classified as lipids, with choline-containing phospholipids and sphingomyelins having the highest discriminatory score. The results of this preliminary study could help in understanding the roles of different metabolic changes that occur during thrombosis and cerebral ischemia and possibly suggest new metabolic biomarkers for ischemic stroke.

A recently discovered haplotype- CYP2C:TG -determines the ultrarapid metabolism of several CYP2C19 substrates. The platelet inhibitor clopidogrel requires CYP2C19-mediated activation: the risk of ischemic events is increased in patients with a poor (PM) or intermediate (IM) CYP2C19 metabolizer phenotype (vs. normal, NM; rapid, RM; or ultrarapid, UM). We investigated whether the CYP2C:TG haplotype affected efficacy/bleeding risk in clopidogrel-treated patients. Adults ( n = 283) treated with clopidogrel over 3-6 months were classified by CYP2C19 phenotype based on the CYP2C19*2*17 genotype, and based on the CYP2C19/CYP2C cluster genotype, and regarding carriage of the CYP2:TG haplotype, and were balanced on a number of covariates across the levels of phenotypes/haplotype carriage. Overall, 45 (15.9%) patients experienced ischemic events, and 49 (17.3%) experienced bleedings. By either classification, the incidence of ischemic events was similarly numerically higher in PM/IM patients (21.6%, 21.8%, respectively) than in mutually similar NM, RM, and UM patients (13.2-14.8%), whereas the incidence of bleeding events was numerically lower (13.1% vs. 16.6-20.5%). The incidence of ischemic events was similar in CYP2C:TG carries and non-carries (14.1% vs. 16.1%), whereas the incidence of bleedings appeared mildly lower in the former (14.9% vs. 20.1%). We observed no signal to suggest a major effect of the CYP2C19/CYP2C cluster genotype or CYP2C:TG haplotype on the clinical efficacy/safety of clopidogrel.

Background: Decisions about limitations of life sustaining treatments (LST) are made for end-of-life patients in intensive care units (ICUs). The aim of this research was to explore the professional and ethical attitudes and experiences of medical professionals on treatment of end-of-life patients in ICUs in the Republic of Croatia., Methods: A cross-sectional study was conducted among physicians and nurses working in surgical, medical, neurological, and multidisciplinary ICUs in the total of 9 hospitals throughout Croatia using a questionnaire with closed and open type questions. Exploratory factor analysis was conducted to reduce data to a smaller set of summary variables. Mann-Whitney U test was used to analyse the differences between two groups and Kruskal-Wallis tests were used to analyse the differences between more than two groups., Results: Less than third of participants (29.2%) stated they were included in the decision-making process, and physicians are much more included than nurses (p < 0.001). Sixty two percent of participants stated that the decision-making process took place between physicians. Eighteen percent of participants stated that 'do-not-attempt cardiopulmonary resuscitations' orders were frequently made in their ICUs. A decision to withdraw inotropes and antibiotics was frequently made as stated by 22.4% and 19.9% of participants, respectively. Withholding/withdrawing of LST were ethically acceptable to 64.2% of participants. Thirty seven percent of participants thought there was a significant difference between withholding and withdrawing LST from an ethical standpoint. Seventy-nine percent of participants stated that a verbal or written decision made by a capable patient should be respected. Physicians were more inclined to respect patient's wishes then nurses with high school education (p = 0.038). Nurses were more included in the decision-making process in neurological than in surgical, medical, or multidisciplinary ICUs (p < 0.001, p = 0.005, p = 0.023 respectively). Male participants in comparison to female (p = 0.002), and physicians in comparison to nurses with high school and college education (p < 0.001) displayed more liberal attitudes about LST limitation., Conclusions: DNACPR orders are not commonly made in Croatian ICUs, even though limitations of LST were found ethically acceptable by most of the participants. Attitudes of paternalistic and conservative nature were expected considering Croatia's geographical location in Southern Europe., (© 2022. The Author(s).)

