[Ischemic manifestation of adult moyamoya disease: a case report]

Moyamoya disease is a chronic non-inflammatory cerebrovascular steno-occlusive disorder of unknown origin, with a typical pattern of collateral netlike vessels visualized in angiography. In Poland it is a relatively rare condition. A case of a 44-year-old non-Japanese woman with moyamoya disease is presented. Ischemic manifestation of the disease, rather uncommon in adults, and a long asymptomatic post-operative period are discussed.

An evaluation of the reproducibility of the measurement of the intima-media thickness of carotid arteries

The intima-media thickness (IMT) of carotid arteries was demonstrated to be a reliable measure for early stages of atherosclerosis. B-mode ultrasound may be used to measure carotid IMT. The measurements of the IMT of the carotid artery (CA) conducted by different investigators can be comparable and enable the implementation of clinical trial successfully while maintaining a high reproducibility value. The objective of the study was to evaluate the reproducibility of the measurements made by the same investigator on two separate occasions (intraobserver variability) and the reproducibility of the off-line measurements between four sonographers in our laboratory (interobserver variability). The IMT of CA in 25 subjects (15 post stroke and 10 healthy persons) was investigated with the use of high-resolution ultrasonography. The CA subdivided into the common, bulbs and internal segments were scanned twice with a 3-week interval. Additionally three other readers with different levels of experience and skills in ultrasonography were asked to perform the same measurements in duplicate with at least a 3-week interval between. A high concurrence for intraobserver variability was detected with a correlation coefficient ranging from 0.92 to 0.95; p < 0.0001, and maximal bias 0.019 mm. Interobserver variability for all four readers also demonstrated a high correlation coefficient ranging from 0.72 to 0.83; p < 0.0001, and the maximal bias of measurements did not exceed 0.08 mm. The analogue measurements performed by the team demonstrate a reliable reproducibility in terms of the results of morphologic measurements. The differences obtained in the study were less than the error of the method (i.e. 0.1 mm) and should not influence clinical decision-making. Additionally, this study demonstrated that interobserver concurrence increases with the increasing experience of the investigators.

[Paroxysmal focal dystonia as the initial manifestation of multiple sclerosis: case report]

Paroxysmal phenomena such as dystonia in multiple sclerosis (MS) have approximate incidence ranged between 3.8%-17%. These symptoms in MS may represent transient phenomena related to inflammation in acute plaques and probably are secondary to irritation of demyelinated axons by lymphokines. Paroxysmal dystonia can occur at any time during the course of MS, but usually is the initial manifestation of demyelinating disease. We present the case of 42-year old woman with paroxysmal dystonia as the initial symptom of MS. Further MRI studies and CSF analysis revealed findings typical for MS. Patient's neurological status improved temporary after methyloprednisolone therapy. Paroxysmal dystonia may be related to ectopic impulses, release of inflammatory soluble factors, dysfunction of ion channels and accumulation of extra-cellular potassium. Paroxysmal dystonia often causes diagnostic difficulties, especially when it is the only or the initial symptom of the disease. It requires differential diagnosis with other diseases of central nervous system such as epilepsy and neurodegenerative or inflammation pathology.

Serum autoantibodies to actin are associated with carotid artery wall adventitial thickness assessed using B-mode ultrasound

Atherosclerosis, as a chronic inflammatory condition, can be mediated by immunological reactions. Therefore, it is possibly related to a specific antigen. Because autoimmunological reactions occur during atherogenesis, it is possible that alpha-actin expression induces a specific autoimmune reaction. We determined whether the intima-media (IMT) and adventitial thickness (AT) of carotid arteries, assessed by an ultrasound method, correlate with the level of anti-actin autoantibodies (AAA) in human serum. The study involved a group of 128 patients (66 women and 62 men). The mean age was 65.0 (+/- 7.9) years. Fifty-four patients had suffered an ischaemic stroke, whereas the remaining (as controls) had no history of cerebrovascular disease. High-resolution ultrasonography was used to evaluate the IMT and AT of their common carotid arteries. The mean carotid IMT was 0.95 (+/- 0.36) mm and the mean AT was 0.94 (+/- 0.20) mm. There was a significant correlation between carotid AT and the AAA serum level (r = 0.20; p = 0.024). However, there was no association between the mean IMT and AAA serum levels in the carotid arteries (r = 0.08; p = 0.328). In this preliminary (in vivo) study, we found that the level of AAA correlated positively with ultrasonographically assessed AT during carotid atherosclerosis.

