2014, Vol 14, No 4
Pharmacotherapy in Alzheimer’s disease and other dementias in practical settings: which drug, when and for whom?
Aktualn Neurol 2014, 14 (4), p. 218–227
DOI: 10.15557/AN.2014.0025

Dementia is characterised by a combination of different types of cognitive impairment, which is so significant that it affects daily living, disrupts patients’ professional activity and leads to complete dependence on relatives or adequate institutions. Dementias are usually caused by neurodegenerative processes or damage of vascular origin within the central nervous system. Alzheimer’s disease, which is fatal and progressive, is the main cause of dementia. Drugs used in modern medicine have only symptomatic effects and have no influence on the cause of the illness. Drugs registered for Alzheimer’s disease treatment (cholinesterase inhibitors and memantine) have been available for many years. The majority of doctors involved in treating dementia believe that they are well acquainted with the above substances which they often use. In clinical trials, it has been proven that the drugs have a moderate influence on cognitive functions, behavioural and psychological symptoms of dementia, and on activities of daily living. The influence of the drugs on the natural course of the disease in the central nervous system is still a controversial issue. This article discusses the clinical use of anti-dementia drugs available in Poland and practical recommendations regarding their choice in daily practice. Moreover, current recommendations for a change of the therapy (to a different inhibitor), combination therapy (cholinesterase inhibitors and memantine) and necessary safety procedures (contraindications, interactions) are presented.

Keywords: Alzheimer’s disease, cholinesterase inhibitors, memantine, treatment, dementia
Causative (reperfusion) treatment in acute ischaemic stroke – from the first attempts until today
Aktualn Neurol 2014, 14 (4), p. 228–234
DOI: 10.15557/AN.2014.0026

The review presents the development of causative treatment in the acute phase of ischaemic stroke over the past 20 years. The earliest methods of brain reperfusion, still in use today, are based on intravenous administration of a thrombolytic agent, but as the protocols improved, it was possible to extend the therapeutic time window for this method from initial 3 hours up to 4.5 hours (as standard), and even up to 6 hours in selected patients. The next step of brain reperfusion evolution was local, intra-arterial administration of a thrombolytic drug, and finally mechanical intravascular procedures were developed, which allowed the therapeutic window to be extended to 8 hours. The most advanced approaches, which combine 2 or 3 methods, enable safe and efficacious treatment of the acute phase of ischaemic stroke even up to 12 hours from its onset. This creates new perspectives for a development of vascular neurology and neurointerventional radiology, which in the future will give patients suffering from acute ischaemic stroke much more chances for survival and functional recovery than it has been very recently.

Keywords: stroke, reperfusion therapy, thrombolysis, fibrinolysis, rt-PA
The role of decompressive craniectomy in ischaemic stroke
Aktualn Neurol 2014, 14 (4), p. 235–244
DOI: 10.15557/AN.2014.0027

Malignant ischaemic stroke i.e. one accompanied by extensive oedema bringing about raised intracranial pressure, carries a significant mortality risk as well as a substantial likelihood of permanent neurological deficits. This paper reviews the history of decompressive craniectomy in the management of ischaemic stroke and presents the current views on its usefulness in both supra- and infratentorial infarctions. The surgical technique was looked over along with common complications of surgery. The results of prospective randomised clinical trials: DECIMAL, HAMLET and DESTINY I and II were presented. They have confirmed the role of decompressive surgery in the cases of infarction in the MCA territory. In patients who deteriorate neurologically despite the best medical therapy, decompressive craniectomy, particularly if carried out within the first 48 hours from the onset, yet before the decline of the neurological condition, considerably improves the outcome. Nonetheless, various issues require further studies. The most important ones are: to define the age limit beyond which the patients would not benefit from surgery, to list clearly clinical and radiological indications for decompression, including the cases in which thrombolysis or mechanical revascularisation have been attempted, and finally, to work out the standards of an informed consent for the procedure. To date, no prospective randomised trials assessing the role of surgery in infratentorial infarctions have been conducted. However, on the basis of retrospective studies, suboccipital decompressive craniectomy is strongly recommended in patients with cerebellar ischaemic stroke and decreased level of consciousness, in whom medical treatment failed. The outcome improves along with the better clinical condition at surgery. Ventricular drainage as a single means of decompression does not seem to be indicated whereas its use before suboccipital craniectomy is still a matter of debate.