A prospective study was carried out at the Zagreb University Hospital Centre to evaluate the relationship between epilepsy, antiepileptic drugs (AEDs) and quality of life (QoL) in patients with epilepsy (PE), and its association with depressive symptoms and sexual dysfunction (SD). QoL was assessed by use of the Quality of Life in Epilepsy-31 Inventory (QOLIE-31), SD by the Arizona Sexual Experiences Scale (ASEX), and depressive symptoms by the Hamilton Rating Scale for Depression (HAM-D17). The study included 108 PE (women 63% and men 37% men), mean age 39.54±15.91 years. Focal type epilepsy was diagnosed in 14.8%, generalized type in 35.2%, and both types were present in 40.7% of study patients. Drug-resistant epilepsy (DRE) was present in 44/108 and vagus nerve stimulation (VNS) was implanted in 27/44 patients. The mean response on QOLIE-31 was 62.88±17.21 with no significant differences according to gender, type of epilepsy, and age. A statistically significantly lower QoL was found in the 'Overall QoL' domain (35-55 vs . <35 age group). Patients taking both types of AEDs had a significantly lower QoL compared to those on newer types of AEDs. Higher QoL was associated with less pronounced depressive symptoms (p=0.000). Significant correlations were found between lower QoL and SD (p=0.001). In 27 patients with DRE having undergone VNS, a favorable effect of VNS implantation on the QoL and mood was observed as compared with 18 patients without VNS (p=0.041).

Purpose: Acute hydrocephalus is a common complication after aneurysmal subarachnoid hemorrhage (aSAH). It can be self-limiting or require cerebrospinal fluid diversion. We aimed to determine the transient acute hydrocephalus (TAH) rate in patients with aSAH treated endovascularly and evaluate its predictive factors., Methods: A retrospective review of 357 patients with aSAH who underwent endovascular treatment from March 2013 to December 2019 was performed. Clinical and radiographic data were analyzed and risk factors with potential significance for acute hydrocephalus were identified. We constructed a new risk score, the Drainage Or Transiency of Acute Hydrocephalus after Aneurysmal SAH (DOTAHAS) score, that may differentiate patients who would experience TAH from those needing surgical interventions., Results: Acute hydrocephalus occurred in 129 patients (36%), out of whom in 66 patients (51%) it was self-limiting while 63 patients (49%) required external ventricular drainage placement. As independent risk factors for acute hydrocephalus, we identified older age, poor initial clinical condition, aSAH from posterior circulation, and the extent of cisternal and intraventricular hemorrhage. The following three factors were shown to predict acute hydrocephalus transiency and therefore included in the DOTAHAS score, ranging from 0 to 7 points: Hunt and Hess grade ≥ 3 (1 point), modified Fisher grade 4 (2 points), and Ventricular Hijdra Sum Score (vHSS) ≥ 6 (4 points). Patients scoring ≥ 3 points had significantly higher risk for EVD (P < 0.0001) than other patients., Conclusion: The newly developed DOTAHAS score can be useful in identifying patients with transient acute hydrocephalus. Further score evaluation is needed., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Aim: To report on the outcomes of spinal dural arteriovenous fistulas (sDAVFs) treatment in a single-center retrospective cohort., Methods: Data were retrieved on sDAVF cases treated surgically and endovascularly between January 2009 and January 2020. Sociodemographic, clinical, imaging data, and outcomes were analyzed., Results: Thirty-four patients were identified: 11 female, mean age 64.1 ± 11.5 years; mean time of symptom duration 12 (range 1-149) months. The sDAVF locations were the following: 18 (62.1%) thoracic, 4 (13.8%) lumbar, 4 (13.8%) sacral, and 3 (10%) with multiple location feeders. All patients had a motor deficit and affected walking, and the majority had a sensory deficit, bowel, and bladder dysfunction. Fifteen (44.1%) patients underwent surgical treatment, 7 (20.6%) underwent endovascular treatment, and 12 (35.3%) underwent both (crossover). Radiological myelopathy showed regression in 19 (55.9%) patients. Overall, clinical improvement (decrease in modified Rankin score) following treatment was observed in 14 patients (41.2%), worsening in 1 (2.9%), while other had unchanged status. The proportion of patients with initial treatment failure markedly differed between the before-2014 and after-2014 period. Patients who failed to improve had more extensive myelopathy., Conclusion: Patients who underwent surgery or endovascular treatment had on average significant clinical recovery, while those who underwent treatment crossover had negligible improvement. The extent of myelopathy seems to be associated with clinical improvement.

