[Estimation of brain atrophic processes among patients with past history of TBE (with EEG evaluation)]

The aim of the study was estimation of brain atrophic processes among patients with past history long lasting, or encephalitic course (8-10 years after) TBE with using planimetric measurements of CT scans in connection with EEG evaluation. 34 patients were enrolled to the study. First results suggest the presence of sequel past TBE as increased percentage pathology in EEG evaluation as well increasing of anterior horns lateral ventricules, dilatation the III ventricule as a result of fastened brain atrophy in relation to the age of the patients.

Asymptomatic visual field disturbances in multiple sclerosis patients without a history of optic neuritis

BACKGROUND AND PURPOSE

The aim of our study was to evaluate visual field in patients with multiple sclerosis without a history of optic neuritis. We assessed presence and localisation of visual field defects and evaluated correlation between visual field disturbances and patient's neurological status.

MATERIAL AND METHODS

A group of 52 patients with multiple sclerosis and 17 healthy persons who served as the control group were enrolled into the study. The patients went through a routine neurological examination, ophthalmologic check-up and perimetric visual field assessment. Visual fields were examined with static perimetry Medmont M700. In all of the patients, results of perimetry were evaluated according to localisation of lesions. A decibel scale was used to quantitatively assess disturbances in patient's visual field.

RESULTS

We found that "asymptomatic" visual field disturbances were present in a large number (38, 73.1%) of multiple sclerosis patients. Among these patients, we diagnosed concentric visual field lesions in 46.2%, and we recognized disturbances in the upper part of the visual field in 26.9%. There was a correlation between the presence of those visual field lesions, duration of multiple sclerosis, and the degree of patients' disability.

CONCLUSIONS

Asymptomatic visual field disturbances occur frequently in MS patients (despite no history of retrobulbar optic neuritis). Static perimetry may be a valuable, complementary method in addition to examinations used so far in the diagnosis of multiple sclerosis.

Metabolite Profile in Pyramidal Tracts after Ischemic Brain Stroke Assessed by 1H MRS. A Multicenter Study

The magnitude of the motor deficit in patients with stroke depends not only on the size and location of the destroyed brain tissue, but also on axonal injury in the descending motor pathways which appears after stroke. After cerebral ischemia, there are no visible abnormalities in conventional MRI in the intact pyramidal tracts despite the process of neuronal destruction by Wallerian degeneration. Conventional MRI is not a sensitive test for Wallerian degeneration in the acute or subacute time period as it shows no changes within the first four weeks. Magnetic resonance spectroscopy (MRS) has been used for better quantification of the extent or severity of fibre damage by evaluating metabolite alterations in normal-appearing corticospinal and corticopontal tracts. This study assessed the role of 1H MRS in the detection of changes in cerebral metabolite levels in pyramidal tracts after cortical/ subcortical infarction and to compare metabolite alterations to clinical outcome (assessed by Barthel index, Scandinavian Stroke Scale). The study included 31 patients who had suffered an ischemic cortical/subcortical stroke involving the motor cortex or the descending fibers. Ratios of NAA/Cr, Cho/Cr, lip/Cr and Lac/Cr from internal capsules and cerebral peduncles were measured and compared with clinical status assessed by Barthel index and Scandinavian Stroke Scale (SSS). The ratio of NAA/Cr was significantly decreased (p<0.001) in the normal-appearing ipsilateral internal capsule in comparison with the control group. Cho/Cr and lac/Cr ratios were increased compared to the control group (p=0.019). Decrease of NAA/Cr ratio correlated with clinical status assessed by Barthel index and there was a correlation between clinical improvement (assessed by SSS) and lac/Cr ratio. Tissue metabolite concentrations distant from the infarcted region correlated with the clinical course and had predictive value. Proton MRS is very useful tool for evaluating major changes in metabolite levels in pyramidal tracts after brain stroke.

