Analysis of C9orf72 repeat expansions in Georgian patients with Amyotrophic lateral sclerosis (ALS)

Background

Amyotrophic lateral sclerosis (ALS) is a fatal progressive neurodegenerative disorder that affects the upper and lower motor neurons. Several genetic risk factors have been identified in the past decade with a hexanucleotide repeat expansion in the C9orf72 gene being the most significant. However, the presence of C9orf72 repeat expansion has not been examined in the Transcaucasian region, therefore we aimed to analyse its frequency in Georgian patients with ALS.

Methods

We included 64 self-reported Georgian patients with ALS from different parts of the country, fulfilling the Gold Coast criteria. To investigate the presence of an expanded GGGGCC hexanucleotide repeat in the non-coding region of the C9orf72 gene, we performed Repeat-Primed PCR (RP-PCR).

Results

In total, 62 sporadic and two familial ALS cases were identified. Patients were aged 26 to 84 years with a mean age of 58.3 years at disease onset. Bulbar onset was observed in 21.88%, upper limb onset in 34.38%, and lower limb onset in 43.75% of the patients. Frontotemporal dementia (FTD) fulfilling the Strong criteria was diagnosed in seven patients (10.94%). C9orf72 repeat expansion was detected in only one case using RP-PCR; the patient had a family history of dementia.

Conclusions

Our results indicate that C9orf72 hexanucleotide expansion does not belong to the major genetic risk factor of ALS in Georgian patients. Further genetic studies in a bigger study population are needed to reveal the genetic causes of ALS in the Transcaucasian population.

Effects of blood pressure and tranexamic acid in spontaneous intracerebral haemorrhage: a secondary analysis of a large randomised controlled trial

Background

Tranexamic acid reduced haematoma expansion and early death, but did not improve functional outcome in the tranexamic acid for hyperacute spontaneous intracerebral haemorrhage-2 (TICH-2) trial. In a predefined subgroup, there was a statistically significant interaction between prerandomisation baseline systolic blood pressure (SBP) and the effect of tranexamic acid on functional outcome (p=0.019).

Methods

TICH-2 was an international prospective double-blind placebo-controlled randomised trial evaluating intravenous tranexamic acid in patients with acute spontaneous intracerebral haemorrhage (ICH). Prerandomisation baseline SBP was split into predefined ≤170 and >170 mm Hg groups. The primary outcome at day 90 was the modified Rankin Scale (mRS), a measure of dependency, analysed using ordinal logistic regression. Haematoma expansion was defined as an increase in haematoma volume of >33% or >6 mL from baseline to 24 hours. Data are OR or common OR (cOR) with 95% CIs, with significance at p<0.05.

Results

Of 2325 participants in TICH-2, 1152 had baseline SBP≤170 mm Hg and were older, had larger lobar haematomas and were randomised later than 1173 with baseline SBP>170 mm Hg. Tranexamic acid was associated with a favourable shift in mRS at day 90 in those with baseline SBP≤170 mm Hg (cOR 0.73, 95% CI 0.59 to 0.91, p=0.005), but not in those with baseline SBP>170 mm Hg (cOR 1.05, 95% CI 0.85 to 1.30, p=0.63). In those with baseline SBP≤170 mm Hg, tranexamic acid reduced haematoma expansion (OR 0.62, 95% CI 0.47 to 0.82, p=0.001), but not in those with baseline SBP>170 mm Hg (OR 1.02, 95% CI 0.77 to 1.35, p=0.90).

Conclusions

Tranexamic acid was associated with improved clinical and radiological outcomes in ICH patients with baseline SBP≤170 mm Hg. Further research is needed to establish whether certain subgroups may benefit from tranexamic acid in acute ICH.

Trial registration number

ISRCTN93732214.

The Elemental Composition of the Child's Body and Its Effect on General and Dental Health

The Article Abstract is not available.

RISK FACTORS OF AMYOTROPHIC LATERAL SCLEROSIS IN GEORGIA

Objective - to identify risk factors in patients diagnosed with Amyotrophic Lateral Sclerosis in Georgia directed to The First University Clinic of TSMU and P. Sarajishvili Institute of Neurology. Totally 53 patients, aged 24 to 82 years, were investigated with Amyotrophic Lateral Sclerosis (ALS), defined by "Gold Coast " criteria. We have used the Questionnaire for Environmental Exposures, Toxins, and Neurological diseases developed by Dartmouth-Hitchcock Medical center to identify risk factors, and categorized patients according to the place of settlement and environmental hazards. The control consisted of age and sex matched 50 healthy individuals. The brain was visualized by MRI (1.5T), and Electromyography (EMG) was performed on all patients. ALS risk was higher among those ever holding a job in mechanics, painting, or construction (p<0.05), head trauma or concussion that caused a "blackout" or loss of consciousness was associated with a higher risk of ALS (p<0.01). Demographically more ALS cases were found in Tbilisi and Imereti, compared to other regions (p<0.05). According to our research on Georgian ALS cases, several occupational jobs, Head trauma is associated with developing ALS in Georgia, Research is needed to identify environmental risk factors attributing to higher rates of ALS in Tbilisi and Imereti.

Brief Consent Methods Enable Rapid Enrollment in Acute Stroke Trial: Results From the TICH-2 Randomized Controlled Trial

BACKGROUND

Seeking consent rapidly in acute stroke trials is crucial as interventions are time sensitive. We explored the association between consent pathways and time to enrollment in the TICH-2 (Tranexamic Acid in Intracerebral Haemorrhage-2) randomized controlled trial.

METHODS

Consent was provided by patients or by a relative or an independent doctor in incapacitated patients, using a 1-stage (full written consent) or 2-stage (initial brief consent followed by full written consent post-randomization) approach. The computed tomography-to-randomization time according to consent pathways was compared using the Kruskal-Wallis test. Multivariable logistic regression was performed to identify variables associated with onset-to-randomization time of ≤3 hours.

RESULTS

Of 2325 patients, 817 (35%) gave self-consent using 1-stage (557; 68%) or 2-stage consent (260; 32%). For 1507 (65%), consent was provided by a relative (1 stage, 996 [66%]; 2 stage, 323 [21%]) or a doctor (all 2-stage, 188 [12%]). One patient did not record prerandomization consent, with written consent obtained subsequently. The median (interquartile range) computed tomography-to-randomization time was 55 (38-93) minutes for doctor consent, 55 (37-95) minutes for 2-stage patient, 69 (43-110) minutes for 2-stage relative, 75 (48-124) minutes for 1-stage patient, and 90 (56-155) minutes for 1-stage relative consents (P<0.001). Two-stage consent was associated with onset-to-randomization time of ≤3 hours compared with 1-stage consent (adjusted odds ratio, 1.9 [95% CI, 1.5-2.4]). Doctor consent increased the odds (adjusted odds ratio, 2.3 [1.5-3.5]) while relative consent reduced the odds of randomization ≤3 hours (adjusted odds ratio, 0.10 [0.03-0.34]) compared with patient consent. Only 2 of 771 patients (0.3%) in the 2-stage pathways withdrew consent when full consent was sought later. Two-stage consent process did not result in higher withdrawal rates or loss to follow-up.

CONCLUSIONS

The use of initial brief consent was associated with shorter times to enrollment, while maintaining good participant retention. Seeking written consent from relatives was associated with significant delays.

REGISTRATION

URL: https://www.isrctn.com; Unique identifier: ISRCTN93732214.

[OUTCOMES OF SURGICAL TREATMENT OF COMPLEX PATHOLOGY OF THE ASCENDING AORTA, AORTIC ARCH, DESCENDING THORACIC AORTA, THROUGH THE "ELEPHANT TRUNK" HYBRID METHOD]

Complete prosthetic surgery of the ascending aorta, aortic arch branches, and descending aorta in patients with aortic arch aneurysm, study and demonstration the possibility of the "elephant trunk" method. The paper describes the technology and demonstrates the results of the first 29 operations of ascending aorta, aortic arch, aortic arch branches and descending thoracic aortic prostheses performed by the staff of the Department of Aortic Pathologies of the Amusov State Institute during 2016-2020. All patients, underwent elephant trunk prosthesis surgery of the ascending aorta, aortic arch, aortic arch branches, and descending thoracic aorta as the first stage of reconstruction of aortic arch pathology. Most of the patients, except for three, underwent the second stage of surgery, endoprosthesis of the aortic arch and descending thoracic aorta through a vascular stent. In case of an aortic arch aneurysm or disruption of the anatomical integrity of blood vessels, restoration of the anatomical integrity of the aortic arch and aortic arch blood vessels or prosthesis of blood vessels in this basin can be performed through "elephant trunk" surgery. Optimization and improvement of preoperative diagnostics, surgical techniques, methods of protection of the brain, spinal cord and visceral organs, the use of hybrid / endovascular techniques allows treatment in case of complex damage to the ascending arch and descending thoracic aorta. The first completely satisfactory results of the performed operations were obtained, the hospital lethality was demonstrated within 10.3%.