Keywords: ischaemic stroke, malignant MCA infarction, cerebellar infarction, decompressive craniectomy, suboccipital craniectomy
Increasing occurrence of multiple sclerosis in women correlates to hygiene level
Aktualn Neurol 2014, 14 (4), p. 245–249
DOI: 10.15557/AN.2014.0028

Introduction: The increasing incidence of multiple sclerosis, particularly among women in Europe and North America, has a multifactorial aetiology. Method: The aim of the current study was to ascertain the relation between the hygiene level and occurrence of multiple sclerosis in women in Poland. The study was based on a large cohort of 14,200 multiple sclerosis individuals (male – 6,106, female – 8,094) who died in the years 1981–2010 in Poland. The female to male ratio (the F:M ratio) in the multiple sclerosis group was calculated using the number of deaths per year. The rate of late mortality in infants (LMI) per 1,000 live births yearly was used as a marker of the hygiene level. A correlation analysis was carried out between the rate of LMI and the F:M ratio in the multiple sclerosis cohort in the years 1981–2010. Demographic data were obtained from the Central Statistical Office in Warsaw. Results: The F:M ratio in the multiple sclerosis group evidently increased (range 1.08–1.79) in the years 1981–2010, showing increasing occurrence of multiple sclerosis in women (p < 0.0001). A significant, strong and inverse correlation was found between the marker of the hygiene level (LMI rate) and the F:M ratio in the multiple sclerosis group over three decades: linear correlation coefficient by Pearson: r = –0.693, p < 0.0001. By contrast with this result, no correlation was established between the hygiene level marker and proportion of women to men in the general population on account of extremely low variance of the F:M ratio (0.000025). Conclusion: The improvement of the hygiene level showed association with the increasing occurrence of multiple sclerosis in women in the years 1981–2010. The higher the hygiene level was, the greater the occurrence of female multiple sclerosis in Poland.

Keywords: multiple sclerosis, sex ratio, hygiene level, Poland
Vertebral artery dissection – aetiology, clinical features and treatment
Aktualn Neurol 2014, 14 (4), p. 250–256
DOI: 10.15557/AN.2014.0029

Dissection of the extracranial carotid and vertebral arteries is responsible for 2–3% of all strokes and for 20% of ischaemic events in the population of young people under the age of 45. Vertebral artery dissection is a very rare yet serious condition. The annual overall incidence of vertebral artery dissection is estimated at 1 to 1.5 per 100 000 persons. Its clinical manifestation is very nonspecific and diverse. The most typical clinical sign is sudden unilateral headache accompanied by neck pain. Other symptoms include systemic and non-systemic headaches as well as infarction or transient ischaemic attack in posterior circulation territorial area inn case where the intracranial vertebral artery dissection is associated with subarachnoid haemorrhage. The aetiology of dissection remains unclear and connected with multiple risk factors. Vertebral artery dissection can be caused by blunt force trauma of the head or neck or it can be spontaneous. The aetiology of spontaneous vertebral artery dissection includes vascular and genetic factors as well as structural defects of the arterial wall associated with connective tissue disorders. The diagnosis of vertebral artery dissection has to be established based on anamnesis, clinical features and imaging examination. Catheter cerebral angiography is the gold standard of diagnosis of arterial dissection, but also computed tomography angiography has been proven to have a very high sensitivity and specificity. In most cases extracranial vertebral artery dissection carries a good prognosis. The treatment of vertebral artery dissection is conservative and includes the use of anticoagulation and antiplatelet drugs. Surgical or endovascular treatment can be applied only for selected and small group of patients. Authors emphasize that clinical features can be very unspecific and vertebral dissection may be misdiagnosed especially in the first hours following the manifestation of symptoms. Vertebral artery dissection should be taken into consideration in the diagnosis of stroke in young persons despite unspecified symptoms and without traumatic history.

Keywords: vertebral artery dissection, ischaemic stroke, neck trauma, headache, computed tomography angiography
Hyponatraemia in a patent after craniocerebral injury – problems of diagnosis and treatment
Aktualn Neurol 2014, 14 (4), p. 257–263
DOI: 10.15557/AN.2014.0030

Hyponatraemia is the most common electrolyte disorder observed in patients with a severe neurological condition, significantly affecting mortality. Both cerebral salt wasting syndrome and the syndrome of inappropriate antidiuretic hormone secretion manifest with hyponatraemia, showing at the same time a lot of similarities in the clinical picture and laboratory findings. However, due to different diagnostic and therapeutic processes, misdiagnosis can be a great danger for the patient. The treatment of inappropriate antidiuretic hormone secretion is associated with restricted fluid supply, as hyponatraemia is a result of an excess of free water in the body. In the case of cerebral salt wasting syndrome, severe loss of sodium in the urine is the main pathological mechanism of hyponatraemia; hence its treatment consists in sodium supplementation and fluid intake. The authors present a case of a 16-year-old patient treated surgically at the Department of Neurosurgery of the Provincial Medical Centre in Opole due to severe craniocerebral injury, as a result of which cerebral salt wasting syndrome developed on the 8th day. The diagnostic and therapeutic process, differential diagnosis and a review of the literature are included in the discussion. The authors believe that the information contained in the article will be helpful in the diagnosis and treatment of hyponatraemia in patients with a severe neurological condition.

Keywords: hyponatraemia, cerebral salt wasting syndrome, brain injury, syndrome of inappropriate antidiuretic hormone secretion