Purpose: Posterior circulation perforator aneurysms (PCPAs) are a rare type of intracranial aneurysms whose natural history and optimal clinical management are still largely unexplored. This study aims to report our experience with treating ruptured PCPAs and to provide a systematic review of the literature to compare the two most established treatment options, endovascular stenting, and conservative management including administration of antifibrinolytic drugs and watchful waiting., Methods: We performed a systematic review of the literature following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Major databases were searched for case reports and case report series written in the English language between 1995 and 2020. Additionally, we retrospectively reviewed our stroke center database for cases of ruptured PCPAs between January 2014 and July 2020. Endovascular stenting and conservative treatment were compared using endpoints, including favorable outcome rate (mRS 0-2), occlusion rate, mortality rate, periinterventional complication rate, and re-hemorrhage rate., Results: We identified 31 patients treated endovascularly using stents and 33 patients treated conservatively, with the administration of antifibrinolytic drugs in 3 of them. Our analysis showed no statistically significant difference between the groups, except for the occlusion rate., Conclusions: The optimal management strategy of PCPAs is still unknown, but stenting can be considered as an effective occlusion method with an acceptable complication rate. Preventive ventricular drainage may be necessary due to the high hydrocephalus rate encountered in ruptured PCPAs.

Background: Patients with epilepsy commonly report depressive symptoms. The main aim of this study was to evaluate the relationship between epilepsy, antiepileptic drugs (AEDs) and depression. We also wanted to evaluate possible association between depressive symptofigms in patients with epilepsy with the quality of life (QoL)., Material and Methods: This was a prospective cross-sectional study carried out at the tertiary teaching hospital (University Hospital Centre Zagreb, Croatia) with Ethics committee approval. Questionnaires evaluating depressive symptoms and QoL were administered to consecutive patients treated in the Referral Centre of the Ministry of Health of the Republic of Croatia for Epilepsy. Depressive symptoms were evaluated using Hamilton Rating Scale for Depression (HAM-D17). Quality of life was assessed using Quality of life in epilepsy-31 inventory (QOLIE-31)., Results: 108 patients (63% women, 37% men; mean age 39.54±15.91 years, range 18-80 years) with epilepsy were included. 14.8% of patients had focal, 35.2% generalised and 40.7% both types of epilepsy. Majority of patients (65.74%) were on two and more AEDs and quarter was on monotherapy (25%); 42% were on newer, 19% on older and 39% on both AEDs. Mean total score on HAM-D17 was 9.94±8.18 (men - mean total score 10.16±8.85, women - mean total score 9.81±7.84). There were no significant differences on HAM-D17 regarding gender and age. We didn't find statistically significant differences regarding AEDs (older vs. newer AEDs, or both types AEDs) and results on HAM-D17, nor between the type of epilepsy and results on HAM-D17. We found strong negative correlation between the higher QoL and HAM-D17 (p=0.000)., Conclusions: Results of this study evaluating depressive symptoms in patients with epilepsy demonstrate that our patients mainly experience mild depressive symptoms, with no significant differences on HAM-D17 regarding gender and age. Patients with epilepsy with less pronounced depressive symptoms were found to have higher QoL. We did not find statistically significant differences regarding the type of epilepsy and results on HAM-D17, nor between the AEDs (older vs. newer AEDs, or both types AEDs) and results on HAM-D17.

Introduction: Carotid angioplasty and stenting (CAS) represents an effective procedure for treating carotid artery disease. The acute in-stent thrombosis is an extremely rare complication of CAS especially when it occurs postprocedurally during the first 24 hours. Improper antiplatelet therapy or poor response to antiplatelet medications is known to be associated with a higher risk of in-stent thrombosis during early postprocedural period following a successful intervention., Material and Methods: A patient who experienced acute carotid in-stent thrombosis in early postprocedural period is described. He had been taking dual antiplatelet therapy for 2 weeks before undergoing a successful CAS. Moreover, pharmacogenetics studies showed the patient to be a clopidogrel ultrarapid metabolizer, which theoretically confers hyperresponsivity to medication. Alongside the report itself, a brief literature review of relevant sources pertinent to the case has been conducted., Results: According to the available literature, this is the first case report describing an ultrarapid clopidogrel metabolizer who underwent an uneventful CAS but experienced acute carotid in-stent thrombosis in early postprocedural period. A rescue procedure included an endovascular intervention consisting of thrombectomy and local alteplase application, followed by postprocedural administration of intravenous eptifibatide. At discharge, patient's dual antiplatelet therapy included ticagrelor instead of clopidogrel., Conclusion: Acute carotid in-stent thrombosis is a highly unexpected complication of CAS and can occur despite ultrarapid clopidogrel metabolism trait.

