Background: More than 50% of stroke patients have sleep-disordered breathing (SDB), mostly in the form of obstructive sleep apnea (OSA). SDB represents both a risk factor and a consequence of stroke. The presence of SDB has been linked with the poorer long-term outcome and increased long-term stroke mortality. About 20 to 40% of stroke patients have sleep-wake disorders (SWD), mostly in form of insomnia, excessive daytime sleepiness/fatigue, or hypersomnia (increased sleep needs). Objective: The aim of this study was to analyze the frequency of risk factors in patients with acute stroke and sleep apnea. Methods: The study included patients without cognitive impairment or with mild cognitive impairment. The diagnosis of apnea syndrome was made on the basis of the Snoring and Apnea Syndrome Questionnaire, the Epworth Sleep Scale, the Berlin Questionnaire, the Stanford Sleepiness Scale, and the General Sleep Questionnaire. The severity of stroke was assessed by the National Institutes of Health Stroke Scale and the Rankin Disability Scale. Patients with a Glasgow score <8 on the day of neuropsychiatric examination were excluded from the study, as well as patients with epileptic seizures at the onset of stroke, with aphasia, with Mini - mental test <23, with verified previous dementia / cognitive impairment. Results: There is no statistically significant difference in the age of men and women, both with apnea and without apnea. In patients with apnea, heart disease was in the first place 91.8%, followed by hypertension 86.4%, Body mass index 79.1%, hyperlipidemia 50%, smoking 38.2 % and diabetes mellitus 20.9%. Hypertension was the most common risk factor in patients without apnea 83.6%, followed by heart disease 81.0%, Body mass index 60.9%, hyperlipidemia 48.21%, smoking 28.2 % and diabetes mellitus 20%. Conclusion: Heart diseases, hypertension and body mass index are significantly more frequent in patients with than in patients without sleep apnea.

The aim of this study was to show the trends of cerebrovascular disease (CVD) in two analyzed periods at the Department of Neurology Tuzla, Bosnia and HerzegovinaPatients and methods. This retrospective study included 2363 patients with acute stroke who were hospitalized at the Department of Neurology Tuzla in the period from 2013 to 2015. Demographic data, types of stroke and mortality were analyzed in the three years period and compared with the previously analyzed period (2001-2005). The necessary data were taken from the standard history chart. The inclusion criterion was stroke confirmation with neuroimaging techniques. Results. Out of 2363 patients with acute stroke, there were 1186 (50.2%) women and 1177 (49.8%) men without statistical significance. The average age was 70 years. Ischemic strokes (IS) were statistically more frequent in the period 2013-2015 (p=0.02), while intracerebral hemorrhage (ICH) was more common in the previously analyzed period (2001-2005) (p=0.0001). There was statistical significance in the distribution of certain types of stroke. The most frequent risk factors were hypertension, hyperlipidemia and diabetes mellitus. The mortality for all types of stroke, and the total in-hospital mortality were lower in comparison to the previously analyzed period (2001-2005).Conclusion. Improved diagnostic procedures lead to a different distribution of stroke subtypes. In the three-year analysis period, the prevalence of ischemic stroke increased and the in-hospital mortality reduced. Adequate control of modifiable stroke risk factors may help to reduce the occurrence of stroke.

Aim: To show a case report of mental health consequances of a felow who survived Trauma brain injury (TBI) with commotio cerebri that was not properly diagnosed in the first emergency medical examination and harm that he and his family suffer because of lack of knowledge and ethics of medical, economic and judical authorities. Case report: A twenty-six year old male survived a traffic accident that caused TBI. He was misdiagnosed during the emergency examination. Because of that (and other factors) he has not returned to his previous level of functioning. After he treated in the Department of Psychiatry, he went back to his environment a sick leave council interrupted his sick leave, showing mistrust to him and his condition and towards the discharge diagnoses from the Department of Psychiatry. The council sent him to his job without occupational rehabilitation that was recommended. As he could not work in his full capacity, the authorities from his job discharged him on January 2012. When he was on the trial for getting his compensation because of health damages the insurance health expert denied his sufferings and all mental consequences of the commotio cerebri because it was not diagnosed on the first examination in the evening of the accident. So the destiny of this young fellow is very questionable in perspective because of lack of knowledge and ethics of medical staff who are not responsible regarding Hippocratic oath and of industry management who do not take adequate care about their workers who survive traffic accident on the way back to home from their job and who continually suffer because of health particularly mental health consequences. Conclusion: The TBI is an important health public problem and the hospital must establish a perfect managemet in this patients for avoid Mental Changes of Commotio Cerebri.

