The inflammatory reaction following 1-methyl-4-phenyl-1,2,3, 6-tetrahydropyridine intoxication in mouse

In degenerative disorders of the CNS an immune system involvement in the pathological process is postulated. The MPTP model of Parkinson's disease seem to be a good model for studying an inflammation following toxic neurodegeneration. In this model, microglial and astroglial reactions were previously found around impaired neurons. In the present work we showed an immune reaction, including lymphocytic infiltration of CD4+ and CD8+ T cells in the substantia nigra and striatum and elevated MHC class I and II antigens expression on microglia. Many activated lymphocytes were present, showing increased LFA-1 and CD44 antigen expression. We found also that ICAM-1 expression increased on the endothelium and appeared on microglia in the injured regions. Treatment with dexamethasone inhibited T-cell infiltration and MHC class II expression, lessened the glial reaction, and also diminished neuronal impairment. These findings suggest that an immune mechanism may contribute to the neuronal damage following MPTP administration.

Microglial reaction in MPTP (1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine) induced Parkinson's disease mice model

We studied the microglial reaction in mice using the 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP)-induced model for Parkinson's disease (PD). Microglial cells were identified by means of the Griffonia simplicifolia lectin (GSA-I-B4). Dopaminergic neurons were marked by tyrosine hydroxylase antibodies. Microglial activation was demonstrated by an increase in cellular number and changes of morphology (increased lectin staining, larger cell bodies and thicker processes) were seen in the substantia nigra from the 1st to the 14th day and in the striatum from the 1st to the 4th day after intoxication. Depletion of dopaminergic neurons was most pronounced 7 and 14 days following the treatment. The results suggest that microglial activation may be involved in the sequence of pathological changes that lead to dopaminergic neuronal damage after MPTP intoxication.

Microglial and astrocytic involvement in a murine model of Parkinson's disease induced by 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP)

We have studied the reaction of glial cells in mice treated with an intraperitoneal administration of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP), a selective neurotoxin of dopaminergic nigrostriatal neurons. Signs of injury to the dopaminergic neurons started on the 1st day after MPTP administration and progressed up to the end of the observation time (21st day). A transient microglial reaction was demonstrated from the 1st until the 14th day in the substantia nigra (SN) and striatum. The cells showed an increase in number and changes in morphology. At the ultrastructural level, signs of phagocytosis and features indicating the secretion of biologically active substances were observed. Astrocytosis followed the microglial reaction by one day and was noticed until the end of the observation time. Interleukin-6 immunoreactivity was observed within microglia and astrocytes in the SN on days 2 and 3. There were no signs of depletion of dopaminergic cells or glial activation after the administration of MPTP simultaneously with pargyline, an inhibitor of monoamine oxidase-B that prevents MPTP neurotoxicity. Our study indicates that microglia and astrocytes are involved in the pathological process in the nigrostriatal system following MPTP administration. MPTP alone is not responsible for glial cell activation but its metabolite MPP+ and/or agents released by injured neurons may participate in this process.

Frameshift and nonsense mutations in the gene for ATPase7B are associated with severe impairment of copper metabolism and with an early clinical manifestation of Wilson's disease

Wilson's disease (WD) is an autosomal recessive disorder of copper metabolism. The clinical phenotype of the disease is varied. It is proposed that this variation may be a result of differential functional disruption of ATPase7B (ATP7B) resulting from mutations in the gene ATP7B. We aimed to assess the relationship between specific mutational defects in ATP7B and divergence in the phenotypic expression of WD. One hundred and forty-two patients with clinically, biochemically and genetically diagnosed WD were included in the study. The phenotypic expression of WD was compared between patients with different types of mutations in ATP7B, detected by direct sequencing of exons 1-21 of the gene. Twenty-six mutations were identified in ATP7B; eleven of them were mutations predicted to result in the absence of a full-length normal protein [frameshift/nonsense mutations; classified as 'severe' mutations (SMs)], 14 were missense mutations (MMs) and one was a splice site mutation. Patients with one or two SMs on their alleles had lower serum copper and ceruloplasmin and were younger when the first symptoms of the disease appeared, compared with individuals with two MMs. The effect of SMs on the WD phenotype was dose-dependent. It is concluded that mutations within ATP7B are very heterogeneous. Frameshift and nonsense mutations are associated with a severe phenotype of WD.