Background: Acute stent thrombosis is a rare adverse event following endovascular treatment of carotid artery. Experience on the topic is scarce, making the therapeutic approach a clinical challenge. In cases of intraprocedural acute carotid stent thrombosis, thromboaspiration, thrombectomy, and thrombolysis have been used as successful modalities for achieving recanalization., Case Description: We describe a case of carotid artery dissection treated endovascularly and complicated by intraprocedural stent thrombosis, which was ultimately managed by emergent extracranial-intracranial bypass with radial artery graft connecting the external carotid artery to the ipsilateral middle cerebral artery., Conclusions: Neurosurgical management may represent a rescue option for otherwise unmanageable acute carotid stent thrombosis., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Patients with certain types of stroke need urgent anticoagulation and it is extremely important for them to achieve fast and stable anticoagulant effect and receive individualized treatment during the initiation of warfarin therapy., Methods: We conducted a prospective study among 210 acute stroke patients who had an indication for anticoagulation and compared the impact of CYP2C9 and VKORC1 genotype-guided warfarin dosing (PhG) with fixed dosing (NPhG) on anticoagulation control and clinical outcome between groups., Results: PhG achieved target INR values earlier, i.e., on average in 4.2 (4.1-4.7, 95% CI) days compared to NPhG (5.2 days [4.7-6.4, 95% CI]) (p = 0.0009), spent a higher percentage of time in the therapeutic INR range (76.3% [74.7-78.5, 95% CI] vs. 67.1% [64.5-69.6, 95% CI] in NPhG), and spent less time overdosed (INR > 3.1) (PhG 0.4 [0.1-0.7, 95% CI], NPhG 1.7 [1.1-2.3, 95% CI] days; p >0.000). PhG reached stable maintenance dose faster (10 [9.9-10.7, 95% CI] vs. 13.9 [13.3-14.7, 95% CI] days in controls; p = 0.0049) and had a better clinical outcome in relation to neurological deficit on admission as compared to NPhG., Conclusion: We confirmed that warfarin therapy with genotype-guided dosing instead of fixed dosing reduces the time required for stabilization and improves anticoagulant control with better clinical outcome in early stages of warfarin therapy introduction among acute stroke patients, which is essential for clinical practice., (Copyright © 2015 IMSS. Published by Elsevier Inc. All rights reserved.)

Aim: To compare angiographic result at long-term follow-up, and rates of progressive occlusion, recurrence, and retreatment of stent-assisted coiled (SAC) and non-assisted coiled (NAC) intracranial saccular aneurysms., Methods: Retrospective evaluation of department records identified 260 patients with 283 saccular intracranial aneurysms who had long-term angiographic follow-up (more than 12 months) and were successfully treated with SAC (89 aneurysms) or NAC (194 aneurysms) at the University Hospital Center Zagreb from June 2005 to July 2012. Initial and control angiographic results in both groups were graded using Roy/Raymond scale, converted to descriptive terms, and the differences between them were evaluated for statistical significance. A multivariate analysis was performed to identify factors related to progression of aneurysm occlusion and recurrence at follow-up, and those related to aneurysm retreatment., Results: There were more progressively occluded aneurysms in SAC group (38 of 89 aneurysms, 42.7%) than in NAC group (46 of 194, 23.7%) (P=0.002), but there were no significant differences in the rates of recanalization, regrowth, and stable result. Multivariate logistic regression identified the use of stent as the most important factor associated with progressive occlusion (P=0.015, odds ratio 2.22, 95% confidence interval 1.17-4.21), and large aneurysm size and posterior circulation location as most predictive of aneurysm recurrence and retreatment., Conclusion: The use of stent is associated with delayed occlusion of initially incompletely coiled aneurysms during follow-up, but does not reduce the rate of recurrence and retreatment compared to coiling alone. Long-term angiographic follow-up is needed for both SAC and NAC aneurysms.