CLINICAL CHARACTERISTICS OF ALS IN GEORGIAN PATIENTS

Amyotrophic Lateral sclerosis (ALS ) is a fatal progressive neurodegenerative disease that affects the upper and lower motoneurons. .The disease is characterized by a plethora of neurological symptoms. There is a lot of information in the medical literature about ALS phenotypes, but the clinical diversity of ALS has not been studied in the Caucasus region and a unified clinical picture has not been conclusively established. In this regard, it is very important to study the symptoms among patients with ALS in Georgia. From 2018 to 2021, we examined 47 patients with ALS living in Georgia from different parts of the country, 23 - female, 24 - male, diagnosed based on clinical picture, electromyographic studies (AWAJI) and who met the EL ESCORIAL -Revised criteria. Also clinical symptom studies were conducted using the Mayo Clinic Laboratory Neurological Questionnaire. Cognitive changes were assessed using Addenbrooke's Cognitive Examination scale (ACE III) and the Frontal Behavioral Questionnaire, the patient's quality of life was assessed by ALSFRS-R. Patients were 26 to 84 years old, the age of onset of the disease was 58-60 years in men, 55-57 years in women. The bulbar type was observed in 21.3%, the upper limb type in 38.3% and the lower limb type in 40.4%. Frontotemporal dementia (FTD), diagnosed in 6 patients (12.7%). No reliable correlation was found between the forms of ALS and FTD. The results of the study showed that ALS is a multisystem disease and is not limited to damage to motoneurons. It is safe to say that ALS has characteristics of polysystemic degeneration, with the predominance of motorneuron damage. Therefore, we consider it advisable to screen all patients with ALS for additional symptoms with a focus on the examination of cognitive function, which ensures the proper management of the disease in the future.

ELEMENTAL CONTENT - GENERAL AND ORAL HEALTH OF CHILDREN

Aim of study - to determine the composition of the essential macro and microelements in the hair and dental hard tissues and to study the influence of their imbalance on the general and dental health of the child. To assess the state of dental hard tissues, 375 children aged 3 to 12 years were randomly examined in Batumi. Monitoring of the examined children was carried out using standard indices provided by the World Health Organization. To determine the composition of the chemical elements in hair and dental hard tissues, according to the caries status 48 children were chosen from the examined 375 children. We used X-ray fluorescent spectroscopy method to study the qualitative and quantitative content of the chemical elements in the hair and dental hard tissues. The comparative analysis of the dental experience (dmft/DMFT) and the composition of chemical elements in dental hard tissues showed a statistically significant difference depending on caries status. The effect of some essential elements on the general health of the child has also been identified. The study into the composition of the essential macro and microelements in the hair and dental hard tissues revealed a high coefficient of correlation both with the mineralization of dental hard tissues and with the general health of the growing body.

Outcomes in Antiplatelet-Associated Intracerebral Hemorrhage in the TICH-2 Randomized Controlled Trial

Background

Antiplatelet therapy increases the risk of hematoma expansion in intracerebral hemorrhage (ICH) while the effect on functional outcome is uncertain.

Methods and Results

This is an exploratory analysis of the TICH‐2 (Tranexamic Acid in Intracerebral Hemorrhage‐2) double‐blind, randomized, placebo‐controlled trial, which studied the efficacy of tranexamic acid in patients with spontaneous ICH within 8 hours of onset. Multivariable logistic regression and ordinal regression were performed to explore the relationship between pre‐ICH antiplatelet therapy, and 24‐hour hematoma expansion and day 90 modified Rankin Scale score, as well as the effect of tranexamic acid. Of 2325 patients, 611 (26.3%) had pre‐ICH antiplatelet therapy. They were older (mean age, 75.7 versus 66.5 years), more likely to have ischemic heart disease (25.4% versus 2.7%), ischemic stroke (36.2% versus 6.3%), intraventricular hemorrhage (40.2% versus 27.5%), and larger baseline hematoma volume (mean, 28.1 versus 22.6 mL) than the no‐antiplatelet group. Pre‐ICH antiplatelet therapy was associated with a significantly increased risk of hematoma expansion (adjusted odds ratio [OR], 1.28; 95% CI, 1.01–1.63), a shift toward unfavorable outcome in modified Rankin Scale (adjusted common OR, 1.58; 95% CI, 1.32–1.91) and a higher risk of death at day 90 (adjusted OR, 1.63; 95% CI, 1.25–2.11). Tranexamic acid reduced the risk of hematoma expansion in the overall patients with ICH (adjusted OR, 0.76; 95% CI, 0.62–0.93) and antiplatelet subgroup (adjusted OR, 0.61; 95% CI, 0.41–0.91) with no significant interaction between pre‐ICH antiplatelet therapy and tranexamic acid (P interaction=0.248).

Conclusions

Antiplatelet therapy is independently associated with hematoma expansion and unfavorable functional outcome. Tranexamic acid reduced hematoma expansion regardless of prior antiplatelet therapy use.

Registration

URL: https://www.isrctn.com; Unique identifier: ISRCTN93732214.

Tranexamic acid to improve functional status in adults with spontaneous intracerebral haemorrhage: the TICH-2 RCT

BACKGROUND

Tranexamic acid reduces death due to bleeding after trauma and postpartum haemorrhage.

OBJECTIVE

The aim of the study was to assess if tranexamic acid is safe, reduces haematoma expansion and improves outcomes in adults with spontaneous intracerebral haemorrhage (ICH).

DESIGN

The TICH-2 (Tranexamic acid for hyperacute primary IntraCerebral Haemorrhage) study was a pragmatic, Phase III, prospective, double-blind, randomised placebo-controlled trial.

SETTING

Acute stroke services at 124 hospitals in 12 countries (Denmark, Georgia, Hungary, Ireland, Italy, Malaysia, Poland, Spain, Sweden, Switzerland, Turkey and the UK).

PARTICIPANTS

Adult patients (aged ≥ 18 years) with ICH within 8 hours of onset.

EXCLUSION CRITERIA

Exclusion criteria were ICH secondary to anticoagulation, thrombolysis, trauma or a known underlying structural abnormality; patients for whom tranexamic acid was thought to be contraindicated; prestroke dependence (i.e. patients with a modified Rankin Scale [mRS] score > 4); life expectancy < 3 months; and a Glasgow Coma Scale score of < 5.

INTERVENTIONS

Participants, allocated by randomisation, received 1 g of an intravenous tranexamic acid bolus followed by an 8-hour 1-g infusion or matching placebo (i.e. 0.9% saline).

MAIN OUTCOME MEASURE

The primary outcome was functional status (death or dependency) at day 90, which was measured by the shift in the mRS score, using ordinal logistic regression, with adjustment for stratification and minimisation criteria.

RESULTS

A total of 2325 participants (tranexamic acid, n = 1161; placebo, n = 1164) were recruited from 124 hospitals in 12 countries between 2013 and 2017. Treatment groups were well balanced at baseline. The primary outcome was determined for 2307 participants (tranexamic acid, n = 1152; placebo, n = 1155). There was no statistically significant difference between the treatment groups for the primary outcome of functional status at day 90 [adjusted odds ratio (aOR) 0.88, 95% confidence interval (CI) 0.76 to 1.03; p = 0.11]. Although there were fewer deaths by day 7 in the tranexamic acid group (aOR 0.73, 95% CI 0.53 to 0.99; p = 0.041), there was no difference in case fatality at 90 days (adjusted hazard ratio 0.92, 95% CI 0.77 to 1.10; p = 0.37). Fewer patients experienced serious adverse events (SAEs) after treatment with tranexamic acid than with placebo by days 2 (p = 0.027), 7 (p = 0.020) and 90 (p = 0.039). There was no increase in thromboembolic events or seizures.

LIMITATIONS

Despite attempts to enrol patients rapidly, the majority of participants were enrolled and treated > 4.5 hours after stroke onset. Pragmatic inclusion criteria led to a heterogeneous population of participants, some of whom had very large strokes. Although 12 countries enrolled participants, the majority (82.1%) were from the UK.

CONCLUSIONS

Tranexamic acid did not affect a patient's functional status at 90 days after ICH, despite there being significant modest reductions in early death (by 7 days), haematoma expansion and SAEs, which is consistent with an antifibrinolytic effect. Tranexamic acid was safe, with no increase in thromboembolic events.