Post-stroke quality of life and depression

BACKGROUND

Studies on the determinants of the quality of life (QOL) after stroke bring differing results depending on the applied concept of QOL. This may lead to confusion about the contribution of various factors to the post-stroke QOL.

OBJECTIVE

The aim of the study was: (i) to investigate functional and psychological QOL in the individuals after the first ischemic stroke; (ii) to identify the most important correlates of QOL; and (iii) to examine the significance of depression among the other possible predictors of QOL.

METHODS

A hospital-based sample of 72 stroke patients was followed up to 6 months after stroke onset. QOL was assessed using the Polish version of the Quality of Life Index and the Sickness Impact Profile. A multiple regression procedure was performed to examine relationships between QOL and the study variables.

RESULTS

In spite of good recovery, the psychological and functional QOL of the examined patients was impaired, although the negative impact of stroke was greater on the objective QOL than on the subjective QOL. Stroke-related impairment, depression, functional disability and marital status predicted 80% of the variance in the functional QOL. Emotional support, depression and functional disability explained 38% of the variance in psychological well-being.

CONCLUSIONS

Depression and physical disability were the most important predictors of QOL after stroke since their impact on QOL was more robust in comparison to the remaining variables. For improving QOL, a comprehensive care for patients aimed at reducing physical dependence and ameliorating depressive symptoms could be recommended.

[Clinical picture of patients with Huntington's disease in relation to the number of trinucleotide CAG repeats in IT-15 gene]

Huntington's disease (HD) is a neurological condition of progressive course that results from abnormally increased number of CAG repeats within IT-15 gene, coding for huntington. The main symptoms consist of choraetic movements, dementia, and characteropathy. The aim of the present study was to search for possible correlation between the age of the onset of HD, time from the onset, clinical status of the patients, and CAG repeats number. Ten patients were studied altogether. Modified UHDRS (MUHDRS) was applied for the estimation of patients' clinical status. The number of CAG repeats in examination of the IT-15 gene was determined by polymerase chain reaction (PCR) and separation of radioisotope labelled PCR product against DNA size marker in polyacrylamide gel. A negative significant correlation was found between the CAG repeats number and the disease onset age (r = -0.67; p < 0.05) and MUHDRS score (r = 0.75; p < 0.05), as well. Negative significant correlation between time from the onset and MUHDRS score (r = -0.95; p < 0.05) and negative correlation between summarised: time from the onset and CAG number on the one site and MUHDRS on the other (p = -0.91) were found, as well. Our findings indicate an interdependence between CAG repeats number within the IT-15 gene, the course of the disease and the clinical status of HD patients.

Microtubule associated protein (tau) gene variability in patients with frontotemporal dementia

