2018, Vol 18, No 2
Idiopathic intracranial hypertension: long-term follow-up and impact on patients’ visual function with a literature review
Aktualn Neurol 2018, 18 (2), p. 61–67
DOI: 10.15557/AN.2018.0008

Aim: The aim of the study was a long-term observation (particularly in terms of visual function) of patients hospitalised at the Neurology Department of St. Adalbert Hospital in Gdańsk, Poland, due to an episode of idiopathic intracranial hypertension. Material and methods: The Department’s archives held records of 13 cases of idiopathic intracranial hypertension treated from 2007 to 2015. The retrospectively retrieved data concerned: age, sex, height, weight, comborbidities, symptoms of idiopathic intracranial hypertension, neurological abnormalities, fundoscopy findings, vision field, brain magnetic resonance findings, visual evoked potentials and employed treatment. Eleven patients reported for a follow-up examination, and 6 patients completed it. The patients were examined neurologically and ophthalmologically with fundoscopy, visual field test, visual acuity and visual evoked potentials. The results were compared with the disease history data. The follow-up period lasted 4–47 months. Results: Nine of 11 patients were females. In 2 of them, the initial diagnosis was revised, and 3 did not complete all procedures. Six patients were included in the analysis. The most common complain upon admission was headache and tunnel vision. Brain magnetic resonance imaging scans revealed changes characteristic of idiopathic intracranial hypertension in 5 patients. Therapeutic drainage of cerebrospinal fluid was performed in all the patients, and all of them were treated with acetazolamide. Visual disturbances (visual field loss or impaired visual evoked potentials) persisted in 3 patients. Significant risk factors for idiopathic intracranial hypertension in the analysed group were: female sex, increased body mass index and reproductive age. Permanent vision impairment was observed in patients who required more intensive treatment. Conclusion: Weight gain is a significant risk factor for poor outcome. Visual field assessment and fundoscopy seem to be superior than visual acuity in the monitoring of disease activity.

Keywords: idiopathic intracranial hypertension, visual evoked potentials, visual field loss, papilloedema, headache, long-term follow-up
Motor re-training and immobilisation in the treatment of writer’s cramp: a clinical and fMRI study
Aktualn Neurol 2018, 18 (2), p. 68–73
DOI: 10.15557/AN.2018.0009

Objectives: The aim of the paper was to: (1) evaluate the effectiveness of the physiotherapeutic program in writer’s cramp, (2) compare the brain activity while writing in patients with writer’s cramp and in healthy controls, (3) compare the brain activity of subjects with writer’s cramp before and after the physiotherapy. Material and methods: Nine patients with diagnosed writer’s cramp and nine age-matched healthy controls were studied. The functional magnetic resonance imaging while writing was performed in the writer’s cramp subjects and in the controls. The patients with writer’s cramp participated in a 3-week therapeutic program of individualised exercises in combination with the immobilisation of the affected limb. The functional magnetic resonance imaging was repeated after completing the therapeutic program. Results: Only the results of the coil drawing test significantly improved after completing the therapeutic program. All other clinical tests did not reveal any significant changes after the therapy. Activation of primary motor cortex, premotor cortex and primary sensory cortex was observed while writing in the subjects with writer’s cramp and in the controls. Brain activation in clusters located in the areas BA4, BA7, BA18 and BA37 was more pronounced in the writer’s cramp group. Individual analysis revealed a significantly increased activation of the cerebellum in the writer’s cramp patients and it decreased after physiotherapy. Conclusion: In the writer’s cramp subjects, functional magnetic resonance imaging revealed increased – when compared to the controls – activity of several brain structures while writing. This activity was modified by individualised physiotherapeutic program.