FUTURE WORK

Future work should focus on enrolling and treating patients early after stroke and identify which participants are most likely to benefit from haemostatic therapy. Large randomised trials are needed.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN93732214.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 35. See the NIHR Journals Library website for further project information. The project was also funded by the Pragmatic Trials, UK, funding call and the Swiss Heart Foundation in Switzerland.

[; SURGICAL TREATMENT OF TRANSPOSITION OF THE GREAT ARTERIES AND AORTIC ARCH HYPOPLASIA]

Aortic arch hypoplasia is a congenital anomaly of the development of the aortic arch, characterized by hemodynamically significant narrowing of one or more segments of the aortic arch. The combination of simple transposition of the great arteries (TGA) and obstruction at the level of the aortic arch is not very common. However, when transposition is combined with the VSD, Taussig-Bing anomaly, this combination is more common. The degree of obstruction at the level of the aortic arch may vary from discrete coarctation of the aorta, tubular hypoplasia of the aortic arch, to interruption. Despite the improvement in the results of surgical treatment of this pathology in recent years, the question of the stage of treatment remains debatable.; The objective of the study was to analyze immediate and long-term results of the correction of transposition of the great arteries and aortic arch hypoplasia.; From 2010 to 2019 at the "Amosov National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine" and "Scientific Center For Pediatric Cardiology and Cardiac Surgery of the Ministry of Health of Ukraine" 76 infants underwent repair of TGA and aortic arch hypoplasia. The study included only patients with two-ventrical physiology and subsequent two-ventrical repair. There were 49 (64%) male patients and 27 (36%) female patients. The mean age of patients was 1.1 ± 0.5 months, mean body weight was 3.7 ± 1.4 kg. The average body surface area was 0.23 ± 0.05 m². Patients were divided into two groups: group I involved 52 (68%) individuals - patients who underwent one-stage repair of TGA and aortic arch hypoplasia, group II included 24 (32%) patients with two-stage repair, consisting of aortic arch reconstruction and pulmonary banding at the first stage and correction of TGA at the second stage. Antegrade selective cerebral perfusion was performed in 24 (46%) patients during reconstruction of the aortic arch.; The in-hospital mortality rate was 5.3% (n= 4). In group I, in-hospital mortality was 3.8% (n=2), and was significantly lower compared to the group II - 8.3% (n=2), p<0.05. Eight patients (14.5%) had delayed sternal closure in the early postoperative period. The average long-term follow-up was 3.7±2.8 years (from one months to 9.1 years). One late death occurred in group II. Aortic arch restenosis developed in 11 (14.4%) patients: 7 (13.4%) patients in group I and 4 (16.6%) patients in group II. Right ventricle outflow tract and pulmonary artery obstruction occurred in 9 (11.8%) patients: in 2 (3.8%) patients from group I and in 7 (29.1%) patients from group II. In the long term follow-up there were no neurological complications and compression of the trachea.; Surgical treatment of TGA with aortic arch hypoplasia is effective in infants with good immediate and long-term results. The study indicates that one-stage repair has better immediate and long-term results, compared to two-stage treatment and may be the method of choice in the treatment of this complex pathology.

Incidence and predictors of early seizures in intracerebral haemorrhage and the effect of tranexamic acid

Introduction

Seizures are common after intracerebral haemorrhage. Tranexamic acid increases the risk of seizures in non-intracerebral haemorrhage population but its effect on post-intracerebral haemorrhage seizures is unknown. We explored the risk factors and outcomes of seizures after intracerebral haemorrhage and if tranexamic acid increased the risk of seizures in the Tranexamic acid for IntraCerebral Haemorrhage-2 trial.

Patients and methods

Seizures were reported prospectively up to day 90. Cox regression analyses were used to determine the predictors of seizures within 90 days and early seizures (≤7 days). We explored the effect of early seizures on day 90 outcomes.

Results

Of 2325 patients recruited, 193 (8.3%) had seizures including 163 (84.5%) early seizures and 30 (15.5%) late seizures (>7 days). Younger age (adjusted hazard ratio (aHR) 0.98 per year increase, 95% confidence interval (CI) 0.97-0.99; p = 0.008), lobar haematoma (aHR 5.84, 95%CI 3.58-9.52; p < 0.001), higher National Institute of Health Stroke Scale (aHR 1.03, 95%CI 1.01-1.06; p = 0.014) and previous stroke (aHR 1.66, 95%CI 1.11-2.47; p = 0.013) were associated with early seizures. Tranexamic acid did not increase the risk of seizure within 90 days. Early seizures were associated with worse modified Rankin Scale (adjusted odds ratio (aOR) 1.79, 95%CI 1.12-2.86, p = 0.015) and increased risk of death (aOR 3.26, 95%CI 1.98-5.39; p < 0.001) at day 90.Discussion and conclusion: Lobar haematoma was the strongest independent predictor of early seizures after intracerebral haemorrhage. Tranexamic acid did not increase the risk of post-intracerebral haemorrhage seizures in the first 90 days. Early seizures resulted in worse functional outcome and increased risk of death.

Refined Sphenopalatine Ganglion Stimulator Placement and Intensity Setting to Augment Blood Flow and Neurologic Function

Background and Purpose- Two large, randomized trials indicated that sphenopalatine ganglion (SPG) stimulation improves final disability outcome in acute anterior circulation patients with ischemic stroke with confirmed cortical involvement. This study evaluated 2 refinements in SPG stimulation treatment technique: (1) SPG electrode placement with real-time optical tracking guidance; and (2) stimulation intensity comfortable tolerance level selection using non-noxious facial physiological markers. Methods- This study was a single, active arm trial at 4 centers, enrolling patients with anterior circulation ischemic stroke, National Institutes of Health Stroke Scale 1 to 6 including arm weakness subitem score ≥1, not receiving recanalization therapies, and within 24 hours of onset. Stimulation level was set based on ipsilateral facial tingling sensation or lacrimation. SPG stimulation effects were assessed by measuring volumetric blood flow in the ipsilateral common carotid artery by ultrasound and grasp and pinch strength in the affected hand before and during stimulation, and by change in National Institutes of Health Stroke Scale from day 1 to 7. Results- Among 50 enrolled patients, age was median 66 years (interquartile range, 60-74), 44% were female, National Institutes of Health Stroke Scale median was 5 (interquartile range, 4-5), and median onset-to-screening time was 18 hours (interquartile range, 9-20). Median implantation skin-to-skin time was 4 minutes (interquartile range, 3-7), and all 50 implants were placed correctly. Comfortable tolerance level was found based on physiological biomarkers in 96% of patients, including 86% in the optimal, low-medium intensity range. SPG stimulation significantly increased common carotid artery peak systolic and end-diastolic blood flow (44%, P<0.0001; and 52%, P<0.0001) and improved pinch strength (42%, P<0.0001) and grasp strength (26%, P<0.0001). Degree of National Institutes of Health Stroke Scale recovery by day 7 was greater than in matched historic controls, median 75% versus 50%, P=0.0003. Conclusions- SPG stimulator placement with real-time optical tracking guidance was fast and accurate, and selection of stimulation intensity levels based on non-noxious facial tingling and lacrimation was feasible in nearly all patients. SPG stimulation led to cervico-cranial blood flow augmentation and improved hand motor function. Clinical Trial Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT03551093.

[THE ROLE OF ESSENTIAL MACRO- AND MICROELEMENTS IN THE DEVELOPMENT OF SOMATIC AND DENTAL DISEASES]

The purpose of our study was to monitor the prevalence and intensity of dental caries, to establish the relationship between general and dental health and the content of essential macro- and micronutrients in the hair and teeth of children and adolescents. A comprehensive epidemiological study was conducted according to the WHO methodology in 375 children aged 3 to 12 years. It was revealed that the prevalence of dental caries increases with age and amounts to 79.6% at the age of 3-6 years, with an intensity of 5.8; at 7-9 years old - 89.5% with DMF + DF - 6.3; at 10-12 years old - 95.6% with a DMF of 5.2. To establish the relationship between general and dental health and the elemental composition of the body in 47 children, the content of essential macro - and microelements was revealed in the hair and dental hard tissues. The established regularity of the content of chemical elements allows us to assume that elemental homeostasis has a significant effect on the human body, which may be impaired by inadequate supply or incompatibility of the elements. Determination of macro - and micronutrients in hair and teeth is an integrative test in the diagnosis of human health.

Triple versus guideline antiplatelet therapy to prevent recurrence after acute ischaemic stroke or transient ischaemic attack: the TARDIS RCT

BACKGROUND

Two antiplatelet agents are better than one for preventing recurrent stroke after acute ischaemic stroke or transient ischaemic attack (TIA). Therefore, intensive treatment with three agents might be better still, providing it does not cause undue bleeding.

