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D. Adam, Gina Burduşa and D. Iftimie

Abstract

Background: Modern treatment of acute ischemic stroke includes thrombolysis and thrombectomy performed for eligible patients in specialized stroke centers. However, a number of patients are admitted in Neurosurgical or Intensive Care Departments of emergency hospitals, units where routine treatment strategies are applied.

Objective: To evaluate the management of patients admitted in these departments that do not benefit from thrombolytic or endovascular treatment.

Methods: A retrospective analysis was performed, including all patients admitted to the Neurosurgery Department and Intensive Care Unit (ICU) of the “St. Pantelimon” Clinical Emergency Hospital with the primary diagnosis of acute ischemic stroke in the year 2016. The following data was retrospectively collected: patient age and sex, comorbidities, risk factors for ischemic stroke, level of consciousness at admission, neurological deficits, stroke location, blood glucose levels, interval from stroke onset to admission, treatment and discharge status.

Results: In 2016, 63 patients with primary diagnosis of acute ischemic stroke confirmed by head CT scan were admitted in our hospital. None presented indication for decompressive craniectomy. Over a half of them (57,14%) were comatose. The majority of patients admitted to the ICU (76,47%) received glucose 10% infusions in the first 24 hours from admission, despite increased blood glucose levels at admission. A number of 38 (60,32%) of these patients died.

Conclusions: Patients with acute ischemic stroke should be treated in stroke units with proper equipment and specialists. National public health institutions should take the necessary measures in order to ensure that patients get to the best facility in order to receive the right therapy in the right amount of time.

Open access

D. Adam, D. Iftimie, Gina Burduşa and Cristiana Moisescu

Abstract

Background and importance: “Fish vertebra” is an uncommon anomaly of vertebral body shape, consisting of central depression of the superior and inferior vertebral surfaces. It has been associated with various conditions: osteoporosis, osteomalacia, hyperparathyroidism, Paget disease, sickle cell disease, multiple myeloma and systemic lupus erythematosus.

Clinical presentation: A 29-year-old male patient, previously treated for ankylosing spondylitis (with NSAIDs and TNFα inhibitor), without any clinical improvement, was admitted to our Neurosurgical Department. He complained of difficult gait, possible only with the aid of a cane, low back pain and bilateral hip pain, but without leg pain. He denied any history of recent trauma. Neurological examination was normal. Plain thoracic and lumbar spine X-rays revealed multilevel “fish vertebrae”. Lumbar spine MRI and contrast thoraco-abdominal CT scan showed fractures of multiple structures: left L4 pedicle, right L4 lamina and pars interarticularis, right II-VII costal arches, left I-V costal arches and bilateral sacral alae. We performed extensive laboratory tests that detected low seric phosphorous and PTH levels, with increased alkaline phosphatase, indicating a possible endocrinological cause for this condition. Subsequently, we decided to transfer the patient to an Endocrinological Department. A diagnosis of hypophosphatemic osteomalacia was established and increased FGF23 levels, later determined, suggested it was tumor-induced osteomalacia. Whole-body MRI was unable to locate the tumor, but Gallium-68 DOTATATE PET/CT revealed a small (15 mm in diameter), hyperfixating mass in the head of the right femur. The patient was treated with oral calcitriol and phosphate, with alleviation of symptoms. Surgical excision of the tumor was recommended, but the patient decided to postopone the operation.

Conclusion: Modern medical imaging and biochemical testing have made the leap from merely observing vertebral biconcavities to diagnosing their cause and, consequently, the possibility to adequately treat uncommon causes of “fish vertebra”, such as neuroendocrine tumor-induced osteomalacia.

Open access

D. Adam, Ioana Hornea, Gina Burduşa, D. Iftimie and Cristiana Moisescu

Abstract

Background: Neural decompression for lumbar spinal stenosis (LSS) can be performed, besides conventional lumbar laminectomy, by many other surgical techniques.

Objective: The goal of this study is to analyze the results of laminectomy versus unilateral fenestration and foraminotomy with bilateral neural decompression in LSS patients.

Methods: A number of 58 patients with lumbar spinal stenosis were divided into two groups: group A (no.=22) consists of patients that underwent a laminectomy procedure and group B (no.=36) of cases where unilateral fenestration with foraminotomy was used. Outcome was assessed at 1, 6 and 12 months postoperatively. Two parameters were evaluated: level of pain with the VAS (Visual Analogue Scale) score and the ODI (Oswestry Disability Index) scale for functional improvement.

Results: The level of pain was reduced in both patient groups. Cases in group A maintained higher levels of back pain in the first postoperative month versus group B. Improvement was faster for those operated by unilateral approach. At 6 months and 1 year follow-ups, VAS values were very similar. All patients presented functional recovery evaluated with the ODI scale, that showed continuous improvement at 6 months and 1 year.

Conclusions: Bilateral decompression by unilateral approach is an efficient method that represents the first option of treatment for patients with lateral lumbar spinal stenosis with unilateral or predominantly unilateral symptoms. For patients with severe central stenosis, classic laminectomy remains the first surgical choice.

Open access

D. Adam, R. Cergan, D. Iftimie and Cristiana Moisescu

Abstract

Background: There is a significant variety of odontoid fracture classifications along with corresponding treatment strategies. There are though cases which cannot be framed within the existing classifications.

Clinical presentation: We report the case of a 91 years old female patient who suffered a cervical trauma secondary to a ground level fall. The cervical CT scan revealed a particular type of odontoid fracture, unframeable within existing classifications. The fracture line was at the base of the odontoid process and continued in an oblique trajectory through the right pedicle of the axis. As treatment strategy, we opted for external immobilization in a Minerva jacket and, after 3 months, the patient is symptom free, with partial bone fusion.