Aim. To demonstrate our experiences of thrombolytic therapy in acute ischemic stroke. Subjects and Methods. Patients with ischemic stroke treated with rt-PA, admitted at the Department of Neurology, Tuzla, Bosnia and Herzegovina, in the period between April 1, 2008, and December 31, 2012, were included. Results. Between April 2008 and December 2012, intravenous rt-PA was given to 87 patients with acute ischemic stroke, which represents 3.2% of patients with acute ischemic stroke admitted to our department in that period. Hypertension was the leading stroke risk factor. The mean NIHSS score before thrombolysis was 12 (range 4–21). Large artery arteriosclerosis was the most common stroke etiology. The mean door-to-needle time was 72 minutes and onset-to-needle time 152 minutes. Half of patients (44/87) had a significant improvement within the first 24 hours. Parenchymal hemorrhage occurred in 5 patients (6%) and was fatal in two cases. At 3-month follow-up, 45% of patients (39/87) had good outcome (mRS 0 or 1). Sixteen patients were dead at 3 months, and mean baseline stroke severity was significantly higher in patients who died (NIHSS 16.5 versus 11, ). Conclusion. The number of patients with acute ischemic stroke treated using rt-PA in the Department of Neurology, Tuzla, is lower than in developed countries. Thrombolytic therapy is safe and leads to favorable outcome in half of the patients.

It is well known that thrombolysis with intravenous recombinant tissue plasminogen activator (rt-PA) is the first evidence-based treatment for acute ischemic stroke. In the European Union (EU), rt-PA was approved in 2002 and has been used widely since then. Bosnia and Herzegovina is one of the few European countries not yet part of the EU, and approval for rt-PA in acute ischemic stroke was granted in 2007 under the same conditions as in other European countries. We presented our results with the use of intravenous thrombolytic therapy in patients with acute ischemic stroke in Tuzla Canton, Bosnia and Herzegovina. Between April 2008 and December 2011, intravenous rt-PA was administered to 72 patients with acute ischemic stroke, which represents 3·5% of patients with acute ischemic stroke admitted to the Department of Neurology Tuzla in that period (2067 patients). Baseline characteristics of the patients treated with thrombolytic therapy are provided in Table 1. Figure 1 illustrates the three-month outcome of our patients treated with thrombolytic therapy in comparison with the results of the neighboring countries: Sestre milosrdnice University Hospital Zagreb, Croatia (1) and Institute of Neurology Belgrade, Serbia (2). We wish to emphasize that these are only the results from our department, not at the national level. Bosnia and Herzegovina is one of the few countries in Europe that does not have an official National Stroke register, primarily because of the political situation. Therefore, our participation in multicenter studies is limited. With this article we want to demonstrate that we are working in line with the established protocols and show that our results are approximate to the results of other countries, despite the aforementioned shortcomings. These are small steps for world’s neurology but big ones for neurology in Bosnia and Herzegovina.

Dear Editor, International Journal of Stroke readers will probably be surprised by the fact that Bosnia and Herzegovina is one of rare countries in Europe that does not have an official Stroke register, mainly because of a complex political system. Our country is divided in two entities of which one entity is separated in 10 cantons, besides Brčko District. Our clinic is located in Tuzla, the largest city of Tuzla Canton, that has 500 000 inhabitants. All patients with stroke in Tuzla region were hospitalized at our department. We did a few studies in domain of cerebrovascular diseases, but all the data were based on hospital records due to the aforementioned situation. Despite this situation, we are making efforts to keep up with the trends in domain of cerebrovascular diseases, and we managed to form a Stroke unit on our clinic and to start applying thrombolytic therapy for the last four-years. The main goal for this article is to show results in one of our studies about intracerebral hemorrhage, which is done in the Department of Neurology Tuzla, for the period June 1, 2007 to March 31, 2008. It was one of the first studies of this kind in our country and it contained analysis of clinical and neuroradiological characteristics of intracerebral hemorrhage (ICH) and its influence on short-term outcome. Based on 75 patients, we came up with following results: 40 patients (53·4%) were male, the mean age for all patients was 64·3 13·7 years, and men were older than women (P = 0·031). The disturbance of consciousness on admission significantly influenced the sixmonth outcome (P < 0·0001). Patients with multiple hematomas had higher mortality rate (41%); however, localization of hematomas did not have any significant influence on the six-month mortality. Surviving of patients highly depended of volume of hematomas (P < 0·0001). Less than half of patients (39%) who survived six-months after stroke were functionally depended (Rankin scale >2, Barthel Index <90). Predictors of poor six-month prognosis were brain edema (P = 0·002), intraventricural bleeding (P = 0·004), and Glasgow Coma Scale <8 (P < 0·0001) (Table 1). It can be concluded that there are certain clinical and neuroradiological predictors for short-term prognosis in intracerebral hemorrhage. Intracerebral hemorrhage has high mortality rate (52%), and most of the survivors are functionally independent six-months after stroke (61%). Our results do not differ from studies with similar design (1–3). Perhaps, we could provide better results, but due to the aforementioned shortcomings, we are limited to participation in larger multicenter studies.