OBJECTIVE

To compare the safety and efficacy of intensive therapy with guideline antiplatelet therapy for acute ischaemic stroke and TIA.

DESIGN

International prospective randomised open-label blinded end-point parallel-group superiority clinical trial.

SETTING

Acute hospitals at 106 sites in four countries.

PARTICIPANTS

Patients > 50 years of age with acute non-cardioembolic ischaemic stroke or TIA within 48 hours of ictus (stroke).

INTERVENTIONS

Participants were allocated at random by computer to 1 month of intensive (combined aspirin, clopidogrel and dipyridamole) or guideline (combined aspirin and dipyridamole, or clopidogrel alone) antiplatelet agents, and followed for 90 days.

MAIN OUTCOME MEASURES

The primary outcome was the incidence and severity of any recurrent stroke (ischaemic, haemorrhagic; assessed using the modified Rankin Scale) or TIA within 90 days by blinded telephone follow-up. Analysis using ordinal logistic regression was by intention to treat. Other outcomes included bleeding and its severity, death, myocardial infarction (MI), disability, mood, cognition and quality of life.

RESULTS

The trial was stopped early on the recommendation of the Data Monitoring Committee after recruitment of 3096 participants (intensive, n = 1556; guideline, n = 1540) from 106 hospitals in four countries between April 2009 and March 2016. The incidence and severity of recurrent stroke or TIA did not differ between intensive and guideline therapy in 3070 (99.2%) participants with data [93 vs. 105 stroke/TIA events; adjusted common odds ratio 0.90, 95% confidence interval (CI) 0.67 to 1.20; p = 0.47]. Major (encompassing fatal) bleeding was increased with intensive as compared with guideline therapy [39 vs. 17 participants; adjusted hazard ratio (aHR) 2.23, 95% CI 1.25 to 3.96; p = 0.006]. There were no differences between the treatment groups in all-cause mortality, or the composite of death, stroke, MI and major bleeding (aHR 1.02, 95% CI 0.77 to 1.35; p = 0.88).

LIMITATIONS

Patients and investigators were not blinded to treatment. The comparator group comprised two guideline strategies because of changes in national guidelines during the trial. The trial was stopped early, thereby reducing its statistical power.

CONCLUSIONS

The use of three antiplatelet agents is associated with increased bleeding without any significant reduction in recurrence of stroke or TIA.

FUTURE WORK

The safety and efficacy of dual antiplatelet therapy (combined aspirin and clopidogrel) versus aspirin remains to be defined. Further research is required on identifying individual patient response to antiplatelets, and the relationship between response and the subsequent risks of vascular recurrent events and bleeding complications.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN47823388.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 48. See the NIHR Journal Library website for further project information. The Triple Antiplatelets for Reducing Dependency after Ischaemic Stroke (TARDIS) vanguard phase was funded by the British Heart Foundation (grant PG/08/083/25779, from 1 April 2009 to 30 September 2012) and indirect funding was provided by the Stroke Association through its funding of the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK. There was no commercial support for the trial and antiplatelet drugs were sourced locally at each site. The trial was sponsored by the University of Nottingham.

Tranexamic acid for hyperacute primary IntraCerebral Haemorrhage (TICH-2): an international randomised, placebo-controlled, phase 3 superiority trial

BACKGROUND

Tranexamic acid can prevent death due to bleeding after trauma and post-partum haemorrhage. We aimed to assess whether tranexamic acid reduces haematoma expansion and improves outcome in adults with stroke due to intracerebral haemorrhage.

METHODS

We did an international, randomised placebo-controlled trial in adults with intracerebral haemorrhage from acute stroke units at 124 hospital sites in 12 countries. Participants were randomly assigned (1:1) to receive 1 g intravenous tranexamic acid bolus followed by an 8 h infusion of 1 g tranexamic acid or a matching placebo, within 8 h of symptom onset. Randomisation was done centrally in real time via a secure website, with stratification by country and minimisation on key prognostic factors. Treatment allocation was concealed from patients, outcome assessors, and all other health-care workers involved in the trial. The primary outcome was functional status at day 90, measured by shift in the modified Rankin Scale, using ordinal logistic regression with adjustment for stratification and minimisation criteria. All analyses were done on an intention-to-treat basis. This trial is registered with the ISRCTN registry, number ISRCTN93732214.

FINDINGS

We recruited 2325 participants between March 1, 2013, and Sept 30, 2017. 1161 patients received tranexamic acid and 1164 received placebo; the treatment groups were well balanced at baseline. The primary outcome was assessed for 2307 (99%) participants. The primary outcome, functional status at day 90, did not differ significantly between the groups (adjusted odds ratio [aOR] 0·88, 95% CI 0·76-1·03, p=0·11). Although there were fewer deaths by day 7 in the tranexamic acid group (101 [9%] deaths in the tranexamic acid group vs 123 [11%] deaths in the placebo group; aOR 0·73, 0·53-0·99, p=0·0406), there was no difference in case fatality at 90 days (250 [22%] vs 249 [21%]; adjusted hazard ratio 0·92, 95% CI 0·77-1·10, p=0·37). Fewer patients had serious adverse events after tranexamic acid than after placebo by days 2 (379 [33%] patients vs 417 [36%] patients), 7 (456 [39%] vs 497 [43%]), and 90 (521 [45%] vs 556 [48%]).

INTERPRETATION

Functional status 90 days after intracerebral haemorrhage did not differ significantly between patients who received tranexamic acid and those who received placebo, despite a reduction in early deaths and serious adverse events. Larger randomised trials are needed to confirm or refute a clinically significant treatment effect.

FUNDING

National Institute of Health Research Health Technology Assessment Programme and Swiss Heart Foundation.

Antiplatelet therapy with aspirin, clopidogrel, and dipyridamole versus clopidogrel alone or aspirin and dipyridamole in patients with acute cerebral ischaemia (TARDIS): a randomised, open-label, phase 3 superiority trial

BACKGROUND

Intensive antiplatelet therapy with three agents might be more effective than guideline treatment for preventing recurrent events in patients with acute cerebral ischaemia. We aimed to compare the safety and efficacy of intensive antiplatelet therapy (combined aspirin, clopidogrel, and dipyridamole) with that of guideline-based antiplatelet therapy.

METHODS

We did an international, prospective, randomised, open-label, blinded-endpoint trial in adult participants with ischaemic stroke or transient ischaemic attack (TIA) within 48 h of onset. Participants were assigned in a 1:1 ratio using computer randomisation to receive loading doses and then 30 days of intensive antiplatelet therapy (combined aspirin 75 mg, clopidogrel 75 mg, and dipyridamole 200 mg twice daily) or guideline-based therapy (comprising either clopidogrel alone or combined aspirin and dipyridamole). Randomisation was stratified by country and index event, and minimised with prognostic baseline factors, medication use, time to randomisation, stroke-related factors, and thrombolysis. The ordinal primary outcome was the combined incidence and severity of any recurrent stroke (ischaemic or haemorrhagic; assessed using the modified Rankin Scale) or TIA within 90 days, as assessed by central telephone follow-up with masking to treatment assignment, and analysed by intention to treat. This trial is registered with the ISRCTN registry, number ISRCTN47823388.

FINDINGS

3096 participants (1556 in the intensive antiplatelet therapy group, 1540 in the guideline antiplatelet therapy group) were recruited from 106 hospitals in four countries between April 7, 2009, and March 18, 2016. The trial was stopped early on the recommendation of the data monitoring committee. The incidence and severity of recurrent stroke or TIA did not differ between intensive and guideline therapy (93 [6%] participants vs 105 [7%]; adjusted common odds ratio [cOR] 0·90, 95% CI 0·67-1·20, p=0·47). By contrast, intensive antiplatelet therapy was associated with more, and more severe, bleeding (adjusted cOR 2·54, 95% CI 2·05-3·16, p<0·0001).

INTERPRETATION

Among patients with recent cerebral ischaemia, intensive antiplatelet therapy did not reduce the incidence and severity of recurrent stroke or TIA, but did significantly increase the risk of major bleeding. Triple antiplatelet therapy should not be used in routine clinical practice.

FUNDING

National Institutes of Health Research Health Technology Assessment Programme, British Heart Foundation.