[Moyamoya disease as a cause of ischemic cerebral stroke in young people]

35-year old patient was admitted to the Department of Neurology, Medical University of Bialystok because of paresis of his left upper limb, progressing over last 10 months and right facial nerve paresis, which started a month ago. During neurological examination he presented with right facial and arm paresis, dysarthric speech, obesity and hypertension. The patient was previously hospitalized in regional hospital, where a lumbar puncture was done revealing normal composition of cerebrospinal fluid. His brain CT revealed bilateral hypodensive areas in frontal and parietal regions of vasogenic character. Doppler ultrasound showed significant slowing of blood flow velocity in both internal carotid arteries. Brain angiography presented with very weak contrast filling of intracranial branches of carotid and vertebral arteries and showed stenosis at the terminal portion of the internal carotid arteries and at the proximal portion of the anterior and middle cerebral arteries. The patient had transthoracic and transesophageal echocardiography, Holter ECG, lab tests (routine lab tests plus coagulation system evaluation with C protein resistance test, anticardiolipne antibodies, antinuclear antibodies, anticytoplasmatic antibodies and thyroid hormones) checked--all tests were within normal range. Based on cerebral angiography and clinical symptoms, after excluding any other reasons of cerebral ischemia, the patient was diagnosed with moyamoya disease and arterial hypertension. The patient was treated pharmacologically with improvement--regression of face assymetry and dysarthria and diminishing of his right arm paresis. The authors of this paper pay attention to moyamoya disease as a rare reason of ischemic strokes in the young in our geographic region. They remind moyamoya disease diagnostic criteria, its etiology and treatment.

[Multifocal central nervous system lesions --multiple sclerosis or neuroborreliosis?]

Multiple sclerosis is the most frequent multifocal disease of the central nervous system, but in a diagnosis of atypical cases about 100 other diseases should be considered. Neuroborreliosis plays a particular role among them, especially in endemic regions. Difficulties result from similarities of clinical symptoms and lack of specific diagnostic investigations. Diagnostic procedures in neuroborreliosis are mostly based on laboratory analyses and serologic examinations of serum and cerebrospinal fluid, in connection with a clinical picture and an epidemiological state. Since the year 2001, multiple sclerosis neurological diagnostic is based on the diagnostic criteria established under the auspices of The US National Multiple Sclerosis Society and International Federation of Multiple Sclerosis Societies. Those recommendations regarding relapsing-remitting MS and primary progressing MS are discussed in this paper. Current knowledge of those diseases warrants cautiousness in the diagnostic of atypical cases.

[Effect of methylprednisolone on the attention in patients with multiple sclerosis]

The aim of the study was to examine effects of high doses of intravenous methylprednisolone (MP, 1 g daily, for 5 days) on the sustained attention and attention focusing in multiple sclerosis (MS) patients with clinical relapse.

MATERIAL AND METHODS

Thirty four relapsing-remitting patients were included. The mean age was 39.4 (20-56) years, mean disease duration and mean Expanded Disability Status Scale scores were 6.6 (0.8-18) years and 4.1 (2.0-6.0), respectively. MS patients underwent psychological testing three times: before and immediately after MP treatment, and 6 months later. The trials: "100-7" and "months of year backwards", The Brickenkamp d2 test, and The Visual Continuous Attention Test (DAUF) were used. Thirty two control subjects (mean age 37.2 years) with ischialgia, not receiving steroids, underwent the same testing procedure two times: at admission and on 6th day of hospitalization.

RESULTS

Before and immediately after MP treatment MS patient obtained significantly worse scores than controls on the DAUF test (significantly decreased number of correct reactions (p<0.05), significantly increased number of incorrect reactions (p<0.05), and significantly increased mean value of reaction times (p<0.05)). There were no significant differences within MS and control subjects on other tests. Therapy with MP did not markedly change an ability to focus attention and keep the concentration over long period of time in MS patients.

CONCLUSIONS

MS subjects show disturbances in the sustained attention. Therapy with MP does not significantly change the sustained attention and attention focusing in MS patients.

[Brain perfusion disturbances in patients with vertigo -- a study with SPECT]

BACKGROUND AND PURPOSE

The aim of our study was to evaluate brain perfusion in patients with vertigo using the SPECT technique.