Conclusion: We named this rare case of odontoid fracture type II B for which external immobilization seems sufficient.

Open access

D. Adam, D. Iftimie, Gina Burduşa and Cristiana Moisescu

Abstract

Background and importance: Butterfly vertebra is an uncommon congenital spinal anomaly, which can be easily mistaken for vertebral fracture, infection or tumor.

Clinical presentation: We report the case of a 20-year-old male patient with a 3-year history of intermittent mid-thoracic spinal pain. Local examination showed a mild thoracic kyphoscoliosis. Neurological examination was normal. Computer tomography revealed the presence of a T6 butterfly vertebra associated with morphological anomalies in adjacent vertebral bodies and T6-T9 Schmorl’s nodes. MRI scan confirmed the diagnosis and additionally showed a mild spinal stenosis caused by apparent posterior epidural fat hypertrophy. The patient was treated with painkillers and physical therapy.

Conclusion: Butterfly vertebra is a benign condition. Once diagnosed, additional diagnostic procedures are not necessary. Neurosurgeons must be aware of this congenital anomaly that should not be confused with a vertebral fracture.

Open access

D. Adam, D. Iftimie, Gina Burduşa and Cristiana Moisescu

Abstract

Background: Degenerative spinal disease surgery is frequently performed in most neurosurgical departments. Unplanned 30-day readmissions represent a significant economic burden and have been used in several studies as a tool to evaluate quality of patient care.

Objective: To review 30-day unplanned readmission rates after degenerative spinal disease surgery in our department, in order to identify their causes and determine strategies aimed at decreasing their frequency.

Methods: A retrospective analysis was performed on all patients operated in our department for spinal stenosis or disc herniation over a 3 year period (January 2014 – December 2016), evaluating the rate and causes of unplanned readmission in the first month after discharge. Complications were divided in medical and surgical.

Results: Out of the 1106 patients included, 33 (2,98%) presented a 30-day unplanned readmission. The percentage was higher after disc herniation surgery (3,40%), compared to spinal stenosis (1,92%). Pain management was the most common medical cause for readmission (45,45%), while in the surgical group, CSF leaks were the most frequent complication (18,18%).

Conclusions: The rate of 30-day readmissions was low in our series but, even so, they associate significant costs. They could be avoided by applying correct and aseptic surgical technique, proper availability of dural sealing agents and superior patient medical education.

Open access

D. Adam, D. Iftimie, Cristiana Moisescu and Gina Burduşa

Abstract

Clinical presentation: We report the case of a 68-year-old patient that presented at our department 6 weeks after a mild traumatic brain injury with confusion and drowsiness. Emergency head CT scan revealed chronic bilateral subdural hematomas with no midline shift. His neurological status quickly deteriorated after admission (GCS of 9 points) and he was operated immediately. Although surgery was uneventful and his neurological status markedly improved, in the first postoperative day he developed blindness with visual anosognosia and visual confabulations, suggestive for Anton-Babinski syndrome. Emergency head MRI performed on the same day was normal but a repeat head MRI in the seventh postoperative day revealed bilateral occipital ischemia, thus explaining his symptoms. The patient became aware of his deficit two weeks after surgery, but was surprisingly ambivalent regarding it. Conclusion: Cortical blindness (sometimes presenting in the context of Anton-Babinski syndrome) is a rare complication of chronic bilateral subdural hematomas, a rather common neurosurgical pathology. Although it can be overlooked on the initial neurological examination, it should be taken into account, prompting emergency surgical treatment in order to prevent permanent visual deficits.

Open access

D. Adam, D. Iftimie, Gina Burduşa and Cristiana Moisescu

Abstract

Background and importance: Chronic subdural hematomas are a frequently encountered neurosurgical pathology, especially in the elderly. They often require surgical evacuation, but recent studies have shown good results with conservative treatment in selected cases.

Clinical presentation: We report the case of a 72-year old patient that developed large, non-traumatic, bilateral, acute-on-chronic subdural hematoma after repeated abdominal surgery for appendicular carcinoma. He presented an abdominal wound infection and good neurological status (GCS score of 14 points), factors that indicated the delay of surgical intervention. Subsequent clinical and radiological improvement forestalled the operation altogether and he presented complete spontaneous resolution of subdural hematomas at only 5 months after diagnosis.

Conclusion: Although surgical treatment is performed in the majority of chronic subdural hematomas, in clinically and radiologically selected cases, the operation can be avoided. The hematoma can present resolution, either spontaneously or with the help of conservative treatment.

Open access

A. Grajcar, D. Woźniak and A. Kozłowska

Abstract

The work addresses the production of medium-Mn steels with an increased Al content. The special attention is focused on the identification of non-metallic inclusions and their modification using rare earth elements. The conditions of the thermomechanical treatment using the metallurgical Gleeble simulator and the semi-industrial hot rolling line were designed for steels containing 3 and 5% Mn. Hot-working conditions and controlled cooling strategies with the isothermal holding of steel at 400°C were selected. The effect of Mn content on the hot-working behaviour and microstructure of steel was addressed. The force-energetic parameters of hot rolling were determined. The identification of structural constituents was performed using light microscopy and scanning electron microscopy methods. The addition of rare earth elements led to the total modification of non-metallic inclusions, i.e., they replaced Mn and Al forming complex oxysulphides. The Mn content in a range between 3 and 5% does not affect the inclusion type and the hot-working behaviour. In contrast, it was found that Mn has a significant effect on a microstructure.