2016, Vol 16, No 4
The significance of NNT parameter for the evaluation of therapy effectiveness
Aktualn Neurol 2016, 16 (4), p. 175–179
DOI: 10.15557/AN.2016.0022

Clinical trials provide a practicing clinician with an abundance if not excess of data to draw on when comparing treatment methods and deciding the potentially optimal therapeutic option for a given patient. NNT, or number needed to treat, has been identified as one of the parameters useful for assessing the effectiveness of therapy. It represents the number of patients who must undergo a given health-care intervention instead of another one to see a difference in the effectiveness of obtaining a desired outcome within a set timeframe. NNT is a derivative of absolute risk reduction (ARR) or initial risk and its relative reduction. It represents the relative superiority of a given treatment. NNT is primarily used for comparing the advantages and disadvantages of alternative health-care interventions, and its assessment is important for estimating the clinical value of statistically significant clinical trial results. Utilization of NNT allows to predict therapy outcome both in terms of its effectiveness and tolerance. Also, clinical trial results presented in the form of NNT may be easily shared with patients, their families, and the institutions deciding the availability of a given drug. In multiple sclerosis, clinical trial results have been concerned with the impact of therapeutics on decrease of annualized relapse rate (ARR) and reduction of lesions visible in magnetic resonance images as well as slowing of disability progression. Analyses of first-line multiple sclerosis treatments reveal their NNT referred to prevention of relapses, disability progression and lesions in magnetic resonance image to vary significantly. Similar differences exist across NNT values established for second-line treatments or the oral therapies being currently introduced. The data clearly show that when evaluating clinical trial results, it is not enough to consider only given parameters, as they must all be critically and constructively analysed. NNT’s importance is also stressed as a clear parameter to be used for the evaluation of economic outcomes in healthcare.

Keywords: number needed to treat, NNT, multiple sclerosis
Trigeminal autonomic cephalalgias: a review
Aktualn Neurol 2016, 16 (4), p. 180–186
DOI: 10.15557/AN.2016.0023

Trigeminal autonomic cephalalgias are a group of primary headache disorders presenting as unilateral pain in the somatic distribution of the trigeminal nerve, associated with ipsilateral cranial autonomic symptoms. This clinicopathologic group includes cluster headache, paroxysmal hemicrania, hemicrania continua and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing/cranial autonomic features, which differ mainly as regards the duration and frequency of pain as well as response to treatment. These disorders are not as rare as they were thought to be and due to the severity of the pain can substantially affect the patients’ quality of life. Many other forms of primary headaches, such as migraine, trigeminal neuralgia and primary stabbing headache, as well as secondary headaches, particularly those caused by pituitary, posterior fossa, orbital, paranasal sinus and vascular pathology, need to be carefully considered in the diagnosis of trigeminal autonomic cephalalgias. Research in this field, particularly using functional neuroimaging, has resulted in a much better understanding of these disorders. Dysfunction in the nociceptive modulatory pathways in brain’s pain matrix is currently thought to produce a permissive state for the occurrence of a trigeminal autonomic cephalalgia attack, with posterior hypothalamus serving as a terminator rather than the generator of the attack. The current treatment strategies include medical and surgical approaches; of the latter, neuromodulation techniques, particularly deep brain stimulation of posterior hypothalamus, have proven to be particularly effective and promising.

Keywords: trigeminal autonomic cephalalgia, cluster headache, paroxysmal hemicrania, hemicrania continua, SUNCT, SUNA
Methods for in vivo determination the amygdala organisation in humans: state of the art
Aktualn Neurol 2016, 16 (4), p. 187–193
DOI: 10.15557/AN.2016.0024

The amygdala is a subcortical structure located bilaterally in the medial temporal lobes. This structure captures the attention of neuroscientists due to its role in emotion processing and learning. Animal studies indicate that groups of nuclei situated in different parts of the amygdala are components of distinct neural circuits underlying in a varied way emotional and cognitive processes. Some authors even argue that the amygdala is deemed a single unit only owing to nuclei groups located closely. Verifying such a hypothesis with regard to humans is very difficult as, until quite recently, there has been only one method of amygdala parcellation, based on post-mortem anatomical tissue analysis. However, in more recent years, several attempts have been made to parcellate the human amygdala on the basis of structural and functional connectivity with other areas of the brain using magnetic resonance imaging techniques. Results of analyses conducted until now are not congruent in respect of the number and localisation of the obtained amygdala parts. This may be a consequence of using different techniques (functional magnetic resonance imaging or diffusion tensor imaging), various acquisition parameters of scanner and distinct data analysis procedures, especially clustering algorithms. Future research should be focused on the development of the most reliable method for parcellation of the human amygdala to enable clear identification. This will allow one to learn more about the functional organisation of this structure in humans.