D-penicillamine versus zinc sulfate as first-line therapy for Wilson's disease

BACKGROUND AND PURPOSE

To compare the course of treatment in patients with symptomatic Wilson's disease (WD) receiving either D-penicillamine (DPA) or zinc sulfate (ZS) as first-line therapy.

METHODS

In all, 143 consecutive patients diagnosed with symptomatic WD from January 2005 to December 2009, followed until December 2010, were included. The decision about first-line therapy was made individually after discussion with the patient. Physicians had no clear preference of one drug over the other. Data were analyzed in subgroups with predominantly neurological (DPA, 35; ZS, 21) and hepatic (DPA, 36; ZS, 51) presentation of WD.

RESULTS

According to Kaplan-Meier analysis, neurological WD patients scheduled for DPA had a similar probability of not remaining on first-line therapy as patients receiving ZS (20% vs. 24% at the end of follow-up), with adjusted odds ratio (OR) of 0.9 (95% CI 0.2-3.5). In patients with hepatic WD, this probability was significantly higher for DPA (31% vs. 12%; adjusted OR 3.0, 95% CI 0.9-9.9), especially in the first 6 months. Early worsening occurred only in neurological WD patients, with no differences between both treatment groups (35% vs. 19%; OR 2.8, 95% CI 0.7-10.8). Neurological improvement and decrease of liver enzymes were achieved with similar frequency. Compliance with DPA was better in hepatic (97% vs. 80%) but not in neurological patients (91% vs. 81%). Drug adverse effects were more common on DPA (15% vs. 3%).

CONCLUSIONS

DPA and ZS are effective in the majority of WD patients. Neither therapy appears to be clearly superior. Therefore ZS may be considered a reasonable alternative to DPA as a first-line therapy.

Wilson’s disease—cause of mortality in 164 patients during 1992–2003 observation period

We studied the cause of death in a consecutive series of 164 patients with Wilson's disease (WD) diagnosed over an 11 year period. A total of 20 [12% (95% CI 10.3-16.0)] died during the observation period. The relative survival rate of all patients in our group was statistically smaller than in Polish population. The main cause of death was the diagnosis in advanced stage of disease, but in six patients presenting with mild signs, we observed the progression of the disease despite treatment. There was no difference in mortality rate in patients treated with d-penicillamine or zinc sulphate as initial therapy. The prognosis for survival in the majority of WD patients is favourable, provided that therapy is introduced early.

Indomethacin protects against neurodegeneration caused by MPTP intoxication in mice

The anti-inflammatory agents are postulated to be effective in treating neurodegenerative disorders. In this study, we showed that indomethacin (IND) in the dose of 1 mg/kg protected neurons against toxic damage caused by 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) in mice model of Parkinson's disease. IND also diminished microglial activation and lymphocytic infiltration in the injured areas. These observations suggest that anti-inflammatory properties of IND may play a role in the neuron's protection in this model. However, diminished inflammatory reaction may be secondary to less neuronal damage.

Compliant treatment with anti-copper agents prevents clinically overt Wilson's disease in pre-symptomatic patients

BACKGROUND AND PURPOSE

Wilson's disease (WD) is an inherited copper metabolism disorder that leads to dysfunction of affected tissues, mostly in the liver and brain. Anti-copper treatment should prevent clinically overt WD in pre-symptomatic patients but this has not been supported by strong evidence. Our aim was to evaluate the long-term effectiveness of treatment in clinically pre-symptomatic patients, with particular emphasis on patient compliance with treatment.

METHODS

Data were analyzed for 87 consecutive patients with no clinical symptoms of WD who were identified between 1957 and 2009 by family screening. All of them since diagnosis were treated with either zinc sulphate (Zn) (66.7%) or D-penicillamine (DPA) (33.3%).

RESULTS

During a median follow-up of 12 years (range 3-52), 55 (63%) patients remained without clinical symptoms, 13 (15%) developed neuropsychiatric symptoms and 21 (24%) developed hepatic dysfunction, including five deaths from hepatic failure. Non-compliance for at least three consecutive months was observed in 39 patients, and in 29 cases this extended for more than 12 months. Multivariate analysis showed that the odds of developing symptomatic WD were independently increased by non-compliance (odds ratio 24.0, 95% confidence interval 6.0-99.0). According to Kaplan-Meier analysis patients who were compliant to treatment had a significantly higher likelihood of remaining symptom-free, and their overall survival was similar to the survival rate observed in the general population.