Keywords: writer’s cramp, motor re-training, immobilisation, functional MRI
The role of SPECT-DaTSCAN in the diagnosis of isolated tremor syndromes
Aktualn Neurol 2018, 18 (2), p. 74–78
DOI: 10.15557/AN.2018.0010

Objectives: The purpose of our study was to determine the probability of developing Parkinson’s disease in various syndromes of isolated tremor. Material and methods: We performed a retrospective analysis of the diagnostic process in patients with isolated upper limb tremor where single-photon emission computed tomography (SPECT)-DaTSCAN was performed. Twenty-four consecutive subjects (9 males, 15 females) with isolated tremor of one or both upper limbs were studied. The patients were referred for SPECT by neurologists from various centres. Cases of diagnosed structural, metabolic or druginduced tremor were not included in the study. All patients were examined by a movement disorder specialist before and 1–3 years after SPECT-DaTSCAN. All subjects were classified according to the Consensus Statement on the Classification of Tremors (2018). Results: The lowest probability of developing Parkinson’s disease was found in patients with rest and action (postural and kinetic) tremor, both unilateral and bilateral. The risk was also low in subjects with postural and kinetic tremor. In cases of a combination of rest and postural tremor (both unilateral and bilateral), the likelihood of neurodegenerative parkinsonism was high. Conclusion: Performing SPECT-DaTSCAN in selected cases of isolated of tremor with a high probability of Parkinson’s disease avoids the unnecessary use of drugs recommended in the therapeutic algorithms applicable in essential tremor.

Keywords: isolated tremor syndromes, SPECT-DaTSCAN, probability of Parkinson’s disease
Age as a prognostic factor in episodic memory and executive impairment following traumatic brain injury in children and adolescents
Aktualn Neurol 2018, 18 (2), p. 79–84
DOI: 10.15557/AN.2018.0011

Both episodic memory and executive deficits are considered common and clinically significant consequences of traumatic brain injury. The paper reviews the current literature on memory and executive impairment in children and adolescents after traumatic brain injury so as to determine if children who sustained trauma at younger age are more or less vulnerable to persistent deficits in these domains. Apart from the significance of age at injury, the paper addresses a few methodological issues pertaining to the reviewed studies. The most popular methods used to assess episodic memory and executive function in children and adolescents are discussed in terms of their scope and limitations. Studies on the long-term cognitive sequelae of traumatic brain injury in children are scarce, and the scope of episodic memory and executive function assessment seems insufficient to fully understand the pattern of deficits. The profile of cognitive deficits and their trajectory over time is much less understood in children and adolescents than in the adult population after traumatic brain injury. Adolescents are often included in adult groups, which does not contribute to the understanding of deficits in this patient cohort. It seems that early brain injury is associated with poorer long-term prognosis. However, long-term prospective and comprehensive studies on memory and executive dysfunction due to traumatic brain injury in children and adolescents would be needed to fully understand the trajectory of deficits and the importance of the relationship between the time of injury and critical periods in the cognitive development.

Keywords: craniocerebral trauma, memory impairment, executive disorders
Cognitive training and cognitive rehabilitation as non-pharmacological therapeutic strategies in Parkinson’s disease: a review of research
Aktualn Neurol 2018, 18 (2), p. 85–93
DOI: 10.15557/AN.2018.0012

A diagnosis of Parkinson’s disease is based on axial motor symptoms of the disease, such as stiffness, bradykinesia, postural disturbances and resting tremors. In recent years, attention has also been paid to non-motor symptoms (cognitive, neuropsychiatric and vegetative) that often precede the manifestation of movement symptoms and significantly reduce the patients’ quality of life. Patients with Parkinson’s disease often experience slowness of thought (bradyphrenia), impaired executive and visuospatial functions, and weakening of attention processes. Developing effective therapeutic strategies that will slow or stop the cognitive deterioration becomes the subject of researchers’ interest. The article below presents the results of research on the effectiveness of strictly cognitive non-pharmacological interactions, aimed at improving cognitive performance of patients with Parkinson’s disease (cognitive training, cognitive rehabilitation). These studies suggest that cognitive training and cognitive rehabilitation are safe and effective methods of improving cognitive performance of patients with Parkinson’s disease. All studies report improvement of performance in at least one function under the influence of cognitive training and rehabilitation. Cognitive domains whose efficiency improved the most significantly were: attention, episodic memory and executive functions, which in Parkinson’s disease are particularly susceptible to weakening. Nevertheless, there are still few studies with more numerous intervention groups, studies comparing the effectiveness of training in people at different stages of disease and longitudinal studies, which would show if the improvement lasts over time and whether it has an influence on everyday functioning (transfer of acquired skills).