METHODS

The study involved a group of 32 patients and was performed in the Neurological Department of the Medical University in Bialystok. Patients with vertigo of peripheral origin like middle ear pathology were excluded from the study. Tomographic pictures were taken with Nucline X-Ring camera after administration of Tc99m-ECD. Perfusion maps were estimated by qualitative and semi-quantitative methods.

RESULTS

In 8 patients (25%) perfusion maps were normal in the hemispheres, cerebellum and subcortical structures. In 10 patients (31.2%) there was a substantial decrease in perfusion in the left temporal region, in 8 patients (25%) -- hypoperfusion was seen in the right temporal region. In 4 patients (12.5%) there was a substantial decrease in perfusion in the cerebellum, in two persons -- in the frontal lobes.

CONCLUSIONS

The results obtained so far confirm the major role of ischemia in etiology of the central origin vertigo and balance disturbances. It involves not only the brainstem and cerebellar structures, but the temporal lobes as well. The test has also proved that the qualitative and semi-quantitative methods of assessing brain perfusion with a SPECT are satisfactory in diagnostics of vertigo.

A prospective study of the financial costs of multiple sclerosis at different stages of the disease

The aim of our study was to estimate the costs of multiple sclerosis (MS) in Poland according to severity of disease. Total, direct and indirect costs were compared in 148 patients divided into three groups categorized by disease severity: stage I Expanded Disability Status Scale (EDSS <3.5), stage II (EDSS 4.0-6.0) and stage III (EDSS >6.5). Cost evaluation was performed from the societal perspective and covered the 5-month period. Simple sensitivity analysis was performed by varying the tariffs and valuing caregiving at 40% of the average wage. The mean total cost/patient for 5 months was estimated at 10,955, 15, 603 and 18, 464 PLN for stage I, II and III, respectively [exchange rate: 4 PLN=1 EUR; purchasing power pariety: 1 EUR=2.05 PLN] (P <0.0001). Regardless of EDSS stage indirect costs exceeded direct costs. Both direct and indirect costs increased with MS progression. For indirect cost the main item was productivity loss. This study confirms that MS represents a high economic burden, with indirect costs greatly exceeding direct costs. As costs increase with disease progression, treatment efforts should focus on patients in the early stages of MS.

[Behcet's disease: a rare cause of multifocal lesions in the central nervous system]

Behcet's disease (BD) is a chronic multisystem inflammatory disease characterized mainly by recurrent episodes of orogenital aphthae and uveitis. In 10-30% of cases relapsing multifocal neurological symptoms occur. The authors present a 54-year-old female patient with the central nervous system manifestation of clinically diagnosed BD. Based on the reported case diagnostic (in particular differential diagnosis with multiple sclerosis) and therapeutic problems of BD are discussed.

[Subclinical lesions of peripheral nervous system in multiple sclerosis patients]

BACKGROUND AND PURPOSE

In the last years the presence of peripheral nervous system (PNS) lesions has been noted in patients with multiple sclerosis (MS). The frequency and degree of PNS damage reported by many authors differ among publications, so does the type of PNS lesions. The aim of our study was to perform an electrophysiological evaluation of the peripheral nervous system in patients with a definite diagnosis of multiple sclerosis and without any clinical signs of peripheral neuropathy.

MATERIAL AND METHODS

110 patients were included in the study, comprising 70 people with a definite diagnosis of multiple sclerosis and 40 people without any symptoms of organic nervous system lesion serving as a control group. During neurologic examination of MS patients the degree of disability measured by EDSS scale, the duration of the disease as well as number of relapses were assessed. A "disease progression factor" was calculated by dividing a number of relapses by disease duration in years. Patients with common etiologies for peripheral neuropathy such as diabetes, renal insufficiency, thyroid gland dysfunction, proliferative disorders etc. were excluded from the study. Orthodromic motor conduction and late responses (F wave) in median, ulnar, peroneal and tibial nerves as well as sensory conduction in median, ulnar (orthodromic) and sural (antidromic) nerves were evaluated.