Recurrent epistaxis is a rare presentation of internal carotid artery C4/C5 segment pseudo-aneurysm rupture. We describe a case of a traumatic internal carotid artery pseudo-aneurysm with recurrent epistaxis as a leading symptom that was finally managed with endovascular treatment with stent-assisted coil placement. Clopidogrel and acetylsalicylic acid orally were introduced in the therapy for further stent thrombosis prevention and epistaxis did not recur on six-month follow-up. Endovascular treatment with stent-assisted coil placement seems to be a good method for pseudo-aneurysm treatment while keeping the lumen of the parent artery patent.

Background: Data on the prevalence of CYP2C9 and VKORC1 genes and their influence on anticoagulant effect and warfarin dose in stroke patients are scarce. The aim of this study was to determine the occurrence and significance of these gene polymorphisms and to establish pharmacogenetic algorithm to estimate the dose of introduction. Also, the goal was to determine tailored safety and intensity of anticoagulation response depending on the allelic variants and their impact on the clinical outcome in acute stroke patients in Croatia., Methods: A total of 106 consented acute stroke patients were tested for CYP2C9 2, 3 and VKORC1 1173C>T gene polymorphisms. We estimated the dose of introduction and monitored anticoagulant effect obtained by INR values, time to reach stable dose, stable maintenance dose, time spent within the therapeutic/supratherapeutic INR range, occurrence of dosage side effects and clinical outcome depending on genotypes., Results: We found that 83% of stroke patients in our study were carriers of multiple allelic variants. The predicted initial dose correlated with the stable warfarin maintenance dose (p=0.0311) and we correctly estimated the dose for 81.5% of 61.3% of study patients who required higher/lower doses than average. Warfarin dosage complications were slightly more frequent among the carriers of CYP2C9 2, 3 compared to the carriers of VKORC1 1173T alleles (68. 9% versus 62.5%), but their occurrence did not affect the final clinical outcome., Conclusion: Our data indicated rapid and safe anticoagulation achieved by using pharmacogenetically-predicted warfarin dose in high-risk acute stroke patients without increasing the risk of warfarin dosage complications in an elderly population., (Copyright © 2014 Elsevier B.V. All rights reserved.)

These are evidence based guidelines for the management of medical complications in patients following aneurysmal subarachnoid hemorrhage, developed and endorsed by the Croatian Society of Neurovascular Disorders, Croatian Society of Neurology including Section for Neurocritical Care, Croatian Neurosurgical Society, Croatian Society for Difficult Airway Management and Croatian Medical Association. They consist of recommendations for best monitoring, medical treatment and interventions based on the literature, evaluation of the results of large international clinical trials, and collective experience of the authors.

We herein report the case of a 32-year-old woman with sudden onset ataxia, limb dysmetria and somnolence. Emergency radiological findings showed bilateral cerebellar and thalamic infarctions as a result of a basilar artery occlusion. The patient was treated with intra-arterial (IA) and mechanical thrombolysis 12 hours after symptom onset and showed an excellent recovery. A diagnostic workup revealed a tumor mass on the mitral valve that was surgically removed, while a histological analysis confirmed a diagnosis of cardiac papillary fibroelastoma.

Background: The aims of this paper are: 1) to present the data of systemic thrombolysis for ischemic stroke in five Croatian centers from July 2008 till January 2010; 2) to compare the results between centers and; 3) to compare data with previously published results from 2006 to 2008 period from our center, and with the data from SITS (Safe Implementation of Treatments in Stroke)., Methods: We retrospectively reviewed the medical data of thrombolysed patients in following hospitals: University Hospital Center Zagreb (91 patients), University Hospital Split (25 patients), University Hospital Osijek (22 patients), General Hospital Varaždin (21 patient), and General Hospital Zadar (7 patients)., Results: The "time to door" for all centers was 79.71±38.63 min, the "door to needle" period was 64.39±24.18 min. Systolic and diastolic blood pressures at admission were 158.65±27.72 and 90.18±15.03 mm Hg, respectively. Systolic and diastolic blood pressures measured immediately prior to administering rt-PA were 152.19±23.17 and 85.40±15.27 mm Hg, respectively. Initial median NIHSS score was 12, median NIHSS 2h post thrombolysis was 8, and 7th day after rt-PA treatment 4. Intracerebral hemorrhages or secondary hemorrhagic transformations occurred in 21 (12.65%) patients, among which nine were symptomatic. In a 4.5h time window total of 17 patients were thrombolysed. We did not find any differences in outcome between this group and group of patients thrombolysed in the 3h time-window. The group of patients older than 80 years had a worse outcome., Conclusions: According to our data, treatment with rt-PA is safe, feasible and effective for stroke patients in both university as well as regional hospitals having stroke units established. Organization of stroke units in regional hospitals, as well as systematic education of public health workers and neurologists, leads to the possibility for each patient to reach the nearest stroke unit and gets the thrombolytic therapy in the therapeutic time window., (Copyright © 2011 Elsevier B.V. All rights reserved.)