Frontotemporal dementia represents up to 10% of all dementias and is, next to Alzheimer's disease and Lewy body disease, the third most common cause of degenerative dementia. The term "frontotemporal dementia" covers a range of conditions, including Pick's disease, frontal lobe degeneration and dementia associated with motor neurone disease. Neuropathologically FTD is characterised by atrophy of the frontal and temporal lobes of the cerebral cortex, often with additional subcortical changes. Both familial and more frequently sporadic forms of FTD can be recognised. Recently, mutations in the microtubule-associated protein (tau) gene have been found in families with frontotemporal dementia and parkinsonism linked to chromosome 17 (FTDP-17). The identification of mutations in the tau gene indicates that the protein plays a central role in the process of neurodegeneration. Epidemiology of frontotemporal dementias in Poland remains still unknown. A prevalence of tau mutations among Polish patients has not been established yet. Here, we report results of a mutational analysis of the tau gene among Polish FTD patients. No pathogenic mutation was found in the analysed sample. The study confirmed that the frequency of tau mutations is very low and depends strongly on the clinical criteria used to select patients. Mutations in the tau gene account only for a small number of FTD cases with a clear autosomal dominant pattern of disease inheritance. Therefore there should exist additionalgenetic and non-genetic factors contributing to the pathogenesis of both familial (linked and non-linked to chromosome 17) and sporadic forms of FTD.

[Relationship between the concentration of antibodies to myosin heavy chains in serum and symptomatic carotid atherosclerosis]

It is believed that atherosclerosis could result from inflammatory-fibroproliferative response to various forms of injury of endothelium and smooth muscle cells of arterial wall. The aim of this study was to examine whether immunological reaction against myosin filaments of carotid artery (CA) wall smooth muscle cells is involved in atherogenesis. 43 patients (22 females) with first-ever ischaemic stroke proven by CT were investigated. The results were compared with those obtained in 40 (21 females) healthy sex- and age-matched subjects. Anti-myosin antibodies (AMA) were evaluated by solid phase radioimmunoassay using rabbit myosin heavy chains as an antigen. The intima-media thickness (IMT) of common and CA--a measure for atherosclerosis--was estimated with the use of high-resolution ultrasonography. The AMA serum concentration in stroke patients was significantly greater than in control subjects (p < 0.001). Mean IMT for CA in stroke patients was significantly increased compared with the controls (0.98 +/- 0.17 mm vs. 0.68 +/- 0.13 mm; p < 0.0001). There was a significant correlation between AMA serum antibodies concentration and IMT (r = 0.51; p < 0.001).

CONCLUSION

The significant correlation between AMA concentration and IMT of CA is the basis of the hypothesis that immunological reaction against myosin heavy chains of smooth muscle cells in CA is involved in atherogenesis.

[Effect of Chlamydia pneumoniae infection on carotid atherosclerosis development]

Recently, a growing number of epidemiological, histopathological and microbiological studies have shown that chronic Chlamydia pneumoniae (C. pneumoniae) infection accelerates the progression of atherosclerosis of carotid and cerebral arteries and thus could constitute a risk factor for stroke. We present a number of mechanisms postulated in recent papers that link C. pneumoniae infection with the development of atherosclerosis. The one most important seems to be the effect of activation of nuclear factor--kappa B and the phenomenon of antigenic mimicry between human and C. pneumoniae heat shock proteins. We also discuss the problem of immunological reaction against myosin filaments of carotid artery wall smooth muscle cells and the problem of antigenic mimicry between heavy chains of myosin filaments and antigens presented on C. pneumoniae outer membrane.

Blood platelet membrane fluidity and the exposition of membrane protein receptors in Alzheimer disease (AD) patients--preliminary Study

We estimated membrane fluidity by the (ESR) spectroscopy and the expression of membrane P-selectin and glycoproteins GP Ib alpha and GP IIb/IIIa by flow cytometry in platelets (plts) from 12 AD sufferers. In AD patients membrane fluidity was significantly increased at two different depths (p < 0.05 or less). Platelet reactivity was significantly decreased, as reflected by reduced expression of GP Ib alpha in the resting (p < 0.0001) and activated (p < 0.005) platelets, as well as the expression of P-selectin and beta 3 subunit of GP IIb/IIIa in activated platelets (p < 0.0001; p < 0.04).