RESULTS

There was electrophysiological evidence of peripheral nervous system lesions in at least one nerve in 52 (74.2%) MS patients. In 30 patients (42.8%) more than one peripheral nerve was lesioned. There were more significant differences noted during the examination of sensory nerves. Sensory amplitudes in all of the sensory nerves examined were significantly lower than in control group. Furthermore we observed slow sensory conduction velocities and prolonged sensory latencies in ulnar and sural nerves. There were significant differences between the two groups of patients concerning motor conduction too: prolonged distal latency in tibial and sural nerves, prolonged F wave latency in median, peroneal and tibial nerves, low motor amplitude in ulnar and peroneal nerves, low motor conduction velocity in ulnar nerve -- all noted in MS patients. We found no correlation between conduction parameters and the patients' age, disease duration, number of relapses and disease progression degree.

CONCLUSIONS

We found out that subclinical peripheral nervous system abnormalities are very frequent in MS patients. We noted both sensory and motor nerve lesions of a demyelinating-axonal character. Sensory abnormalities were more pronounced than motor ones. There was no correlation between the degree of PNS lesions and the patients' age and/or progression of multiple sclerosis.

[Neurological disorders after carbon monoxide intoxication]

Carbon monoxide (CO) intoxications still remain an important clinical problem. Under an influence of CO the cellular respiration is inhibited. Structures of the central nervous system (CNS), extremely vulnerable to hypoxia, are usually considerably damaged. In result, a variety of pathologic neurological symptoms may appear and characteristic biphasic course of complaints is often observed. The modern methods of neuroimaging (CT, MRI, SPECT, PET) enable to show a connection between found structural injury and clinical symptoms, and when repeatedly performed allow us to evaluate the dynamics of the CNS dysfunction. Because of late complications, which may occur after the period of latency, the authors stress the value of the prolonged (for up to few years) ambulatory observation of subjects after CO intoxication.

[Features of intracranial hypertension as a manifestation of cauda equina tumor]

A 61-year-old man was admitted to the Department of Neurology, Medical University of Białystok with signs of intracranial hypertension associated with headaches and papilledema, with no other signs of the nervous system dysfunction. CT and MRI brain scans were normal, cerebrospinal fluid contained 1620 mg/dl of proteins. One month later epileptic seizures with a loss of consciousness occurred. Brain CT and MRI scans showed no focal pathology and failed to disclose any intracranial tumor. The acute pain in the lumbar spine region made us perform an MRI scan of the lower spinal cord, which disclosed cauda equina tumor. The tumor was surgically removed and it was histopathologically concluded to be ependymoma. After the operation there were neither headaches nor seizures and we noticed an improvement in his vision acuity. In the postoperative course the patient suffered from urinary and bowel dysfunction. In this article we discuss a pathogenesis of intracranial hypertension occurring in spinal cord tumors and stress the need for a diagnosis of spinal cord lesions in patients with the elevated intracranial pressure.

[Adrenomyeloneuropathy: a late type of adrenoleukodystrophy linked to chromosome X]

Adrenomyeloneuropathy is a late type of adrenoleukodystrophy. It is a hereditary disease linked to chromosome X and it is caused by abnormalities in the function of peroxisomes. Adrenomyeloneuropathy results from mutations in ABCD1 gene, that resides on chromosome Xq28 and encodes an integral peroxisomal membrane protein ALDP that belongs to the ATP-binding cassette-transporter family. The enzymatic defect concerns a transporter protein for acyl-CoA synthetase, taking part in beta-oxidation of very long chain fatty acids. This results in their accumulation in various organs. In the clinical picture spastic paresis of lower limbs, cerebellar ataxia, sensation and sphincteral disturbances predominate. This can lead to a misdiagnosis, especially shortly after the onset of symptoms, namely multiple sclerosis may be wrongly diagnosed. Coexisting endocrinological and quite often psychiatric disorders together with characteristic MRI findings facilitate the diagnosis. The diagnosis can be confirmed by a biochemical assay of very long chain fatty acids. We present a case of a 31-year-old man with adrenomyeloneuropathy. We based our diagnosis on a clinical picture and wide range of diagnostic procedures including: neuroradiologic findings, electrophysiologic, hormonal and biochemical tests, which are discussed in this article.