Vagus nerve stimulation (VNS) for the treatment of refractory partial epileptic seizures with or without secondary generalisation in patients older than 12 years was approved in Europe in 1994 and in the United States in 1997. We have studied the efficacy of VNS in patients with pharmacoresistant epilepsy hospitalized in the Neurology Department of the University Hospital Centre Zagreb. From 1997 to 2001 we have implanted VNS in 11 patients with pharmacoresistant epilepsy, who were magnetic resonance imaging (MRI) negative and from May 2007 to May 2009 in 11 patients with pharmacoresistant epilepsy, 9 of them were MRI positive, and were inoperable due to localisation of the pathomorphologic changes (ganglioglioma, hamartoma, various types of cortical dysplasia, porencephalic cysts), 2 were MR negative. In the group of MRI negative patients 1 patient had complex partial seizures (CPS), 6 patients had CPS with secondary generalisation, 2 patients had primary generalized epilepsy (PGE) including myoclonic, absence, atonic and tonic-clonic seizures, one patient had PGE and CPS, and 3 patients had Lennox-Gastaut syndrome (LGS). In the group of MRI positive patients one patient had elementary partial seizures (EPS) and CPS, two patients had EPS and CPS with secondary generalisation, one patient had CPS, 3 patients had CPS with secondary generalisation, and 2 patients had CPS with secondary generalisation as well as atonic seizures. After continuous follow-up of 11 MRI negative patients during 5 years and 2 MRI negative patients during one year there was decrease in mean-seizure frequency of 51.67%. After continuous follow-up of 9 MRI positive patients during 2 years there was decrease in mean-seizure frequency of 61.9%. The most frequent side effects were hoarseness, throat pain and cough in the "on phase" of the VNS, but they were mild and transitory. We can conclude that VNS was effective mode of therapy in our group of patients with pharmacoresistant epilepsy.

We present the case of a 41-year-old man with sudden development of left hemiparesis due to infarction of the right middle cerebral artery that was successfully treated with intravenous (IV) thrombolysis with alteplase. Transthoracic echocardiography showed a small mass in the left ventricle. The patient underwent surgical resection, and histological examination of the mass confirmed the diagnosis of papillary fibroelastoma. It remains to be investigated whether heart ultrasound evaluation should be performed before IV thrombolysis in selected patients with stroke, given the apparently increased risk of bleeding. However, IV thrombolysis should not be postponed due to a lengthy investigation, because of its potential for reducing morbidity in patients with stroke., (Copyright © 2011 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

It presents a case of a 39-year old woman with acute symptomatic occlusion of basilar artery proximal segment, which was manifested by severe neurological symptomatology and deficits. The patient was treated conventionally (anticoagulant, then antiplatelet agent therapy) with excellent short-term and long-term outcome. In spite of serious acute neurological symptomatology of basilar artery occlusion, proximal localization of the occlusion, fluctuating symptomatology flow, younger age and development of collateral circulation can suggest a good outcome in conventionally treated patients.