The aim of the study was to analyze stroke in young adults in Tuzla Canton, Bosnia and Herzegovina. From January 2001 to December 2005, 3864 patients with first-ever stroke were admitted at the Department of Neurology Tuzla. A retrospective analysis of risk factors, stroke types, severity and one month outcome in all young adults (18-45 years of age) with first-ever stroke was carried out. Out of total, there were 154 (4%) young adults with stroke. Mean age was 38.8 +/- 5.7 years and 47% were women. The leading risk factors were smoking (56%) and hypertension (45%). Subarachnoid hemorrhage (SAH) was more frequent in young adults compared with older patients (> 45 years of age) (22% vs. 3.5%, p < 0.0001), intracerebral hemorrhage (ICH) was similar in both groups (16.9% vs. 15.8%, p = 0.7), but ischemic stroke (IS) was predominant stroke type in the older group (61% vs. 74%, p = 0.0004). Young adults had more frequent lacunar stroke (26.6% vs. 16.1%, p = 0.01) and stroke due to other etiology (8.5% vs. 1.8%, p = 0.0004) than stroke patients over 45 years of age. Stroke severity at admission was lower in young adults than in older patients (p < 0.0001), as well as mortality at one month (11% vs. 30%, p < 0.0001). Favorable outcome (modified Rankin Scale < or = 2) had 71% of young adults compared with only 53% of patients in the older group (p = 0.0003). Stroke in young adults in Tuzla Canton is rare. Risk factors profile, stroke types, severity and outcome at one month in young adults are different from those in older patients.

The aim of this study was to determine whether volume and localization of intracerebral hematoma affects the six-month prognosis of patients with intracerebral hemorrhage (ICH). Patients and Methods. The study included 75 patients with ICH of both sex and all age groups. ICH, based on CT scan findings, was divided in the following groups: lobar, subcortical, infratentorial, intraventricular haemorrhage and multiple hematomas. Volume of intracerebral hematoma was calculated according to formula V = 0.5 × a × b × c. Intracerebral hematomas, according to the volume, are divided in three groups (0–29 mL, 30–60 mL, and >60 mL). Results. The highest mortality rate was recorded in the group with multiple hematomas (41%), while the lowest in infratentorial (12.8%). The best six-month survival was in patients with a volume up to 29 mL, 30 of them (64%) survived. The highest mortality rate was recorded in patients with the hematoma volume >60 mL (85%). Kaplan-Meier's analysis showed that there was statistical significance between the size of the hematoma and the six-month survival (P < 0.0001). More than half of patients (61.1%) who survived 6 months after ICH were functionally independent (Rankin scale ≤2). Conclusion The volume of hematoma significantly affects six-month prognosis in patients with intracerebral hemorrhage, while localization does not.

INTRODUCTION Aphasia is considered to be the most difficult disorders of speech-language communication, and is often companion by all forms of cerebrovascular disease. GOAL To determine the outcome of aphasia disorder a year after a stroke and stroke type influence on the outcome of aphasia disorders. MATERIAL AND METHODS We analyzed one-year outcome of aphasia disorders in patients who had a first stroke. Patients were tested by a speech pathologist with the International test for aphasia, immediately after admission and one year after the stroke. All patients that were hospitalized during treatment had a speech therapy and only a small number of patients were realsed from hospital. RESULTS Out of 74 patients with aphasia who were discharged from hospital within one year 20 patients died and 2 patients did not respond to control clinical treatment review. Analysis of the remaining 52 respondents determined that out of the 10 patients with global aphasia 8 (80%) evolved into another aphasia syndrome, and two (20%) remained unchanged in form. In most cases, global aphasia was transformed in mixed non fluent aphasia (4 of 10 patients or 40%), and in two cases (20%) global aphasia was transformed in Broca aphasia. Broca aphasia (n = 20) in other forms evolved in 9 patients (45%), and 11 patients (55%) remained unchanged in form. Anomic aphasia had 11 patients (78.6%) which remained unchanged in form, while 3 (21.4%) evolved into an Alexia agraphia. Full recovery was noted in two patients (3.84%). Type of stroke did not affect the outcome of aphasia disorders. Out of the 52 analyzed patients after hospitalization, unfortunately, only 11 (21.2%) had some kind of speech pathology treatment after leaving the hospital. CONCLUSION One year after the stroke severe aphasia evolved into a lighter form in a significant number of patients. Most often anomic aphasia remained (34.6%), followed by Broca (25%) and Conductive aphasia (7.7%). Type of stroke does not affect the outcome of aphasia disorders. Unfortunately only a small number of patients (21.2%) continued with aphasia speech therapy after leaving the hospital.