[Cerebral venous thrombosis--clinical aspects and consequences]

The clinical picture of cerebral venous thrombosis (CVT) depends on the site of thrombosis in the venous system including superficial veins, deep veins and venous sinuses. Thrombotic changes may occur simultaneously in various parts of the venous system. Since CVT may have various causes, the knowledge of its etiology helps to make the diagnosis. In systemic diseases multiple intravascular clots may result, while in localized pathological conditions thrombosis maybe restricted to the lesion site. The clinical picture is often serious, leading to death, or to severe complications such as pulmonary embolism, and to distant complications--like epilepsy or intracranial hypertension being the cause of chronic headaches (lumbar puncture and CSF pressure measurement are helpful in the diagnosis of intracranial hypertension). In order to prevent complications of crucial importance is not only the proper diagnosis (with MRI and venography as the diagnostic techniques of choice), but also an early and prolonged treatment with anticoagulants. Heparin or fractionated heparin is recommended even though there is a possibility of cerebral haemorrhagic lesions.

["De novo" non-convulsive status epilepticus in adults and in the elderly]

There is a growing number of publications in the recent literature reporting the incidence of non-convulsive status epilepticus in the elderly, including both absence epilepsy and partial epileptic seizures. Absence status epilepticus creates a diagnostic problem because of its clinical features: confusion ranging from slight disorientation to stupor. Duration of such states may vary from one hour to a few weeks, with fluctuations and epileptic features in EEG recording (a typical pattern of spikes-slow waves, 3 Hz frequency, symmetrical and synchronical) that disappear after an intravenous injection of benzodiazepines. Absence status epilepticus can be evoked by toxic, metabolic or pharmacological factors as well as by convulsive epileptic seizures. Besides absence epileptic states of middle-cerebral origin there is a rising concern about absence status resulting from simple or complex partial seizures. Generalized non-convulsive status epilepticus following either simple partial or simple complex seizures is characterized by the presence of various focal signs associated with confusion, stupor or coma. The latter may be masking the clinical picture of an underlying cerebral pathology (e.g. brain tumor, hemorrhage, etc.), and epileptic changes can be seen in EEG recording only. Absence status epilepticus can occur in various forms of brain pathology, including stroke, brain tumors, traumatic lesions and other conditions, as well as in systemic diseases affecting the central nervous system function. Therefore, the authors emphasize the importance of electroencephalography in severely ill and unconscious patients, as well as the role of proper anti-epileptic treatment, as this may improve the outcome.

[Stiff man syndrome successfully controlled with glucocorticoids and GABA-ergic drug administration: case report]

The stiff man syndrome is a rare CNS disease of a probably autoimmunologic etiology. The paper presents a case of a 45-year-old man hospitalized in our department of neurology because of trunk muscles rigidity and painful, paroxysmal, immobilizing muscle spasms with excessive sweating. On the neurological examination he presented with a restricted range of active movements of the trunk, increased muscle tone in the shoulder girdle, abdominal and paraspinal muscles, as well as lumbar hyperlordosis. The electromyographic needle examination revealed in all his trunk muscles an excess, continuous motor unit activity at rest, diminishing after benzodiazepine administration. This confirmed our initial diagnosis based on clinical symptoms and signs. No abnormalities were found in other examinations, including the cerebrospinal fluid analysis, CT of the brain, and the spinal cord MRI. The patient was treated with glucocorticoids and GABA-ergic drugs (vigabatrin, diazepam and baclofen) with good results, i.e. a considerable amelioration of his complaints. His motor ability has increased so much that he was fully self-dependent. No deterioration in his clinical status has been noted over three years since his discharge.