CONCLUSION

The use of anti-copper agents in clinically pre-symptomatic patients diagnosed with WD allows clinically overt disease to be effectively prevented. However, compliance with therapy is extremely important.

Immunological observations on patients with acute cerebral vascular disease

Cell-mediated and humoral immunity was studied in 74 patients with acute cerebral vascular disease. During the first two days after the onset of disease marked changes of cell-mediated immunity were observed, manifested as a decrease in total lymphocyte count in the peripheral blood, decrease in number of T lymphocytes, depression in lymphocyte blastogenesis and production of the migration inhibition factor, and a delayed-type skin reactivity. The changes were most evident in patients with severe lesions of brain tissue resulting from primary cerebral haemorrhage and cerebral infarction with fatal outcome. In the group of patients with cerebral infarction with improvement of neurological symptoms the immunological changes were not so pronounced as in the two above-mentioned groups, the smallest changes being found in patients with subarachnoid haemorrhage. We suppose that the depression in the immunne function was caused by severe stress during the course of disease. Impairment of the immune function may increase susceptibility to infection. The humoral immune response was not so evidently changed, and the observed increase of IgA in the sera was probably present before the stroke. In cases with good clinical course some improvement in the immunological parameters was observed, but full recovery did not occur until 3 weeks after the onset of disease.

New approach to the rehabilitation of post-stroke focal cognitive syndrome: effect of levodopa combined with speech and language therapy on functional recovery from aphasia

OBJECTIVE

Few studies confirm that pharmacological treatments support post-stroke recovery. The purpose of this study was to determine whether the combination of levodopa with language therapy improves aphasia rehabilitation.

METHODS

We did a prospective, randomized, placebo-controlled, double-blind study in which twenty patients received levodopa before each language therapy session, and an additional 19 received a placebo. Language training was provided during a 3-week period. The efficacy variables were changes from baseline in Boston Diagnostic Aphasia Examination (BDAE) scores.

RESULTS

Patients receiving levodopa experienced greater language improvement in verbal fluency and repetition, compared to patients receiving placebo. Improvement was particularly distinct in patients with anterior lesions.

CONCLUSIONS

Supplementing language therapy with levodopa may improve recovery from aphasia in patients with frontal lesions.

Procreation ability in Wilson's disease

OBJECTIVES

The clinical manifestations of Wilson's disease (WD) take the form of hepatic, neurological, renal as well as hormonal disturbances. Infertility and amenorrhea are reported in women and hypogonadism in men with WD. Our study was designed to analyse the procreation abilities of patients with WD.

MATERIAL AND METHODS

We investigated by a questionnaire the course of pregnancy and delivery in 31 untreated women (mean age 22.5 years, 82 pregnancies) and 15 women (mean age 26.2, 25 pregnancies,) treated with D-penicillamine (D-p) or zinc sulphate (ZnS). We studied also procreation ability of 27 men (mean age 27.2 years). We analysed the congenital abnormalities and frequency of WD in children of our patients.

RESULTS

One of 10 untreated women had difficulties with conception. The number and type of pathology (imminent abortions, gestosis, stillbirth, preterm births) were similar in treated and untreated patients. In both mentioned groups the most frequent pathology were spontaneous abortions, which were found in 26% of untreated and in 26.6% of treated women. This percentage is higher than in general population. Most of deliveries in patients with WD were spontaneous. Neither developmental malformations nor serious disorders were noticed in the offspring of our treated patients, 3 children of untreated patients were born with congenital heart disease. In 78 of the 110 children of our patients we examined the copper metabolism and we diagnosed WD in 5 cases (from 3 families). Among 27 investigated men only 1 was impotent.

CONCLUSION

The risk of complications during pregnancy in asymptomatic and treated patients is higher than in general population, but it does not make the procreation impossible.

