2016, Vol 16, No 1
Survival in multiple sclerosis correlates to the level of hygiene and mortality
Aktualn Neurol 2016, 16 (1), p. 4–8
DOI: 10.15557/AN.2016.0001

Introduction: Survival of patients with multiple sclerosis is a complex variable determined by several factors. Objective of the study was to ascertain the association between the level of hygiene well as regional mortality and survival of patients with multiple sclerosis. Study design: The study of relation between variables included 14,200 multiple sclerosis patients (male – 6,025, female – 8,175) who died in the period 1981–2010 in Poland. The average survival of male and female patients with multiple sclerosis correlated to the marker of hygiene level (the late mortality in infants rate per 1,000 live births) and average, annual, sex-adjusted mortality rates for multiple sclerosis in towns and in the countryside of Poland (1981–2010). All demographic data were obtained from the Central Statistical Office in Warsaw. Results: A longer survival of male and female patients with multiple sclerosis showed a significant correlation to a higher hygiene level in Poland: r = −0.867, r = −0.902, p = 0.0001. Sex-adjusted mortality rates for women with multiple sclerosis in towns and villages were much higher than the analogous rates for men with multiple sclerosis; p = 0.0001, p = 0.019. A longer duration of life in male and female patients with multiple sclerosis demonstrated a strong, inverse correlation to a lower mortality in the countryside: r = −0.803, r = −0.630, p = 0.0001. The survival of women with multiple sclerosis did not show correlation to sex-adjusted mortality rates in towns: r = −0.126, p = 0.90. Conclusions: The higher level of hygiene was associated with the longer survival of multiple sclerosis patients. The survival of male and female patients with multiple sclerosis showed an inverse correlation to the lower mortality in rural regions. The duration of life in women did not correlate to the higher mortality in towns.

Keywords: multiple sclerosis, survival, hygiene level, mortality
Natural course of multiple sclerosis in the first five years of the disease in the Kujawsko-Pomorskie district
Aktualn Neurol 2016, 16 (1), p. 9–14
DOI: 10.15557/AN.2016.0002

Aim: The aim of the study was to emphasize the prognostic value of the first five years of the natural course of multiple sclerosis for the disability progression, and a comparison of the relapsing-remitting and the primary progressive disease course. Material and methods: Using the retrospective design, we have evaluated the first five years of multiple sclerosis in the affected residents of the Kujawsko-Pomorskie district, treated at the Department of Neurology between July 2014 and September 2015. We have assessed the relationships between the Expanded Disability Status Scale score after the first five years of the disease and the clinical course, gender, initial symptoms, age at first symptoms, first magnetic resonance imaging data, cumulative relapse number in the first two or five years of the disease. Results: The investigated group consisted of 129 patients: 97 with the relapsing-remitting and 32 with the primary progressive disease course. The mean patients’ Expanded Disability Status Scale score after 5 years of the relapsing-remitting disease course was 2.1 ± 1.2. The mean number of relapses in the first two and five years in this subgroup was 2.2 ± 1.2 and 4.2 ± 2.5. The mean patients’ Expanded Disability Status Scale score after 5 years of the primary progressive disease course was 4.1 ± 1.4. A progression to Expanded Disability Status Scale score ≥3 in the period of evaluation was predicted by the primary progressive clinical course, older age at first symptoms, and more than five relapses in the first five years from the disease onset. Conclusions: This study confirms that early clinical differences of the natural course of multiple sclerosis could be strong predictors for moderate disability.

Keywords: relapsing-remitting multiple sclerosis, primary progressive multiple sclerosis, The Kurtzke Expanded Disability Status Scale
Statistical, pathophysiological and clinical aspects of the relationship between multiple sclerosis and osteoporosis
Aktualn Neurol 2016, 16 (1), p. 15–20
DOI: 10.15557/AN.2016.0003

Recently there has been a large increase in a number of publications regarding bone health in multiple sclerosis as well as studies exploring the possible role of vitamin D in the aetiology of the condition. However, the relationship between multiple sclerosis and osteoporosis remains not widely discussed among clinicians. The aim of our review article is to present crucial aspects of such relationship as well as therapeutic options. There are many statistical facts suggesting that correlation between two said diseases occurs. The prevalence of osteoporosis clinical features, like pathological fractures, decreased bone mineral density or low vitamin D serum level, is greater in patients with multiple sclerosis. These facts can be explained by a wide variety of areas and pathways which are common for multiple sclerosis and osteoporosis. The functions of different mediators involved in the pathophysiology of diseases, the role of vitamin D and the adverse effects of drugs administered in multiple sclerosis serve as the best examples. Unfortunately, no uniform guidelines on the management of multiple sclerosis patients with osteoporosis have been established so far. However, the guidelines of the United Kingdom National Institute for Health and Care Excellence and National Osteoporosis Society are recommended in such cases. The most important are an appropriate vitamin D and calcium supplementation, smoking cessation, alcohol intake reduction and more of physical activity. There is a strong need to spread this knowledge among clinicians. A better understanding of the topic might result in the creation of diagnostic and therapeutic guidelines with this respect.