[Cerebral amyloid angiopathy as a cause of strokes]

Cerebral amyloid angiopathy (CAA), a condition affecting the elderly in a way similar to that of Alzheimer's disease, results from amyloid deposition within small and medium arteries of the cerebral leptomeninges and cerebral cortex. Next to atheromatosis, amyloidosis is the second most frequent cause of cerebral haemorrhage, especially recurrent. The most recent publications suggest that amyloidosis may also cause transient ischaemic attacks (TIA), cerebral infarcts, Binswanger's type leukoencephalopathy, symptoms resembling these of cerebral pseudotumour, and other dysfunctions. A definite diagnosis of cerebral amyloid angiopathy may be determined by autopsy, and sometimes intravital cerebral biopsy is performed. A clinical diagnosis of probable CAA is based on the presence of multiple superficial haemorrhages in the elderly people without hypertension. No CAA treatment methods are known yet. However, to prevent haemorrhages in CAA it is important that anticoagulants and antiplatelet drugs should be avoided in the treatment of cerebral and other ischaemic disorders, because of an increased risk for haemorrhage.

[Cognitive deficits in progressive supranuclear palsy]

Progressive supranuclear palsy (PSP) is one of the most frequent causes of an atypical parkinsonism. The cognitive disturbances in PSP gave rise to the term "subcortical dementia". Cognitive impairment is independent of depression, which is also common in PSP. There is no correlation between cognitive impairment and either disease duration or a level of physical disability. We present a clinical picture and difficulties in PSP diagnosis in three patients--63 to 74 years old, who were hospitalized in the Department of Neurology, Medical Academy in Bialystok. A neuropsychological evaluation revealed significant differences among those patients. The patients presented with: 1. depressive and dementive syndrome, 2. executive dysfunction, 3. slowed information processing with no signs of dementia. Our findings are similar with data presented in literature and confirm the observations that: 1. there is a difference in a degree of cognitive impairment in between the patients with PSP, 2. the most frequent cognitive disturbances in PSP patients are: slowness of thought process and executive dysfunction.

[Wearing off phenomenon presenting with features of paroxysmal abdominal pain]

Degenerative process in Parkinson's disease affects substantia nigra and other central structures of an extrapyramidal system but it can also affect central and peripheral autonomic centres. One of the most frequent late complications in levodopa therapy is a wearing off phenomenon. We present a patient treated for Parkinson's disease in whom during the period of levodopa wearing off we observed a paroxysmal abdominalgia apart from other features of a typical movement disorders like: increasing rigidity, gait disturbances and tremor. Abdominalgia consisted of stomach cramps, with variable localization in epi-, meso- and hypogastrium. Rectal tenesmus was also present. The patient was treated with analgesics, spasmolytics and carminative drugs with no effect. Abdominal pains regressed after an intake of the next levodopa dose. The patient presented with other features of a gastrointestinal tract autonomic system dysfunction like: chronic constipation, preterm satiety resulting in food intake reduction and a decrease in body weight. There was no organic lesions of the gastrointestinal system that could explain such disturbances. Pharmacologic treatment modification (more frequent levodopa dosage, additional dopamine agonist) resulted in some improvement.

CONCLUSION

It is possible that the abdominal pains could be a clinical manifestation of a digestive tract dyskinesias, occurring during

[Effect of methylprednisolone on emotional functioning of patients with multiple sclerosis]