Keywords: Parkinson’s disease, cognitive deficits, cognitive training, cognitive rehabilitation
The role of vertebral artery hypoplasia in neurological practice
Aktualn Neurol 2018, 18 (2), p. 94–98
DOI: 10.15557/AN.2018.0013

Doppler assessment of the intracranial arteries is one of the most commonly ordered additional tests in neurology. The main purpose of the test is to assess morphology and blood flow in the extracranial segments of the internal carotid arteries as well as vertebral and common carotid arteries. The paper presents a brief literature review on the role of a vascular anomaly known as vertebral artery hypoplasia, in everyday clinical practice. The abnormality is a subject of much controversy, including the definition and consistent criteria for the diagnosis of hypoplastic vertebral artery. In literature, the diameter threshold for vertebral artery is most often defined as 2 mm. However, as pointed out in some studies, there are certain situations when vascular diameter below 3 mm may reduce perfusion in the supplied brain region. Depending on the diagnostic criteria and the study population, the estimated incidence of hypoplastic vertebral artery is 1.9–26.5%. Published studies suggest a possible relationship between a hypoplastic vertebral artery and an increased risk of posterior circulation ischaemia. A similar relationship was also shown for congenital vertebral artery asymmetry of more than 1:1.7. It is beyond doubt that the clinical significance of hypoplastic vertebral artery is additionally conditioned by a number of parameters, such as age and comorbidities. The efficiency of collateral circulation, especially in the posterior communicating arteries that make up the circle of Willis, is another important aspect. Another interesting problem is the potential relationship between vertebral artery hypoplasia and migraine with aura. In conclusion, despite much controversy, it seems that hypoplastic vertebral artery should not be automatically considered a vascular anomaly of no clinical significance for the patient.

Keywords: vertebral artery, hypoplasia, ischaemic stroke, dizziness, TIA
CGRP antagonists in treatment of migraine attacks
Aktualn Neurol 2018, 18 (2), p. 99–102
DOI: 10.15557/AN.2018.0014

Triptans are the drugs of choice in moderate to severe migraine attacks. It is estimated that they are ineffective in one-third of patients. Furthermore, triptans are contraindicated in patients with cardiovascular diseases. Calcitonin gene-related peptide (CGRP) is a 37-amino-acid neuropeptide. It has been suggested that it plays a critical role in migraine pathophysiology. Increased CGRP levels have been reported during migraine and cluster headache attacks. Furthermore, it was shown that intravenous CGRP induces migraine-like headaches in susceptible individuals. Triptans decrease elevated CGRP level back to normal. Based on these findings, it was proposed that blockage of CGRP receptors may be effective in aborting a migraine attack. Olcegepant was the first CGRP antagonist investigated in patients with migraine. Despite confirmed efficacy, its development was discontinued due to the difficulties in producing an orally available formulation. Telcagepant was the first CGRP antagonist available in tablets. Despite promising clinical data, the clinical development program for the drug was discontinued due to concerns about liver toxicity. This year, the results of phase III trial on ubrogepant, a new CGRP antagonists, were published. Its efficacy is comparable to that of triptans, and its adverse event profile is similar to that of placebo. No serious adverse reactions were reported in patients treated with this drug. Since CGRP antagonists do not show vasoconstrictive proprieties, they may be used in patients with cardiovascular diseases, in whom triptans are contraindicated. The studies on the efficacy and tolerability of CGRP antagonists are promising, and it is hoped that they will expand the possibilities of effective abortive treatment of migraine.

Keywords: migraine, CGRP, treatment