Genetic analysis in patients with familial and sporadic frontotemporal dementia: two tau mutations in only familial cases and no association with apolipoprotein epsilon4

We screened for tau gene mutations among 24 Japanese (6 familial and 18 sporadic cases) and 4 Polish patients with frontotemporal dementia (FTD) using PCR-SSCP analysis followed by DNA sequencing. We identified 2 missense mutations in exon 10: N279K and P301L in 2 Japanese patients with familial FTD. Additionally 3 DNA polymorphisms: 2 known (3' exon 3 + 9, A --> G and exon 7, codon 176, G --> A) and 1 new (exon 8, codon 185, T --> C) were identified in 1 Polish patient. Tau mutations were not found in subjects with a negative family history suggesting that tau mutations do not account for most sporadic cases of FTD. We also found no association of apolipoprotein E4 allele with FTD.

[Leukocytosis in the first day of acute ischemic stroke as a prognostic factor of disease progression]

It has been reported that white blood cells (WBC) may contribute to the initiation and further development of stroke. WBC count could have influence on hemorheology, thrombosis and induction of vasoconstriction in cerebral arteries. The aim of this work was to determine whether WBC count assessed in patients with acute stroke in the first day of the disease have a predictive value for the late clinical outcomes. Peripheral WBC count was measured at the admission to the hospital in 100 consecutive patients with acute stroke. Ischemic stroke was confirmed in all patients by head CT. Neurological status was evaluated with the use of modified Rankin's Scale. We assessed the following clinical outcomes: in-hospital mortality, the lack of neurological improvement on the 21st day of disease, and the need for hospital stay longer than 21 days. Odds ratio (OR) with 95% confidence interval (95% CI) adjusted for patient's age, gender, cardiovascular diseases, diabetes mellitus and previous stroke was calculated with the use of logistic regression. OR was evaluated both for the presence of WBC count > 10.000 cells/microliter and for each 1000 leukocytes/microliter increase. WBC count greater than 10.000 cells/microliter was associated with a more than seventy-fold greater risk for death (OR--75.18; 95% CI: 8.89-635.84; p = 0.0001), nearly eight times increased risk for the no-improvement status (OR--7.78; 95% CI: 2.51-24.17; p = 0.0004) and approximately four times increased risk for the prolonged hospital stay (OR--4.20; 95% CI: 1.50-11.72; p = 0.0062). Each 1000 cell/microliter increase in WBC count at the admission was associated with increased risk for in-hospital mortality (OR--2.24; 95% CI: 1.39-3.57; p = 0.0008), no neurological improvement (OR--1.43; 95% CI: 1.15-1.76; p = 0.0009) and the need for prolonged hospitalization (OR--1.26; 95% CI: 1.07-1.49; p = 0.0066). Increased WBC count within the first 12 hours of stroke is an independent and strong risk factor for mortality, no neurological improvement, and the need for prolonged hospitalization in the course of acute ischemic stroke.

[Changes of regional cerebral blood flow in stroke patients assessed by SPECT]

The aim of our work was to evaluate changes in regional cerebral blood flow (rCBF) in patients with TIA and/or completed stroke and localisation of fotopenic foci in basal conditions and, in some cases, after stimulation pharmacological trial with acetazolamide. One hundred and fifty three patients participated in the study--105 with completed stroke and 48 with TIA. Regional CBF (rCBF) was evaluated using a single-headed rotating gamma camera (Diacam, Siemens) with high resolution collimator, after injection of 740 MBq 99mTc-HMPAO (Ceretec, Amersham). Sixteen patients with TIA underwent SPECT at baseline and after injection of acetazolamide (ACZ). Relative regional perfusion was expressed as the ratio of cerebral/cerebellar activity. In the completed stroke population, the perfusion ratios were significantly lower than those of controls and TIA at baseline (p < 0.001) and TIA after ACZ (p < 0.01).

CONCLUSIONS

This study shows a significant difference in rCBF in patients with completed stroke and/or TIA and controls. In patients with TIA and rCBF similar to that observed in controls, perfusion deficits may be visible after ACZ injection.