The effects were examined of high doses of intravenous methylprednisolone (MP; 1 g daily, administered for 5 days) on emotional functions in multiple sclerosis (MS) patients with clinical relapse. Thirty two patients with relapsing-remitting disease were included. The mean age was 39.4 (20-56) years, mean disease duration and mean Expanded Disability Status Scale scores were 6.6 (0.8-28) years and 4.1 (2-6.5), respectively. MS patients were subjected twice to psychological tests: immediately after MP treatment and 6 months later. Hamilton Rating Scale for Depression (HRSD) and Hopkins Symptom Check List (HSCL) were used. Thirty two control subjects (mean age 37.2 years) with ischialgia, not receiving steroids, underwent the same testing procedure. On the basis of their results in learning tests (Nonverbal Learning Test and Rey Auditory Verbal Learning Test) upon admission, MS subjects were allocated into 2 different subgroups: 20 patients were included into cognitively preserved group (cpMS) and 12 patient into the group with cognitive decline (cdMS). Immediately after MP treatment, MS patients (total group) achieved significantly higher scores than controls on the HRSD and two subclasses of the HSCL: depression with inhibition and phobic anxiety. There were no significant differences between cpMS and control subjects in HRSD and HSCL tests. CdMS patients, as compared with controls and cpMS subjects upon admission showed depressed mood, obsessive-compulsive disorder, increased anxiety and interpersonal hypersensitivity. Therapy with MP did not markedly change emotional functions in all MS patients (total group, cpMS, cdMS).

CONCLUSIONS

1. Only cdMS patients show emotional disturbances. 2. Therapy with MP does not significantly change the emotional profile of MS patients.

[Neuropsychological deficits after surgical repair of anterior communicating artery aneurysm]

Based on the review of literature we tried to establish the pattern and dynamic of psychoneurological disturbances as a result of rupture and surgical procedures of anterior communicating artery (ACoA) aneurysm in three aspects: pathoanatomy, pathophysiology and rehabilitation. Anterior communicating artery syndrome (amnesia, confabulation, personality changes) was observed in very few patients, especially in those after clipping of an anterior communicating artery (trapping). Mostly neuropsychological pattern consisted of anterograde memory problems, executive dysfunctions, global attention impairments, confabulations and personality changes. Neuropsychological deficits observed in ACoA patients were probably a result of basal forebrain lesions. The precise analysis of the disturbances is necessary especially in the early stage. Proper cognitive rehabilitation of attention and memory functions is recommended to improve professional and daily living activities.

[Idiopathic autonomic neuropathy (pandysautonomia)]

On the basis of current literature, clinical and neuropathologic features of idiopathic autonomic neuropathy is presented. Idiopathic autonomic neuropathy is a disease characterized by acute or subacute onset, monophasic course over a period of several years, it is often preceded by an infection. The spectrum of autonomic changes ranges from cholinergic or adrenergic dysfunction to pandysautonomia, leading to heterogeneity of its clinical features. Possible sympathetic system abnormalities found in autonomic neuropathy are: poor pupillary response to light in darkness, orthostatic hypotension leading to syncope, hypotension without compensatory tachycardia, ejaculation disturbances and vasomotor instability. Possible parasympathetic dysfunctions are: salivation and lacrimation disturbances, absent pupillary constriction to light and near gaze, gastrointestinal tract immobility and impairment of gastrointestinal function, atonic bladder with large residual volume, erectile impotence. Pandysautonomia is thought to result from an immune mediated mechanism and responds well to plasmaferesis and intravenous immunoglobin therapy leading to gradual, sometimes not full, recovery. Moreover in this article we pay attention to the clinical value of many tests like cardiovascular or pharmacological studies in the diagnosis of pandysautonomia and in differentiation of pre- and postganglionic changes. In order to diagnose idiopathic autonomic neuropathy one has to rule out a large number of diseases with autonomic dysfunction e.g.: diabetes, malignant neoplasms, acute intermittent porphyria, Shy-Drager syndrome, Riley-Day's dysautonomia, Parkinson's disease, amyloidosis and others.

[Post lumbar puncture syndrome and the manner of needle insertion]

We have analysed the correlation between the direction of needle bevel insertion and the occurrence of post-puncture syndrome appearing after diagnostic lumbar puncture. Post-puncture headache was observed in 38 of 380 patients (13.6%). The syndrome occurred in 11 patients (7.9%) in whom the needle bevel had been inserted parallel to the patient's backbone and in 27 patients (19.3%) in whom the needle bevel had been inserted perpendicularly to the backbone. The complications after lumbar puncture could be reduced by inserting the needle bevel parallel to the patient's backbone.