Although many aspects of stroke are similar at both sexes, however, there are some differences and characteristics as well. The aim of this study was to analyze sex differences in patients with acute ischemic stroke (IS) regarding to risk factors, subtypes, stroke severity and outcome. From January 1st 2001 to December 31st 2005 at the Department of Neurology Tuzla 2833 patients were admitted with acute ischemic stroke (IS). We were analyzed risk factors, subtypes, stroke severity (Scandinavian Stroke Scale), and thirty-day outcome. There were 1484 (52.3%) female, and they were older than male (67.8 +/- 10.6 vs. 65.7 +/- 10.5, p<0.0001). Hypertension (78% vs. 67%, p<0.0001), heart diseases (50% vs. 45%, p=0.009), atrial fibrillation (22% vs. 14%, p<0.0001) and diabetes mellitus (33% vs. 21%, p<0.0001) were frequently in female, while smoking (45% vs. 14%) and alcohol overuse (18% vs. 0,6%) in male (p<0.0001). Atherothrombotic type of ischemic stroke was frequently in male (37.4% vs. 31.6%, p=0.0013) and cardioembolic in female (21.7% vs. 15.5%, p<0.0001). At admission female had lower SS (SS 31.0 +/- 15 vs. 34.0 +/- 15, p<0.0001). Thirty-day mortality was significantly higher in female (23.3% vs. 18.4%, p=0.0015), and favourable outcome within one month (Rankin Scale <or= 2) had 58% male and 51% female (p=0.001). The frequency of ischemic stroke is higher in female who are older than male. There are some sex differences according to the distribution of risk factors and subtypes of ischemic stroke. Stroke severity at admission, thirty-day mortality, and disability are higher in female.

OBJECTIVE To analyze the frequency, gender and age distribution, risk factors, and hospital mortality of different types of hospitalized patients with stroke. METHODS In this retrospective study, we analyzed the hospital records of 3864 patients with first-ever stroke admitted to the Department of Neurology, University Clinical Center Tuzla, Bosnia and Herzegovina, from January 2001 to December 2005. RESULTS Out of the total number of patients, 2833 (73.3%) had ischemic stroke (IS) 612 (15.8%) intracerebral hemorrhage (ICH), 163 (4.2%) subarachnoid hemorrhage (SAH), and 256 (6.6%) had unknown stroke. The mean age was 68+/-10 years in females, and 65+/-11 years in males (p=0.000). Overall, there were 2045 (53%) women (p=0.000). Women suffered from cardioembolic stroke more than men (21.7% versus 15.6%, p=0.000), and men were more affected by atherothrombotic stroke (37.4% versus 31.6%, p=0.000). The leading stroke risk factors were hypertension (70%), heart diseases (40%), smoking (28%), and diabetes mellitus (21%). The total hospital mortality was 29.6%, and hospital mortality in patients with IS was 20.6%, ICH 43.8%, and SAH 26.4%. CONCLUSION Women are older than men in all types of stroke. The leading risk factors for both genders are hypertension and heart diseases. The hospital mortality rate is lower than 30%.

Aim: To determine the frequency of delirium in patients with acute stroke. Patients and methods: We assessed delirium prospectively in a sample of 233 consecutive patients with an acute (≤ 4 days) stroke using the Delirium Rating Scale R-98 and the Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition criteria for delirium. Results: Delirium was diagnosed in 59 (25.3%) patients. Patients with delirium were older comparing to those without delirium (70.0±11.3 vs. 64.7±10.4 years of age; p=0.001). Delirium was significantly more frequent in hemorrhagic comparing to the ischemic type of stroke (41.6% vs. 22.3%, p=0.02). In patients with the ischemic stroke, the delirium was more frequent among those with right hemispheric lesion (26.2% vs. 20.5%, p=0.0006); however, in hemorrhagic stroke delirium was more frequent in patients with left hemispheric lesion (42.9% vs. 27.8%, p=0.002). Delirium was also more frequent in patients with ischemic stroke in the anterior than posterior cerebral circulation territory (22.7% vs. 5.6%, p=0.0001). Conclusion: Delirium develops in approximately one quarter of patients in the acute phase of stroke. Possible factors which predispose the occurrence of delirium are ages over 65 years, hemorrhagic stroke, ischemic stroke in anterior cerebral circulation, lesion of right hemisphere in ischemic stroke and left hemisphere in hemorrhagic stroke.