Keywords: amygdala, functional magnetic resonance imaging, diffusion tensor imaging, clustering
The use of tetrabenazine for the treatment of drug-induced tardive dyskinesia – report of four cases
Aktualn Neurol 2016, 16 (4), p. 194–200
DOI: 10.15557/AN.2016.0025

Tardive dyskinesias are defined as a syndrome of involuntary, irregular, hyperkinetic movement disorders, including mixed movement disorders of the face and the mouth as well as choreoathetoid movements of the trunk and limbs. They are a serious and usually irreversible side effect of chronic neuroleptic treatment and affect approximately 15–20% of patients. Treatment attempts using amantadine, levetiracetam, piracetam, clonazepam, propranolol, vitamin B6, vitamin E, ondansetron, botulinum toxin and Ginkgo biloba were made. However, in many cases the treatment efficacy has not been confirmed in long-term studies in larger groups of patients. Tetrabenazine, registered in Poland for the treatment of hyperkinetic motor disorders in the Huntington’s disease, is one of the available therapeutic options. We present the course and the effects of tetrabenazine therapy in four patients with antipsychotic-induced tardive dyskinesias. Based on the experience gained during the research program using tetrabenazine, we believe that the use of this agent should be limited to patients in a stable mental condition, with no current symptoms of depression or active psychotic symptoms. In our opinion, suicidal tendencies or thoughts and a history of neuroleptic malignant syndrome are absolute contraindications. The off-label use of tetrabenazine requires a written informed consent of the patient and careful monitoring of their mental and neurological condition.

Keywords: tardive dyskinesia, tetrabenazine, antipsychotics
Therapeutic management in an elderly patient with odontoid fracture
Aktualn Neurol 2016, 16 (4), p. 201–207
DOI: 10.15557/AN.2016.0026

Fracture of the odontoid process is the most common type of cervical spine fracture in elderly patients (i.e. population over the age of 70 years), which can lead to disability or death. The therapeutic management depends on imaging findings and patient’s general condition. The authors present a case of a 71-year-old patient diagnosed with odontoid fracture based on cervical spine computed tomography, who received surgical treatment in the Department of Neurosurgery of the Regional Medical Centre in Opole. The problem of odontoid fractures in the elderly has been a subject of a comprehensive discussion.

Keywords: odontoid fracture, cervical spine, surgical treatment, lag screw, posterior fusion
Early rehabilitation after haemorrhagic stroke in a patient with a history of heart transplantation. A case study
Aktualn Neurol 2016, 16 (4), p. 208–211
DOI: 10.15557/AN.2016.0027

Introduction: Stroke is the most common form of central nervous system condition. An average of about 80 heart transplantations are performed in Poland yearly. A transplanted heart is prone to tachycardia. Early, complex post-stroke rehabilitation requires physical effort from the patient. Case report: We present a clinical case of a patient with left-sided hemiparesis after a haemorrhagic stroke and on immunosuppressive treatment after heart transplantation (2005). Methods: The outcomes of rehabilitation therapy were assessed based on the following scales: the Barthel Index, a modified Rankin Scale, the Rivermead Motor Index, the National Institutes of Health Stroke Scale, the Mini–Mental State Examination, and the Geriatric Depression Scale. Moreover, pre- and post-exercise heart rate monitoring was performed. Results: As a result of comprehensive rehabilitation treatment, functional status improvement was observed in all estimated scales. The highest change was reported for Barthel Index (50%) and National Institutes of Health Stroke Scale (30%). Heart rate was between 75 and 180 bpm. Conclusions: A patient with a history of heart transplantation shows good tolerance of physical exercise despite tachycardia. Early post-stroke rehabilitation significantly improves functional status.

Keywords: stroke, comprehensive rehabilitation, heart transplantation
An outbreak of aseptic meningitis in Podlaskie Voivodeship in 2014
Aktualn Neurol 2016, 16 (4), p. 212–217
DOI: 10.15557/AN.2016.0028

Enteroviruses cause common infections with various clinical course and forms, such as hand-foot-and-mouth disease (Boston exanthem disease), herpangina, myocarditis and pericarditis, widespread myositis (epidemic pleurodynia, Bornholm disease), or aseptic inflammation of the nervous system, among children and adolescents. An increase in aseptic meningitis cases of enteroviral aetiology, including the E30 virus, was occasionally observed in various European countries. In 2014, an outbreak of aseptic meningitis was reported in Podlaskie Voivodeship. A total of 640 cases were reported between June 1 and November 30, 2014, of which 228 had confirmed enteroviral aetiology. Summer and autumn seasons favour the incidence of viral infections of the central nervous system. Symptomatic infections are more common in males than females. Infections with enterovirus show the tendency to form endemic regions.

Keywords: enteroviral aseptic meningitis, echovirus 30, enteroviruses