[Intima-media complex thickness of common carotid artery as a risk factor for stroke]

Intima-Media Thickness (IMT) of Common Carotid Artery (CCA) could be seen as the atherosclerotic risk factors' final morphological effect. We investigated the hypothesis that IMT of CCA is significantly different in sex- and age-matched groups of persons with stroke and healthy subjects. 47 patients with first-ever atherothrombotic stroke proven by CT were investigated. Patients with atrial fibrillation, valvular heart disease and left ventricular hyperthrophy were excluded. The IMT of CCA were estimated by High-Resolution B-Mode Ultrasonography. All the patients had bilateral IMT measurement within 20 mm proximal to the carotid bulb on the far wall in the anterioposterior and laterolateral plane. The results were compared with those obtained in 50 healthy sex- and age-matched subjects. We found a strong association between IMT and stroke (p < 0.0001). Mean IMT was 0.96 mm (SD 0.18) in patients and 0.70 mm (SD 0.09) in controls. The presence of atherosclerotic plaques was 0.34 and 0.08 for patients and controls respectively (p = 0.0025). IMT of CCA is strongly positively associated with the risk for stroke. The frequency of atherosclerotic plaques in CCAs is statistically significantly higher in stroke patients than in control group.

[Morphology of demyelination plaques vs cognitive and emotional disorders in multiple sclerosis patients]

The interrelationship between psychological examination and MRI findings was studied in 70 patients with MS. The cognitive and emotional functions were examined by a battery of tests: Wechsler Adult Intelligence Scale, Visual Retention Test, Hamilton Depression Scale. In MRI examination the localization, area, and the morphology of the plaques were examined. According to plaque's morphology the patients were divided into two groups: with confluent plaques and those with patchy-shaped ones. The signs of dementia were found significantly more frequently in the group with confluent plaques (p. < 0.04). In this group of patients also single-function disorders like disturbances of verbal memory, attention, visual memory, cause- and effect thinking, abstract thinking, and visual-motor coordination were significantly more frequent (p. < 0.01). In the same group the signs of fatigue syndrome were more frequently encountered (p. < 0.02). The authors conclude that the disturbances found in cognitive function may reflect the symptoms of subcortical dementia in MS patients.

Immunofluorescent analysis of antibodies against neurons in the case of paraneoplastic syndrome

The authors report clinical and neuropathological findings especially immunofluorescent detection of antineuronal antibodies in the case of paraneoplastic syndrome in course of the small-cell lung carcinoma. The clinical symptoms, observed in 48-year-old woman, covered bilateral pyramidal syndrome, cerebellar syndrome, myasthenic syndrome and impairment of the cranial nerves. Neuropathological investigation revealed paraneoplastic encephalopathy in the form of encephalitis. Immunofluorescent analysis showed brightly fluorescent neurons standing out against a dull background.

[Platelet membrane fluidity and receptor exposition in patients with Alzheimer's disease]

The majority of reports indicate that blood platelet membrane fluidity is increased in Alzheimer's disease (AD) patients. The increased membrane fluidity implies that platelet membrane receptors are less exposed to the external environment. To verify this hypothesis we tried to estimate platelet membrane fluidity at its two different depths and receptors' exposure after platelet activation in 12 AD sufferers. Platelet membrane fluidity was measured by the EPR with the use of 2 spin-labelled markers. In AD patients both "near surface" (p < 0.04) and "deeper depth" (p < 0.005) fluidity was significantly increased. The exposure of platelet granule membrane protein--P-selectin and membrane glycoprotein receptors: alpha subunit of glycoprotein Ib and beta3 subunit of GP complex IIb/IIIa were measured by flow cytometry with the use of human platelet monoclonal antibodies labelled with fluorescein and ficoerithrin. The exposure of GPIb alpha subunit was significantly decreased both in resting state (p < 0.0001) and after thrombin activation (p < 0.005). In thrombin-activated platelets the expression of P-selectin and beta3 subunit of fibrinogen receptor were also significantly decreased (p < 0.00001 and p < 0.04, respectively). The authors conclude that both platelet membrane fluidity and receptor exposure might serve as an adjunct marker of in vivo AD diagnosis.