Keywords: multiple sclerosis, osteoporosis, bone health, fractures, vitamin D
Therapeutic management of pregnant women with intracranial haemorrhage related to most commonly occurring arteriovenous malformations
Aktualn Neurol 2016, 16 (1), p. 21–28
DOI: 10.15557/AN.2016.0004

Intracranial haemorrhage in pregnancy poses a serious threat to both the mother and the foetus. It is associated with a high mortality and it is the third among non-obstetric causes of death in this group of patients, accounting for 5–12% of all deaths of the pregnant. Vascular malformations, mainly intracranial aneurysms and arteriovenous malformations observed also in the general population, are the most common cause of bleeding in pregnant women. So far, there have been no clear guidelines for the treatment of pregnant women with intracranial haemorrhage in the course of the above mentioned malformations, therefore the objective of this study is to summarize the knowledge about the specificity of therapeutic management in those cases. The study discusses the location of vascular lesions, physiological processes in a pregnant woman that must be taken into consideration during a therapeutic intervention, the problem of selecting the treatment (surgical treatment, endovascular therapy, radiosurgery), method and time of delivery, the use of ionizing radiation and drugs during endovascular procedures. In the available literature a special attention is paid to the mother’s welfare during the undertaken treatment, including the maintenance of normal uteroplacental perfusion, which has an effect on the general condition of the foetus. Therefore, it is essential to know the discussed physiological changes in a pregnant women as they condition specific therapeutic management. The safety of applied endovascular procedures in pregnant women is equally important due to the use of both ionizing radiation and certain medications. It is believed that these procedures are acceptable in pregnant women when appropriate radiological protection is used, radiation doses are reduced and medications are selected properly. However, surgical intervention is still considered to be the main method of treatment in this group of patients. The decision about the delivery in a patient with intracranial haemorrhage should be made depending on the gestational age and the condition of the mother and the foetus. The foetus’ age limit above which its chance of survival outside the mother’s body increases significantly, is the 28th week of gestation, hence above this limit it is recommended to deliver the baby before the patient’s treatment is introduced.

Keywords: pregnancy, intracranial haemorrhage, arteriovenous malformation, intracranial aneurysm
Strength training as a form of rehabilitation in adults with cerebral palsy
Aktualn Neurol 2016, 16 (1), p. 29–36
DOI: 10.15557/AN.2016.0005

This article is a review of the literature concerning the use of lower limb strength training in adults with cerebral palsy. Medical databases were searched using the following keyword sequences: “cerebral palsy,” “adults,” “young adults,” “strength training,” “progressive strength training” and “resistance training.” Nine publications were identified, and seven met our inclusion criteria. The level of evidence of the accepted studies was rated using the criteria propose by Oxford Centre for Evidence-Based Medicine. The results were presented in a table according to the International Classification of Functioning, Disability and Health at three levels: structure, activity and participation. Based on the results of non-randomised studies, it can be stated that strength training in adults with cerebral palsy leads to increased muscle strength in the lower limbs and improves patient’s activity and participation without adverse effects such as increased spasticity or a passive range of motion decline. However, these results have not been clearly confirmed in randomised clinical trials. To achieve the maximum benefits of strength training in adults with cerebral palsy, a number of issues must still be addressed, e.g. the detailed characteristics of patients with cerebral palsy, a training protocol and potential contextual factors that may influence the effectiveness of this kind of therapy.

Keywords: cerebral palsy, strength training, adults, rehabilitation, physiotherapy
Disorders of consciousness in view of neuroimaging
Aktualn Neurol 2016, 16 (1), p. 37–49
DOI: 10.15557/AN.2016.0006

Patients after severe brain injury are often unable to communicate, move on their own or show evidence of a purposeful behaviour, yet at the same time they may remain conscious. Such states are referred to as disorders of consciousness. Their clinical diagnosis, as based on complex behavioural criteria, is still prone to error and may lead to ambiguous cases. This article is an overview of the recent experimental approaches aimed at the assessment of the structure and function of the central nervous system, based on neuroimaging and employing the current knowledge regarding the mechanisms of consciousness. All these approaches are aimed at identifying the most efficient measure to enable a reliable diagnosing. The first approach is based on structural imaging that provides information on the organisation and state of neural connections within the brain. Other approaches are functional studies divided into passive and active ones. Passive paradigms evaluate the ability of the neural networks in the patient’s brain to sustain consciousness without them having to take part in an experimental task, while the active ones enable the assessment of the state of consciousness on the basis of neural correlates of volitional activities recorded as the patient performs mental tasks. The latter approach rests on an assumption that volitional activity requires conscious processing and cannot be explained in terms of stereotypic reaction to stimulation. While a significant number of approaches presented herein works quite well with respect to differentiating the states on the group level, still only a few of them allow such differentiation on the level of an individual patient. On the latter level, the most important challenge (when it comes to choose a particular care for a patient) could be carried out by a complementary use of several methods at the same time or the evaluation of brain function based on various neuroimaging techniques (EEG and fMRI).

Keywords: disorders of consciousness, brain mechanisms of consciousness, neuroimaging, vegetative state, minimal consciousness state
Rehabilitation after brain tumour removal in a two-year follow-up – a case report
Aktualn Neurol 2016, 16 (1), p. 50–52
DOI: 10.15557/AN.2016.0007

Introduction: Brain tumours account for 2% of malignancies in Poland. Comprehensive rehabilitation is essential for regaining psychomotor aptitude following tumour removal. Case report: We present a clinical case of a patient having undergone the removal of a brain tumour (papilloma plexus choroidei) located in the area of the cerebellopontine angle and the 4th ventricle of the brain. The patient went through a 1-month structured rehabilitation programme at the Neurological Rehabilitation Department. Methods: The following tools were used to assess the effectiveness of the treatment: Barthel Index of Activities of Daily Living (Barthel ADL), Rankin, Lovett, Montreal Cognitive Assessment and Beck Depression Inventory scales. Results: First and foremost, the patient’s ability to carry out daily self-care activities improved. She became fully self-reliant within two years (Barthel ADL 12 versus 20). Conclusions: Cases similar to the one discussed here require long-term rehabilitation that may ultimately facilitate significant functional improvement.

Keywords: brain tumour, rehabilitation, functional status, quality of life