[BIOSUBSTRATES AS DENTAL HEALTH INDICATORS IN SCHOOL-AGE CHILDREN]

Lack of essential elements can lead to the development of general and dental diseases. To assess the level of microelements in the human body, the most informative biosubstrates are hair and dental hard tissues, in which the chemical elements are concentrated and fully reflect the quality of essential elements. We examined 34 6-12 years-old children to study the content of essential elements in biosubstrates, as in dental health indicators (in the period of formation and mineralization of most permanent teeth). The analysis was carried out by the X-ray fluorescence spectroscopy method. We studied 8 essential (Ca, Zn, K, Fe, Cu, Se, Mn, Cr) and 9 conditionally essential (S, Br, Cl, Co, Ag, V, Ni, Rb, Mo, Sr, Ti ) chemical elements in hair, and in the teeth - four essential (Ca, Zn, Mn, Fe) and three conditionally essential (Rb, Ni, Sr) trace elements. According to the study, in pupils, with compensated form of caries, was found minimal lack of essential chemical elements with the norm, and in children with decompensated form of caries - significantly low level of essential elements. In particular, the analysis of hair with the X-ray-fluorescence spectrometry method in second group children showed a significant lack of: Ca (0.8 times), Zn (1.2 times), K (1.5 times) Mn (1.8 times), etc. The low content of calcium (259025 ± 35224 ppm), iron (98.59±39.72 ppm), manganese (11.55±7.7ppm) was reported to be relatively low (p<0.05) in dental hard tissues. The exception was the zinc - its number exceeded the established norm by 28.1%, which should be explained by the fact that the zinc reduces the enamel penetration, and thus, transition of chemical elements from saliva to dental hard tissues. Thus, our study has showed that the composition of micro and macro elements in hair and dental hard tissues can be used as indicators of mineralization of dental enamel, dentine and alveolar bone. According to our results dental health changes are associated with the imbalance of chemical elements in biosubstrates.

UNUSUAL MANIFESTATION OF NEUROBORELIOSIS (CASE REPORT)

The paper reported the verified case of neuroboreliosis with unusual clinical presentation of Parkinsonism. Study aimed at establishing the significance of a precise differential diagnosis with substantial analysis of the symptoms of several diseases to avoid the false diagnosis and to conduct the opportune and adequate therapeutic management. We described the case of the diagnosed neuroboreliosis with clinical expression of Multiple Sclerosis (MS) and Parkinsonism. A 44 years old man was diagnosed as MS according to the McDonald's Criteria, who within two years developed typical clinical signs of Parkinsonism. Patient investigated neurologically, Brain contrast MRI (1.5 Tesla) was performed; Cerebrospinal fluid was researched for oligoclonal bands. Blood IgM and IgG were researched against Chlamidia pneumonie, Micoplasma pneumonie, Borrelia Burgdorferi, Herpes simplex 1/2, Cytomegalovirus by ELISA method. Clinically the patient expressed amimic face, oligobradikinesia, extrapiramidal rigidity in all limbs, resting tremor in upper limb fingers, horizontal nystagmus. Brain MRI showed multiple gadolinium enhanced demyelization lesions in periventricular and sub-cortical white matter. CSF oligoclonal bands were positive without dysfunction of blood-brain barrier. Blood IgM, IgG detected to be negative against Chlamidia pneumonie, Micoplasma pneumonie, cytomegalovirus, Herpes simplex ½, while the blood IgG was strongly positive against Borrelia burgdorferi, confirmed by followed Western blot test. Patient was stabilized by puls-therapy with 1 gr/intravenous Solumedrol (5 days) along with Rocephin treatment (2 gr /iv) for 21 days followed by long term treatment with Antiparkin (Carbidopa 250 mg, Levodopa 25 mg). MS and even Parkinsonism in suspicious cases should thoroughly be investigated for differentiation from chronic Neuroboreliosis.

Abstract WP76: Baseline Characteristics of the 3,096 Patients Recruited Into the ‘Triple Antiplatelets for Reducing Dependency After Ischaemic Stroke’ (TARDIS) Trial

Background: The risk of recurrence following ischaemic stroke (IS) or transient ischaemic attack (TIA) is highest immediately after the event. Antiplatelet agents are effective in reducing the risk of recurrence and two agents are superior to one in the early phase after ictus.

Design: The Triple Antiplatelets for Reducing Dependency after Ischaemic Stroke (TARDIS) trial was an international multicentre prospective randomised open-label blinded-endpoint trial that assessed the safety and efficacy of short-term intensive antiplatelet therapy with three agents (combined aspirin, clopidogrel and dipyridamole) as compared with guideline treatment in acute IS or TIA. The primary outcome was stroke recurrence and its severity, measured using the modified Rankin Scale at 90 days. Secondary outcomes included recurrent vascular events, functional measures (cognition, disability, mood, quality of life) and safety (bleeding, death, serious adverse events). Data are number (%) or mean (standard deviation, SD).

Results: Recruitment ran from April 2009 to March 2016. 3,096 patients were recruited from 106 sites in 4 countries (Denmark 1.6%, Georgia 2.7%, New Zealand 0.2%, UK 95.4%). Randomisation characteristics included: age 69.0 (10.1) years; male 1945 (62.8%); time onset to randomisation 29.4 (11.9) hours; stroke severity (National Institutes for Health Stroke Scale) 2.8 (3.6); blood pressure 143.5 (18.2)/79.5 (11.4) mmHg; IS 2143 (69.2%), TIA 953 (30.8%).

Conclusion: TARDIS was a large international trial of intensive/triple antiplatelet therapy in acute IS and TIA, and included participants representative of patients in many western stroke services.

Funders: National Institute of Health Research Health Technology Assessment Programme and British Heart Foundation. Trial registration: ISRCTN47823388

Baseline characteristics of the 3096 patients recruited into the 'Triple Antiplatelets for Reducing Dependency after Ischemic Stroke' trial

Background The risk of recurrence following ischemic stroke or transient ischemic attack is highest immediately after the event. Antiplatelet agents are effective in reducing the risk of recurrence and two agents are superior to one in the early phase after ictus. Design The triple antiplatelets for reducing dependency after ischemic stroke trial was an international multicenter prospective randomized open-label blinded-endpoint trial that assessed the safety and efficacy of short-term intensive antiplatelet therapy with three agents (combined aspirin, clopidogrel and dipyridamole) as compared with guideline treatment in acute ischemic stroke or transient ischemic attack. The primary outcome was stroke recurrence and its severity, measured using the modified Rankin Scale at 90 days. Secondary outcomes included recurrent vascular events, functional measures (cognition, disability, mood, quality of life), and safety (bleeding, death, serious adverse events). Data are number (%) or mean (standard deviation, SD). Results Recruitment ran from April 2009 to March 2016; 3096 patients were recruited from 106 sites in four countries (Denmark 1.6%, Georgia 2.7%, New Zealand 0.2%, UK 95.4%). Randomization characteristics included: age 69.0 (10.1) years; male 1945 (62.8%); time onset to randomization 29.4 (11.9) h; stroke severity (National Institutes for Health Stroke Scale) 2.8 (3.6); blood pressure 143.5 (18.2)/79.5 (11.4) mmHg; IS 2143 (69.2%), transient ischemic attack 953 (30.8%). Conclusion Triple antiplatelets for reducing dependency after ischemic stroke was a large trial of intensive/triple antiplatelet therapy in acute ischemic stroke and transient ischemic attack, and included participants from four predominantly Caucasian countries who were representative of patients in many western stroke services.

Safety and efficacy of intensive vs. guideline antiplatelet therapy in high-risk patients with recent ischemic stroke or transient ischemic attack: rationale and design of the Triple Antiplatelets for Reducing Dependency after Ischaemic Stroke (TARDIS) trial (ISRCTN47823388)

RATIONALE

The risk of recurrence following a stroke or transient ischemic attack is high, especially immediately after the event.

HYPOTHESIS

Because two antiplatelet agents are superior to one in patients with non-cardioembolic events, more intensive treatment might be even more effective.

SAMPLE SIZE ESTIMATES

The sample size of 4100 patients will allow a shift to less recurrence, and less severe recurrence, to be detected (odds ratio 0·68) with 90% power at 5% significance.

METHODS AND DESIGN

Triple Antiplatelets for Reducing Dependency after Ischaemic Stroke (ISRCTN47823388) is comparing the safety and efficacy of intensive (combined aspirin, clopidogrel, and dipyridamole) vs. guideline antiplatelet therapy, both given for one-month. This international collaborative parallel-group prospective randomized open-label blinded-end-point phase III trial plans to recruit 4100 patients with acute ischemic stroke or transient ischemic attack. Randomization and data collection are performed over a secure Internet site with real-time data validation and concealment of allocation. Outcomes, serious adverse events, and neuroimaging are adjudicated centrally with blinding to treatment allocation.

STUDY OUTCOME

The primary outcome is stroke recurrence and its severity ('ordinal recurrence' based on modified Rankin Scale) at 90 days, with masked assessment centrally by telephone. Secondary outcomes include vascular events, functional measures (disability, mood, cognition, quality of life), and safety (bleeding, death, serious adverse events).