Brain metal accumulation in Wilson's disease

INTRODUCTION

Brain metal accumulation is suggested in the pathogenesis of numerous neurodegenerative disorders. In Wilson's disease (WD), only copper has been examined. The aim of the present study was to evaluate the copper, iron, manganese, and zinc concentrations in autopsy tissue samples from the brains of WD patients.

METHODS

The study material consisted of 17 brains (12 WD patients, 5 controls) obtained at autopsy. Samples were taken from four different regions of each brain: frontal cortex, putamen, pons, and nucleus dentatus. The copper, manganese, and zinc content were determined using inductively coupled plasma mass spectrometry, and iron was assessed using flame atomic absorption spectroscopy. The results were analyzed according to select clinical variables.

RESULTS

Copper content was increased homogenously in all investigated structures of the WD brains compared to controls (41.0 ± 18.6 μg/g vs.5.4 ± 1.8 μg/g; P<0.01). The mean concentrations of iron, manganese, and zinc were similar in WD and controls, but the iron level in the nucleus dentatus was higher in WD compared to controls (56.8 ± 14.1 μg/g vs. 32.6 ± 6.0 μg/g; P<0.05). Gender, age, and type and duration of WD treatment did not impact brain metals storage, but some correlations between the duration of the disease and copper and iron accumulation were observed.

CONCLUSIONS

During the course of WD, copper accumulates equally in different parts of the brain. Zinc and manganese do not seem to be involved in WD pathology, but increased levels of iron were found in the nucleus dentatus. Thus, additional studies of brain iron accumulation in WD are needed.

Apolipoprotein E gene (APOE) genotype in Wilson's disease: impact on clinical presentation

BACKGROUND

Wilson's disease (WD), an inherited copper metabolism disorder that leads to pathological tissue copper accumulation and secondary organ damage, is caused by mutations in the ATP-ase 7B gene (ATP7B). The apolipoprotein E gene (APOE) alleles ε2, ε3, and ε4 produce three different apoE isoforms with different biological effects, which can determine risks of many human diseases, including neurodegenerative and liver disease. This study aimed to evaluate the impact of APOE genotype on the variability of WD phenotypic expression.

METHODS

We analyzed data on 383 WD consecutive patients in the WD registry. The APOE genotypes (APOE ε3/ε3 (wild-type), APOE ε2-positive, and APOE ε4-positive) were determined and the APOE genotype effect on the phenotypic WD presentation was assessed in all symptomatic WD patients, as well as in patient subgroups divided according to sex and ATP7B genotype.

RESULTS

APOE genotype had no impact on WD presentation in the general population of symptomatic patients. However, APOE ε4-positive women tended to present WD symptoms earlier than women possessing the wild-type APOE ε3/ε3 genotype (24.2 vs. 27.9 years; p = 0.08). The effect of the APOE ε4-positive genotype was more pronounced in ATP7B p.H1069Q homozygous women, in whom disease symptoms started almost 6 years earlier (23.6 vs. 29.9 years; p < 0.05) than in APOE ε3/ε3 women.

CONCLUSIONS

In women, APOE ε4-positive genotype is associated with earlier onset of WD symptoms, particularly among ATP7B p.H1069Q homozygous patients. Further studies are needed to understand the mechanisms of these gender-dependent phenotypic effects.

Elevated levels of anti-heat shock protein antibodies in patients with cerebral ischemia

One of the important mechanisms involved in the development of vascular lesions leading to ischemic stroke could be an immune response to heat shock proteins (hsp). For carotid atherosclerosis and myocardial infarction, an association with an increase in anti-hsp 65 antibodies has been demonstrated. The aim of our study was (1) to investigate whether ischemic stroke is associated with a humoral immune response to hsp; (2) to study the connection between anti-hsp antibodies and other stroke risk factors; (3) to estimate if the elevated levels of anti-hsp antibodies could be an independent risk factor for stroke. We examined 180 patients (in the first 48 h after stroke onset) and 64 age-matched healthy controls. The levels of IgG and IgM antibodies to hsp 65 and 70 were measured by ELISA. Ischemic stroke was connected with a significant elevation of anti-hsp 65 and anti-hsp 70 antibody levels (IgG and IgM) compared with controls (p < 0.0001). The multifactorial logistic regression analysis showed that increased levels of anti-hsp 65 and anti-hsp 70 IgG antibodies are independent risk factors for stroke. Our results suggest that humoral immunity to hsp is common in stroke patients and that elevated levels of anti-hsp antibodies could be triggering factors for stroke.