Basic Life Support: All rescuers trained or not, should provide chest compressions to victims of cardiac arrest. The aim should be to push to a depth of at least 5 cm at a rate of at least 100 compressions per minute, to allow full chest recoil, and to minimise interruptions in chest compressions. Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2. ELECTRICAL THERAPIES: Much greater emphasis on minimising the duration of the pre-shock and post-shock pauses; the continuation of compressions during charging of the defibrillator is recommended. Further development of AED programmes is encouraged. ADULT ADVANCED LIFE SUPPORT: Increased emphasis on high-quality chest compressions throughout any ALS intervention paused briefly only to enable specific interventions. Removal of the recommendation for a pre-specified period of cardiopulmonary resuscitation before out-of-hospital defibrillation following cardiac arrest unwitnessed by the EMS. The role of precordial thump is de-emphasized. Delivery of drugs via a tracheal tube is no longer recommended, drugs should be given by the intraosseous (IO) route. Atropine is no longer recommended for routine use in asystole or pulseless electrical activity. Reduced emphasis on early tracheal intubation unless achieved by highly skilled individuals with minimal interruptions in chest compressions. Increased emphasis on the use of capnography. Recognition of potential harm caused by hyperoxaemia. Revision of the recommendation of glucose control. Use of therapeutic hypothermia to include comatose survivors of cardiac arrest associated initially with shockable rhythms, as well as non-shockable rhythms, with a lower level of evidence acknowledged for the latter. INITIAL MANAGEMENT OF ACUTE CORONARY SYNDROMES: The term non-ST-elevation myocardial infarction-acute coronary syndrome (non-STEMI-ACS) has been introduced for both NSTEMI and unstable angina pectoris. Primary PCI (PPCI) is the preferred reperfusion strategy provided it is performed in a timely manner by an experienced team. Non-steroidal anti-inflammatory drugs should be avoided, as well as routine use of intravenous beta-blockers; oxygen is to be given only to those patients with hypoxaemia, breathlessness or pulmonary congestion. PAEDIATRIC LIFE SUPPORT: The decision to begin resuscitation must be taken in less than 10 seconds. Lay rescuers should be taught to use a ratio of 30 compressions to 2 ventilations, rescuers with a duty to respond should learn and use a 15:2 ratio; however, they can use the 30:2 compression-ventilation ratio if they are alone. Ventilation remains a very important component of resuscitation in asphyxial arrest. The emphasis is on achieving quality compressions with the rate of at least 100 but not greater than 120 per minute, with minimal interruptions. AEDs are safe and successful when used in children older than 1 year. A single shock strategy using a non-escalating dose of 4 J/kg is recommended for defibrillation in children. Cuffed tubes can be used safely in infants and young children. Monitoring exhaled carbon dioxide (CO2), ideally by capnography, is recommended during resuscitation. RESUSCITATION OF BABIES AT BIRTH: For uncompromised babies, a delay in cord clamping of at least one minute from the complete delivery is now recommended. For term infants, air should be used fro resuscitation at birth. For preterm babies less than 32 weeks gestation blended oxygen and air should be given judiciously and its use guided by pulse oximetry. Preterm babies of less than 28 weeks gestation should be completely covered in a plastic wrap up to their necks, without drying, immediately after birth. The recommended compression: ventilation ratio remains at 3:1 for newborn resuscitation. Attempts to aspirate meconium from the nose and mouth of the unborn baby, while the head is still on the perineum, are not recommended. If adrenaline is given the n the intravenous route is recommended using a dose of 10-30 microg/kg. Newly born infants born at term or near-term with moderate to severe hypoxic-ischaemic encephalopathy should be treated with therapeutic hypothermia. PRINCIPLES OF EDUCATION IN RESUSCITATION: The aim is to ensure that learners acquire and retain skill and knowledge that will enable them to act correctly in actual cardiac arrest and improve patient outcome. Short video/computer self-instruction courses, with minimal or no instructor coaching, combined with hands-on practice can be considered as an effective alternative to instructor-led basic life support (BLS and AED) courses. Ideally all citizens should be trained in standard CPR that includes compressions and ventilations. Basic and advanced life support knowledge and skills deteriorate in as little as three to six months. CPR prompt or feedback devices improve CPR skill acquisition and retention.

In September 2003, recombinant tissue plasminogen activator (rt-PA) for acute treatment of ischemic stroke was finally approved by the Croatian Ministry of Health. For the next 5 years, only three stroke units in the country implemented this therapy in their routine practice until summer 2008, when neurological wards in most Croatian hospitals started to treat acute stroke patients with systemic thrombolysis. We present a 2-year experience of thrombolytic therapy (2006-2008) in the stroke unit of the University Hospital in Zagreb, Croatian largest hospital, serving nearly one-fifth of the citizens of Croatia. Obtained data (vitals at admission and before administration of rt-PA; NIHSS and MRS scores at admission, 2 h and 7th day after rt-PA treatment, "time to door" and "door to needle" intervals, duration of hospital treatment as well as outcomes and complications of our 66 thrombolysed patients) are presented and discussed. We also present our results regarding benefits of this therapy as well as possible reasons for complications noticed.