DISCUSSION

The trial has recruited more than 50% of its target sample size (latest number: 2399) and is running in 104 sites in 4 countries. One-third of patients presented with a transient ischemic attack.

Reversible cerebral vasoconstriction syndrome and migraine: sonography study

RCVS is characterized by severe headaches with or without focal neurologic deficits and segmental constriction of cerebral arteries that resolves within 3 months. The primary clinical manifestation is recurrent sudden-onset and thunderclap headache. Diagnosis requires cerebral or magnetic resonance angiography (MRA) confirmation and ultrasound monitoring. Our purpose is to discover the difference of ultrasound data between RCVS and migraine. 61 patients (age range 17-60y., 41-female, 20-male) underwent sonography examination using Transcranial Dopplerography (TCD) and Transcranial Color-Coded Duplex Sonography (TCCD) methods. In 29 patients MRA examinations were performed. Group I- 27 patients with RCVS with typical acute-onset of severe headaches. Group II-34 patients- migraine in anamnesis, with 1-2 attacks monthly, control group -15 healthy persons. Ultrasound examinations were performed during 2 months with time intervals of 1-20, 21-40, and 41-60 days. Markedly in migraine group examinations were performed in interictal periods also. Group I-the mean maximum (MM) V(CS)-77,8 ± 14,7 cm/sec, V(MCA)- 127,5 ± 22.8 cm/sec, V(ACA) -115.7 ± 18.4, V(BA)- 74.7 ± 20.1. Lindegaard Index (LI) -3.1 ± 0.5. MRA revealed segmental cerebral artery vasoconstriction. The MCA was involved in 62.9%, the ACA- in 51.8%, the PCA- in 37% and the BAS- in 40.7% of patients. Group II- the MM V (CS)-72.8 ± 12.5 cm/sec, V (MCA)- 118,4 ± 26.7 cm/sec, V(ACA) -105.8 ± 17.6, V(BA)- 74.5 ± 18.1, averaged LI -2,9 ± 0.7. In the majority (61.7%) of this group revealed increased MM V in several cerebral arteries with different combination of involving vessels. No correlation was found between incidence side of pain and /or pain intensity. Both groups exceeded of controls -V (MCA) (63.2 ± 9.5 cm/sec), LI (2.1 ± 0.2), p<0.001) and revealed vasospasm. All data were calculated by nonparametric Binomial test. Obtained data showed no significant difference regarding the vasospasm degree between typical RCVS and migraine, whereas revealed that vasospasm in migraine is more determined to posterior circulation but in RCVS vasospasm has the more diffuse character. Despite the extensive knowledge concerning RCVS and migraine, many uncertainties still exist and further randomized controlled trials are needed for understanding the underlying pathophysiology factors.

Prognostic value of EEG in different etiological types of coma

Study aimed at evaluation of prognostic value of standard EEG in different etiology of coma and the influence of etiological factor on the EEG patterns and coma outcome. Totally 175 coma patients were investigated. Patients were evaluated by Glasgow Coma Scale (GCS), clinically and by 16 channel electroencephalography. Auditory evoked potentials studied by EEG -regime for evoked potentials in patients with vegetative state (VS). Patients divided in 8 groups according to coma etiology. All patients were studied for photoreaction, brainstem reflexes, localization of sound and pain, length of coma state and outcome. Brain injury visualized by conventional CT. Outcome defined as death, VS, recovery with disability and without disability. Disability was rated by Disability Rating Scale (DRS). Recovered patients assessed by Mini Mental State Examination (MMSE) scale. Statistics performed by SPSS-11.0. From 175 coma patients 55 patients died, 23 patients found in VS, 97 patients recovered with and without disability. In all etiological groups of coma the background EEG patterns were established. Correspondence analysis of all investigated factors revealed that sound localization had the significant association with EEG delta and theta rhythms and with recovery from coma state (Chi-sqr. =31.10493; p= 0.000001). Among 23 VS patients 9 patients had the signs of MCS and showed the long latency waves (p300) after binaural stimulation. The high amplitude theta frequencies in frontal and temporal lobes significantly correlated with prolongation of latency of cognitive evoked potentials (r=+0.47; p<0.01). Etiological factor had the significant effect on EEG patterns' association with coma outcome only in hemorrhagic and traumatic coma (chi-sqr.=12.95; p<0.005; chi-sqr.=7.92; p<0.03 respectively). Significant correlations established between the delta and theta EEG patterns and coma outcome. Low amplitude decreased power delta and theta frequencies correlated with SND in survived coma patients (r=+0.21; p<0.001; r=+0.27; p<0.001 respectively). Standard EEG is the useful tool for elucidation of coma patients with a high probability to recover as well as those patients, who are at high risk of SND in case of recovery from coma state.

Acute Cerebrovascular Disease in the Young

Background and Purpose—

Strokes have especially devastating implications if they occur early in life; however, only limited information exists on the characteristics of acute cerebrovascular disease in young adults. Although risk factors and manifestation of atherosclerosis are commonly associated with stroke in the elderly, recent data suggests different causes for stroke in the young. We initiated the prospective, multinational European study Stroke in Young Fabry Patients (sifap) to characterize a cohort of young stroke patients.

Methods—

Overall, 5023 patients aged 18 to 55 years with the diagnosis of ischemic stroke (3396), hemorrhagic stroke (271), transient ischemic attack (1071) were enrolled in 15 European countries and 47 centers between April 2007 and January 2010 undergoing a detailed, standardized, clinical, laboratory, and radiological protocol.

Results—

Median age in the overall cohort was 46 years. Definite Fabry disease was diagnosed in 0.5% (95% confidence interval, 0.4%–0.8%; n=27) of all patients; and probable Fabry disease in additional 18 patients. Males dominated the study population (2962/59%) whereas females outnumbered men (65.3%) among the youngest patients (18–24 years). About 80.5% of the patients had a first stroke. Silent infarcts on magnetic resonance imaging were seen in 20% of patients with a first-ever stroke, and in 11.4% of patients with transient ischemic attack and no history of a previous cerebrovascular event. The most common causes of ischemic stroke were large artery atherosclerosis (18.6%) and dissection (9.9%).

Conclusions—

Definite Fabry disease occurs in 0.5% and probable Fabry disease in further 0.4% of young stroke patients. Silent infarcts, white matter intensities, and classical risk factors were highly prevalent, emphasizing the need for new early preventive strategies.

Clinical Trial Registration Information—

URL: http://www.clinicaltrials.gov .Unique identifier: NCT00414583

Neuroprotective treatment of cerebral infarction: an experimental study

We investigated the effect of the amniotic-derived peptide Plaferon-LB on cerebral tissue damage during photochemical insults in rats. Plaferon-LB (US patent number: 20070123467 A1) was extracted from the amniochorionic membrane of a human placenta and showed a relatively strong antihypoxic effect compared to other interferon. Thrombotic infarction was induced by photochemical illumination after intravenous injection of Rose Bengal. The infarct volume, cerebral tissue oxygen tension, cerebral blood flow, and capillary damage were measured in the following groups: untreated control rats, Plaferon-LB-alone rats, insult-alone rats, and insult in Plaferon-LB pretreated rats. The technique of electron paramagnetic resonance (EPR) spectroscopy was used to study free-radical metabolites in the blood and brain tissue ex vivo. Plaferon-LB alone had no effect on systemic blood pressure, cerebral blood flow, and reactive metabolites in the brains of intact animals. In the insult-alone group, a focal hemorrhage was observed in the ischemic area. The cerebral blood flow and tissue oxygen pressure declined to zero within an hour and remained at this level throughout the insult. The treatment with Plaferon-LB 0.5 hr before illumination resulted in a significant reduction of the median infarct size in the insult-alone group. The total length and percentage ratio of thrombotic vessels were significantly diminished in the infarct area. The intensity of Fe2+, Mn2+ -, Mo5+ -xanthinoxidase-containing complexes, and nitric oxide EPR signals was decreased, and the electron transport in the mitochondria was normalized. The results indicate a significant beneficial effect of Plaferon-LB on cerebral infarct, which is likely due to its antioxidative properties.

Non-convulsive status epilepticus in comatose patients (case reports)

Non-convulsive status epilepticus (NCSE) is relatively rare, but recognized condition observed in non-epileptic comatose patients. In coma state NCSE may be precipitated by stroke, severe electrolyte disturbance, acute intoxication, infection, traumatic brain injury and etc. All these critical disorders can cause coma themselves and without clinical EEG investigation it is impossible to attribute impaired consciousness to NCSE, while the condition can be responsive to anticonvulsant medication. The proper and rapid diagnosis of NCSE is challenging, because it can severely impact the patient and often is a treatable and completely reversible state. Case reports describe the state of three comatose patients affected by severe neurological disorders, who were diagnosed as NCSE after EEG investigation. Nor of these patients were noted to have the epileptic seizures and convulsions. The patients were treated with different anticonvulsive medications (Finlepsin, Levetiracetam, Depakin) and fully recovered from coma state. Frequently, physicians could not suspect presence of NCSE in patients with impaired consciousness because of sufficiently complicated underlying illness. Apparently, clinical EEG investigation is useful to be performed in all comatose patients.