Basic analytical parameters as the predictive factors for 30-day case fatality rate in stroke

In a prospective population-based study, analyses were performed to evaluate the 30-day case fatality in stroke as related to the following factors: hematocrit (HCT), hemoglobin (Hgb), red blood cells (RBC), mean cell volume (MCV), platelet count, erythrocyte sedimentation rate (ESR), white blood cells (WBC) and glucose concentration. We studied 345 patients with stroke, 170 men and 175 women, mean age 68.4 +/- 14.2 years, admitted within 72 h of stroke onset. Patients who died had significantly higher mean values of ESR, WBC, HCT and glucose concentration than the patients who survived. Logistic regression analysis revealed that ESR, HCT and WBC are independent factors predicting 30-day case fatality. The odds ratio (OR) for ESR was 1.006 (95% CI 1.0002-1.011), for HCT 1.04 (95% CI 1.01-1.07), for WBC 1.03 (95% CI 1.01-1.05). Glucose concentration after adjusting for the severity of neural deficit did not become an independent predictor.

Increased expression of adhesion molecule CD18 (LFA-1beta) on the leukocytes of peripheral blood in patients with acute ischemic stroke

OBJECTIVES

The aim of this study was to investigate whether adhesion molecules play a role in acute ischemic stroke.

MATERIAL AND METHODS

Using immunofluorescence phenotyping and flow cytometry, the expression of leukocyte adhesion molecules CD54, CD11a, CD11b and CD18 in peripheral blood were measured within 12 h after onset of ischemia in 20 patients with stroke. Follow-up measurements were performed at 7 and 30 days after ictus.

RESULTS

CD18 immunofluorescence was significantly increased on the leukocytes within 12 h after onset in patients with stroke compared with the age-matched control group (20 patients with other neurological diseases). Follow-up measurement of CD18 revealed normal results as found in the control group.

CONCLUSION

Our data support the idea that adhesion molecules are involved in tissue injury in ischemic stroke.

The role of the hippocampus and 5-HT/GABA interaction in the central effects of benzodiazepine receptor ligands

The effects of an intrahippocampal administering of a nonselective full (midazolam), a partial benzodiazepine (BDZ) receptor agonist (bretazenil), and a BDZ1 selective (zolpidem) receptor ligand were examined in the open field test (OFT) of neophobia and Vogel's test (VT) of conflict behavior in rats. Moreover, the influence of local injections of a noncompetitive GABA(A) receptor antagonist, picrotoxin, on the anxiolytic-like effect of serotonin (5-HT) depletion (p-chlorophenylalanine, p-CPA) in the Vogel test was studied. It was found that in the OFT only midazolam (0.1 microg/site) given to the hippocampus (HP) disinhibited rat exploratory behavior, whereas all the examined compounds inhibited animal motor activity when injected locally at 10.0 microg/site, the highest dose used in the tests. In the VT, again, only midazolam disinhibited rat conflict behavior on a dose-dependent basis. Picrotoxin administered to the HP produced a tendency to increase locomotor activity in rats, and significantly attenuated the anti-conflict action of serotonin depletion without changing the pain threshold and spontaneous drinking of the animals. p-CPA induced potent, dose-dependent and selective 5-HT and 5-hydroxyindoleacetic acid decrease in the HP after administering the dose used in the behavioral experiment. Thus, the present data provide evidence for the lack of selective anxiolytic activity of a partial non-selective agonist and a full selective agonist at the BDZ1 receptor after their administration to the HP. The model of intra-HP drug injections appeared effective in discriminating the anxiolytic spectrum of activity of new psychotropic compounds. Moreover, the obtained results indicate that the dorsal HP is one of the central sites important for GABA/5-HT interaction that modulates rat emotional behavior.