[The effect of large dose prednisone therapy on immunological markers in multiple sclerosis]

The effect of large-dose prednisone therapy (3960 mg over 56 days) on humoral immunological markers and MRI pattern was studied in 25 patients with clinically definite multiple sclerosis. There was a decrease in levels of some studied markers (TNF in CSF, MBP level, IgG index, kappa chains in urine and kappa/creatinine ratio) after the treatment, but the differences reached statistical significance in some groups only. The decrease of total lesion area in MRI was not statistically significant. The obtained results proved clearly, that the above mentioned immunological markers might be helpful for monitoring of therapy in MS patients.

Atypical case of sporadic Creutzfeldt-Jakob disease (CJD) in a young adult

The great concern exists that new variant of CJD (nvCJD) developed as a result of exposure to bovine spongiform encephalopathy (BSE)-infected meat products. Therefore, all cases of CJD in the young, as the one of ours are the matter of interest. The 21-year-old female developed a rapid progression of pyramidal, extrapyramidal and cerebellar signs, visual loss and psychiatric symptoms, leading to death in 16 weeks. The microscopic features were: a neuronal loss accentuated in cerebral cortex with extensive astroglia proliferation and spongiform changes. Immunohistochemical staining, revealed the presence of "synaptic" deposits of PrP in the cerebral cortex and in the cerebellum. No florid amyloid plaques were present. The case was diagnosed as a sporadic CJD, with some features of Heidenhein variant (visual symptoms) and corticostriatocerebellar category. The pathological findings excluded a nv CJD which is linked with BSE.

[Controlled study of iprazochrome effectiveness (Divascan) in prophylactic treatment of migraine]

The study was designed as double blind, placebo controlled. The patients were treated with 15 mg of iprazochrome daily in three equal doses for eight weeks, or--with equal amount of placebo tablets. The effectiveness was calculated with the use of Migraine Score (MS) by Couch et. al. 44 patients completed the study. In 21 the therapy was positive: 16 out of them were treated with iprazochrome, 5--with placebo. In 23 patients the treatment was negative: 19 out of them took placebo, 4--iprazochrome. Statistical analysis showed significant influence (chi 2 test: p < 0.001; Youle coeff. = 0.88). In iprazochrome group mean decrease of MS was significant after treatment (p < 0.01), but not significantly changed in the placebo group. According to our results iprazochrome was found effective in the prophylaxis of migraine.

Porównanie skuteczności piracetamu i dekstranu 40 tys. u chorych w podeszlym wieku z niedokrwiennym udarem mózgu

Piracetam is believed to restore the metabolism of glucose and 02, and also to prevent the vasospasm of small arteries in the penumbra of ischaemic focus. Taking the above into account we tried to estimate its effect in elderly patients with stroke. The studied group consisted of 47 patients, aged 60-78 years (mean 67,4 yrs), with the first ischaemic episode. 23 patients were treated with 500 ml of Dextran 40 daily and 60 ml of placebo given separately. The rest of the patients was treated with the same dose of Dextran 40 and 12 g of Piracetam as 60 ml i.v. bolus. The neurological status of the patients was estimated using Scandinavian Neurological Stroke Scale (SNSS). In the patients treated with Dextran and placebo there were no changes in the total score of SNSS, both after 10 and 28 days, comparing with the initial status. In the patients treated with Dextran and Piracetam total SNSS score improved significantly after 10 days (p < 0.05) and the effect was increased after 28 days (p < 0.02). The effect of the treatment with Piracetam was especially accentuated in the patients with aphasia (n = 13), whose status showed the most powerful improvement both after 10 (p < 0.03) and 28 days (p < 0.02). The author believes that Piracetam instituted within the first hours after stroke might improve the neurological status of the patients, especially those with aphasia.