The role of endogenous antiradical protective system in multiple sclerosis

Present research aimed at investigation of the role of several inflammatory cytokines and free toxic radicals in Multiple Sclerosis (MS) course and disability progression as well as factors that can assist to the early transition of Relapse Remitting MS (RRMS) in Secondary Progressive MS (SPMS). Totally 22 MS patients, 14 RRMS and 8 SMPS have been investigated. Age at disease onset, disease duration, number of relapses and the Kurtzke Expanded Disability Status Scale (EDSS) scores were collected. Control comprised 10 healthy volunteers matched for age and sex. Brain was visualized by Magnetic Resonance Tomography (MRT- Siemens AVANTO-1.5-Tesla). Blood pro-inflammatory cytokines were detected by Enzyme Linked immunosorbent Assay (ELISA). Blood free toxic radicals and antioxidant enzymes were detected by Electron Paramagnetic Resonance Method (EPR). Statistics was performed using the SPSS-11.0. Blood pro- and anti-inflammatory factors (γ-Interferon, IL-6, IL-10) were elevated in MS patients against control. Increased blood IL-6 and IL-10 found in RRMS as compared to SPMS, while γ-interferon was higher in SPMS (p<0.000). Blood EPR specters of Lypoperoxiradical (LOO-) and superoxide anion (O2-) were increased in SPMS patients compared to RRMS and control. Blood EPR specters of antioxidant enzymes: superoxidismutase (SOD), catalase (CAT) and Glutathione reductase (GR) found elevated in RRMS against SPMS and control. Positive correlation was found between γ-interferon and EDSS (r=+0.52 p<0.05) in SPMS and negative correlation established between SOD and CAT and EDSS (r=-0.84 and r=-0.60 respectively, p<0.05) in RRMS. Multiple logistic regression toward the brain MRI Injury volume proved significance of C reactive protein, γ-interferon and CAT. Present research suggested that the state of endogenous protection system and blood content of antioxidant enzymes (CAT, SOD) in MS patients could play a significant role for early progression of RRMS in SPMS.

Selected acute phase CSF factors in ischemic stroke: findings and prognostic value

Background

Study aimed at investigation of pathogenic role and prognostic value of several selected cerebrospinal fluid acute phase factors that can reflect the severity of ischemic brain damage.

Methods

Ninety five acute ischemic stroke patients were investigated. Ischemic region visualized at the twenty fourth hour by conventional Magnetic Resonance Imaging. Stroke severity evaluated by National Institute Health Stroke Scale. One month outcome of disease was assessed by Barthel Index. Cerebrospinal fluid was taken at the sixth hour of stroke onset. CSF pro- and anti-inflammatory cytokines were studied by Enzyme Linked Immunosorbent Assay. Nitric Oxide and Lipoperoxide radical were measured by Electron Paramagnetic Resonance. CSF Nitrate levels were detected using the Griess reagent. Statistics performed by SPSS-11.0.

Results

At the sixth hour of stroke onset, cerebrospinal fluid cytokine levels were elevated in patients against controls. Severe stroke patients had increased interleukin-6 content compared to less severe strokes (P < 0.05). Cerebrospinal fluid Electron Paramagnetic Resonance signal of nitric oxide was increased in patients against controls. Severe stroke group had an elevated Electron Paramagnetic Resonance signal of lipoperoxiradical compared to less severe stroke. Cerebrospinal fluid nitrate levels in less severe stroke patients were higher than those for severe stroke and control. Positive correlation was established between the initial interleukin-6 content and ischemic lesion size as well as with National Institute Health Stroke Scale score on the seventh day. Initial interleukin-6 and nitrate levels in cerebrospinal fluid found to be significant for functional outcome of stroke at one month.

Conclusion

According to present study the cerebrospinal fluid contents of interleukin-6 and nitrates seem to be the most reliable prognostic factors in acute phase of ischemic stroke.

Treatment of experimental autoimmune encephalomyelitis by vitamin in animal model

Study purposed to determine the effectiveness of vitamin treatment in experimental autoimmune encephalomyelitis (EAE) animal model of multiple sclerosis (MS) by comparing several blood serum inflammatory markers, neurological deficiency and histopathological changes in untreated and treated EAE animals. Eighteen, 9-13 week old, male Wistar rats were immunised by 100 μl MOG injection. Clinical signs of EAE scored by a masked investigator. After EAE exposition all rats were divided equally as untreated control and experimental group treated by vitamins (E, C, D3). Blood was obtained from all rats before and after immunization and on 7th day of treatment. ELISA method was used to detect the serum cytokine contents of IL-6, IFN-γ, IL-10. On 10th day of disease the rats were euthanized and transverse sections of spinal cord were divided in 16 areas with score of 1 for each area showing lymphocyte infiltration or demyelination. Mann-Whitney U-test was used for determining the level of significance of differences between sample means. On 7th day of treatment neurological deficiency stayed unchanged in control and was ameliorated in experimental group (p<0.05). Significant histopathological differences were found between control and experimental groups on 10th day of EAE. Serum levels of IFN-γ, IL-6 and IL-10 were elevated after exposition of EAE against healthy rats, while on 7th day of treatment the experimental group revealed the significant differences as compared to untreated control. Positive correlation was found between IL-6 and IFN-γ serum contents and neurological deficiency on 7th day of disease (r=+0.53, p<0.02 and r=+0.49; p<0.01).

Dominated EEG patterns and their prognostic value in coma caused by traumatic brain injury

Study aimed at investigation of dominated EEG patterns in traumatic coma of different severity and to elucidate their prognostic value for outcome of disease within month. A total of 53 coma patients with severe traumatic brain injury have been investigated. Exclusion criteria comprised the patients needing the neurosurgical intervention due to hemorrhage. Brain injury was visualized by conventional CT at admission. The level of consciousness was evaluated by Glasgow Coma Scale (GCS). Patients were divided in 5 groups according to GCS. Electrophysiological investigations were performed on 5th day from development of coma by application of 16 channel computer encephalography. Outcome of coma (death, vegetative state, recovery) was evaluated within month from disease onset. According to dominated EEG background activity patterns the 1st group (GCS=4) showed the delta EEG pattern in 50 % of patients, the beta EEG pattern- in 33.4% and the alpha EEG pattern - in 16.6%. The 2nd group (GCS=5) revealed the delta EEG in 40%, the beta EEG- in 6.7% and the theta EEG - in 53.3%. The 3rd group (GCS=6) showed the delta EEG pattern in 27.8% and the theta EEG pattern- in 72.2%. In 4th group (GCS=7) the theta EEG pattern found in 77.7% and the beta EEG pattern in 22.3%. The 5th group (GCS=8) revealed the theta EEG activity in 80% and beta EEG activity - in 20%. Positive correlation was found between the GCS and the frequency of theta EEG pattern (r=+0.62; p<0.05). Positive correlation was established between the frequency of delta EEG pattern, death and persistent vegetative state (r=+0.57 and r=+0.16 respectively, p<0.05) within month. Positive correlation was established between the frequency of delta EEG pattern and the size of brain injury (r=+0.3; p=0.04). Multinomial logistic regression revealed the significance of brain lesion size, GCS and EEG pattern for functional outcome of coma. In severe traumatic coma patients the delta EEG pattern is associating with deep coma state and predicts the poor functional outcome within month.

Headaches and cerebral blood flow disturbances in patients with chronic nasal pathology

Study aimed at research of cerebral blood flow and blood NO contents in patients with chronic non-surgical nasal pathology with accompanying headaches. Eighty five patients with non-surgical chronic nasal pathology with accompanying headaches were investigated. Patients were divided in two age categories: 1st group of 58 patients (18 to 55 years), and 2nd group of 27 patients (>55 years). Control consisted of 30 age-matched healthy individuals. CBF was studied by means of Transcranial Doppler Imaging in patients and control. Free blood NO and NO - complexes were measured by Electron Paramagnet Resonance (EPR) method. Statistics performed by SPSS-11.0. In both age categories of patients the mean blood velocity in middle cerebral artery, anterior cerebral artery, basilar artery of patients was significantly increased against control (p<0.05). Pulsation index (PI) found to be decreased compared to control. The blood free NO signals were non-significantly increased against control. The intensive EPR signals of HbNO and FeSNO were revealed in patients and no signals were detected in control. No differences were revealed between clinical groups regarding the blood EPR signals of NO and NO-complexes (p<0.5). Negative correlation was found between the PI and intensity of headaches (r=-0.37; p<0.01). Multivariate linear regression analysis found the significance of longevity of chronic nasal pathology, Pulastion Index and blood hemoglobin contents for Intensity of headaches (p<0.05). It is concluded that CBF disturbances in chronic nasal pathology may result in intensive headaches.