We present a patient who developed progressive neurological disease caused by lesions histologically compatible with those observed in subacute brainstem angioencephalopathy. The patient was treated with low-molecular weight heparin, and treatment response was monitored clinically and with MRI. Anticoagulation therapy stopped progression of the neurological deficit and led to improvement of MRI findings. This report further supports the existence of subacute brainstem angioencephalopathy as a characteristic disease entity and gives insight into possible therapeutic approach with anticoagulation treatment.

Hashimoto encephalopathy (HE) is a distinct form of encephalopathy, which can manifest itself with purely psychiatric symptoms. A 38-year-old female with history of rheumatoid arthritis was treated with psychotropic drugs for a couple of years in psychiatric structures because of the onset of depressive symptoms, psychoticlike manifestations, and impairment of cognitive functions. The electroencephalography (EEG) was characterized by general slowing with high voltage (2 to 3 Hz) delta biphasic and triphasic waves. Once a firm diagnosis of HE was made, corticosteroid treatment resulted in resolution of her psychiatric symptoms, marked EEG improvement, and partial improvement in her cognitive functions. HE should be suspected in young females with history of autoimmune disorders and EEG abnormalities.

ADULT BASIC LIFE SUPPORT: The ratio of compressions to ventilations is 30:2 for all adult victims of cardiac arrest. AUTOMATED EXTERNAL DEFIBRILLATION: A single defibrillatory shock is delivered, immediately followed by two minutes of uninterrupted CPR. ADULT ADVANCED LIFE SUPPORT: In out-of-hospital cardiac arrest attended, but unwitnessed, by healthcare professionals equipped with manual defibrillators, give CPR for 2 minutes before defibrillation. The recommended initial energy for biphasic defibrillators is 150-200 J, for second and subsequent shocks is 150-360 J. The recommended energy when using a monophasic defibrillator is 360 J for both the initial and subsequent shocks. Rhythm checks must be brief, and pulse cheks undertaken only if an organised rhythm is observed. Adrenaline is given 1 mg i.v. as soon as intravenous access is obtained, and repeated every 3-5 min thereafter until return of spontaneous circulation is achieved. Consider thrombolytic therapy when cardiac arrest is thought to be due to proven or suspected pulmonary embolus. Unconscious adult patinets, with spontaneous circulation, after out-of-hospital VF cardiac arrest should be cooled to 32-34 degrees C for 12-24 hours. PAEDIATRIC BASIC LIFE SUPPORT: Lay rescuers or lone rescuers witnessing paediatric cardiac arrest will start with 5 rescue breaths and continue with the 30:2 ratio as thaught in adult BLS. Two or more rescuers with a duty to respond will use the 15:2 ration in a child up to the onset of puberty. PAEDIATRIC ADVANCED LIFE SUPPORT: When using a manual defibrillator, a dose of 4 J/kg (biphasic or monophasic waveform) should be used for the first and subsequent shocks. Adrenaline iv. or i.o. should be given at the dose of 10 microg/kg (0.01 mg/kg) and repeated every 3-5 minutes. NEONATAL LIFE SUPPORT: Protect the newborn from heat loss. Standard resuscitation in delivery room should be made with 100% oxygen. Suctioning meconium from the baby's nose and mouth before delivery of the baby's chest (intrapartum suctioning) is not useful and no longer recommended.

The first clinical attempts at neuromodulation in the form of applying functional electrostimulations started some thirty years ago. Nowadays, it is obvious that the approach to neuromodulation and functional electrostimulation has changed significantly. Neuromodulation tends to affect the disturbed function either by the modulation of neuronal signals or by abolition of dysfunction, preserving the intact central nervous system. The mechanism of activity is connected through direct afferent projections, neurotransmitter modulation and neuronal network regulation. NeuroCybernetic Prosthesis (NCP; Cyberonics) is a vagal nerve stimulator consisting of a pulse generator, bipolar VNS lead, programming wand with accompanying software for IBM-compatible computer, a tunneling tool and handheld magnets. NCP is placed on the left vagal nerve (middle cervical part). In 1988, Penry JK et al. inserted the first human implant. The Food and Drug Association indicated VNS as add-on therapy for diminishing the number of seizures in the adults and adolescents over 12 years of age with partial seizures, who are resistant to pharmacological therapy.