Dopplerographic correlates of headaches accompanying the chronic nasal and nasopharyngeal pathology

The present study aimed at research of cerebral blood flow in patients with chronic nasal and nasopharyngeal pathology with accompanying headaches before and after appropriate treatment. One hundred and six patients with chronic nasal and nasopharyngeal pathology, aged from 6 to 75 years, 57 male and 49 female have been investigated. According to the type of nasal and nasopharyngeal pathology patients were classified in 5 groups, and were divided in three age categories: 6 -18 years (39 patients), 19- 65 years (38 patients), 66-75 years (29 patients). Headaches were estimated by neurologist before appropriate surgical and conservative treatment, after treatment and 6 months later. Cerebral blood flow was studied before treatment, after treatment and 6 months later by means of Transcranial Dopplerography. Control consisted of 30 age-matched healthy persons. Chronic headaches were established in 63 patients (59%). In all age categories the mean blood velocity in middle cerebral artery, anterior cerebral artery, basilar artery was significantly increased against control (p<0.05), and pulsation index (PI) found to be decreased compared to control. After treatment blood flow velocity in the middle cerebral artery, anterior cerebral artery and in basilar artery in all age groups did not differ significantly from control (p<0.5), and PI was significantly elevated against previous data (p<0.05). Cephalic pains disappeared in 75% of treated patients and 25% noted the significant decrease in pain intensity and frequency. Treatment of chronic nasal and nasopharyngeal pathology can prevent the certain kind of cephalic pains, and improve the clinical course of accompanying headaches.

Probable role of immunological tolerance to ischemia injury in brain

To address the issues of immunological tolerance to ischemia injury in the brain we have researched ischemic stroke patients with and without prodromal transitional ischemic attacks (TIAs) for several blood acute phase reactants involved in inflammatory reactions in respect to initial infarct size, clinical course of disease and functional outcome at 1 month. The study involved 54 ischemic stroke patients aged 45 to 70 years, 46 female and 38 male admitted within 24 hours of symptoms onset in neurological clinic of Georgian State Medical University during 2000-2006. Exclusion criteria comprised severe somatic pathology, liver and renal dysfunctions. Control subjects were aged-matched 15 healthy volunteers, who did not reveal any significant signs of cerebrovascular disease according to the anamnesis, clinical and instrumental investigations. Etiology of stroke was classified according to TOAST criteria. Patients were divided into three groups: the first group - 22 patients with first-ever stroke, the second -17 patients with prodromal TIAs from one to three months before stroke and the third - 15 patients with prodromal TIAs within 4 weeks before stroke. Initial neurological impairment assessed immediately after admission by NIHSS score. All three groups selected with the same initial severity of stroke with mean NIHSS score = 12+/-3.5; for evaluation of clinical course of disease patients were assessed by NIHSS on 7th day of stroke. In 48 hours from stroke onset the blood levels of (IL-1beta, IL-6, TNF-alpha, IL-10) were significantly elevated against control (p<0.05). At this time, no statistical differences were detected between groups regarding the initial blood levels of IL-1beta and TNF-alpha, while the level of IL-6 was significantly lower in the third group (p<0.05). Blood contents of IL-10 and TGF-beta1 found to be non-significantly elevated in the third group against two other groups, while blood TGF-beta1 was significantly increased compared to control. Significant positive correlation was found between IL-6 blood contents and clinical course of disease (r=+0.32, p<0.05). Multivariate logistic regression found the significance of initial blood IL-6 contents for probability of stroke functional outcome at 1 month. It can be supposed that relatively mild blood inflammatory response in third group can be related to occurring of immunological tolerance.

Proinflammatory reactants as determinants of stroke severity in elderly

Investigations aimed at studying of peripheral blood levels of free nitric oxide (NO) and proinflammatory cytokines IL-1beta, IL- 6 and TNF-alpha in correlation with initial ischemic lesion size and neurological dynamics during a month of acute brain ischemia. Forty two patients aged 60-75 (26 male) have been investigated. Initial neurological status, later deterioration and functional outcome were evaluated using Glasgow Coma Scale (GCS), National institutes of Health Stroke Scale (NIHSS) and Barthel Index (BI). Patients were divided into two groups: severe stroke (GCS<or=10, NIHSS >15, BI<16, n=25) and a moderate/mild stroke (GCS>10, NIHSS<or=15, BI>or=18, n=17). The NO concentration was detected by spectrophotometric and Electron Paramagnetic Resonance (EPR) methods. Cytokine plasma levels were determined applying the Enzyme-Linked Immuno Sorbent Assay (ELISA). Statistical evaluation was performed by SPSS. Mean values calculated using the t-paired test. Pearson correlation ad multivariate logistic regression have been applied. In the first days of stroke onset the plasma levels of IL-1beta and TNF-alpha revealed the slight negative correlation toward the functional outcome, while the elderly patients found to have the significant negative correlation of IL-6 plasma levels toward the functional outcome (p<0.01). The NO plasma concentration within 48 hours after stroke onset more profoundly was reduced in aged patients, while in less severe cases and in relatively young patients it was significantly elevated (p<0.01). The high plasma level of IL-6 in the acute phase of stroke seems to be the strong predictor of poor outcome rather for aged, than for younger patients.

Predicting value of cerebrospinal fluid proinflammatory factors in acute phase of ischemic stroke

Study purposed to establish the correlation between proinflammatory cytokines' initial CSF levels and neurological outcome on 7th day of acute ischemic stroke. 58 patients with acute ischemic stroke have been investigated. Neurological impairment assessed in 48 hours and on 7th day of stroke applying the international scales NIHSS and GCS. Patients divided into two groups: with severe stroke (GCS>9, NIHSS>15) and stroke with moderate severity (GCS=14,15; NIHSS=10-15). On 7th day increase of NIHSS score and decrease of GCS score at least 1 point was considered as deterioration and decrease of NIHSS score and increase of GCS score at least 1 point was considered as amelioration. CSF levels of proinflamatory cytokines determined using the enzyme-linked immunosorbent assay (ELISA). Control consisted with 15 patients, which were taken CSF in relation with vertebral discopathies. Means calculated by t-paired test. Pearson correlation and multivariate logistic regression were used. In 48 hours of stroke onset the CSF levels of interleukine-1beta (IL-1beta), interleukine-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha) were elevated compared to control. Statistical differences were not found between groups regarding the initial CSF levels of IL-1beta and TNF-alpha (p<0,5), while the significant statistical differences were found in regard with IL-6 CSF levels (p<0,05) between groups and against control. Significant positive correlation was found between initial CSF IL-6 levels and ischemic lesion size and neurological outcome at 1 week as well (r=+0,48 p<0,05 and r=+0,54 p<0,01 respectively). Thus, the IL-6 CSF levels in acute stage of ischemic stroke might be considered as the relatively stable prognostic indicator of clinical course of the disease.

Effect of nitric oxide initial blood levels on erythrocyte aggregability during 12 hours from ischemic stroke onset

The aim of study was the investigation of blood nitric oxide (NO) and nitrates (NO2) levels in 12 hours of ischemic stroke onset and establishment of correlation of these data with erythrocyte aggregability and initial ischemic lesion size. 48 patients, aged 45 to 70 years, 26 female, 22 male were investigated. Glasgow Coma Scale (GCS) and National Institute Health Stroke Scale (NIHSS) assessed initial neurological impairment. Patients were divided in mild and severe stroke groups. Control comprised 20 healthy individuals. Ischemic lesions were evaluated on conventional MRI scans. NO levels were measured by electron paramagnet resonance (EPR) method. NO2 levels were defined by spectrophotometer method. Erythrocyte aggregability index (EAI) was measured by sound method [Biorheology 30(2) (1993), 153-161]. Pearson correlation and multivariate model of logistic regression was applied. Significant negative correlation was established between NO initial blood levels and the EAI (r=-0.75; p<0.001), as well as between blood NO2 and NO initial levels and ischemic lesion size (r=-0.79, p<0.01; r=-0.61, p<0.02, respectively). Endothelialy derived NO correlates with erythrocyte aggregability and probably has a positive impact on restoration of cerebral blood flow in the initial stage of acute brain ischemia.