The effect of gender on brain MRI pathology in Wilson's disease

Gender influence on the clinical manifestations of Wilson's Disease (WD) has been suggested; however, brain MRI pathology based on sexual dimorphism in WD has not yet been examined. The aim of this study was to analyse the effect of gender on brain MRI pathology according to the predominant form of WD. We retrospectively analysed the brain MR images of 204 newly diagnosed and untreated WD patients. The predominant form of the disease was neuropsychiatric (n = 105), hepatic (n = 67) or presymptomatic (n = 32). Overall, neuroimaging pathologies were found in 64.2 % WD patients. The clinical form analysis revealed significant gender-related differences. In the neuropsychiatric form, men presented with cerebellar atrophy and cortical brain atrophy more often than women (25/58 vs. 11/47; p < 0.05) and (23/58 vs. 12/47; p = 0.09), respectively. In contrast, women tended to present with globus pallidus lesions more often than men (25/47 vs. 20/58; p = 0.054). There were no gender differences observed in the hepatic form, but cortical brain atrophy presented more often in men than women (3/12 vs. 0/20; p < 0.05) in the presymptomatic form. According to our findings, there is a gender-dependent brain vulnerability to copper toxicity. We speculate that these differences are potentially related to an oestrogen protective effect and are due to differences in gender-related clinical forms.

The immune response during aging

Complex studies were carried out on humoral and cell mediated immunity among persons over 60 years of age and persons aged 18-40. Humoral immune responses were not profoundly disturbed in the group of older persons. The level of isoagglutinins was lower in older subjects, but the level of immunoglobulins and antibodies to widespread bacterial and virus antigens (S. typhi O, Kunin's CA, Parainfluenza types I, II and III) was the same in both groups. Cell mediated immunity was more greatly changed. Response to PPD in skin tests, lymphocyte stimulation tests, and the migration inhibition test was reduced in older subjects. Also, in this group, PHA in lymphocyte stimulation tests and the number of E- rosette forming cells was lower than among younger adults. However, responses to other antigens in skin tests, lymphocyte stimulation tests, migration inhibition tests (Candida albicans, SK-SD, Trichophyton) and responses to other stimulants of the lymphocyte stimulation tests (Con A, PWM) were well preserved in older subjects.

The impact of age and gender on the striatal astrocytes activation in murine model of Parkinson's disease

OBJECTIVE

The aim of the present study was to determine how aging and gender influence the response of astrocytes to 1-methyl-4-phenyl-1,2,3,6-tetrahydropiridine (MPTP) intoxication.

MATERIALS AND METHODS

To asses the MPTP-induced astrocytes activation in nigro-striatal system, we measured the temporal changes in mRNA and protein expression of the specific astrocytic marker, glial fibrillary acidic protein (GFAP; by RT-PCR and Western blot), in the striatum of male and female C57BL/6 mice (2 and 12-month old) after 6 h and 1, 3, 7, 14 and 21 days post-intoxication.

RESULTS

We observed the increases of GFAP mRNA level post-MPTP intoxication in both young and aging males only at early time points, whereas in females (both ages) also at later time points. We noticed maximal increase of GFAP protein content on the 3rd day post-intoxication in young and aged males, whereas in females at the 7-daytime point.

CONCLUSIONS

The present results provide additional information of potential relevance to understand the mechanisms of gender and age-related difference in susceptibility of nigro-striatal system to MPTP insult.

Immunological changes in the MPTP-induced Parkinson's disease mouse model

The role of the central dopaminergic system in modulating immune response is not completely established. We examined the influence of central dopamine depletion on selected parameters of immune functions in 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) treated and untreated mice. IgM antibody production of splenocytes to sheep red blood cells was reduced in MPTP-treated mice (P < 0.001). Proliferation of splenocytes in response to a wide range of mitogen concentrations (Concanavalin A, phytohaemagglutinin, lipopolysaccharide) was also significantly diminished in MPTP-treated mice. Production of migration inhibition factor (MIF) was diminished only in low mitogen concentration. Our results obtained in the experimental model of Parkinson's disease provide evidence that the damage of the central dopaminergic pathways induces alterations of some immune functions in mice.

Eligibility of stroke units in Poland for administration of intravenous thrombolysis

Systemic thrombolysis treatment was approved in Poland in 2003 and should be performed in specialist stroke units (SU). We performed a survey to determine stroke service preparedness for thrombolysis treatment in Poland. We sent a questionnaire evaluating the neurological departments in Poland, where stroke patients are treated. We divided them into four categories: (i) class A SU (fulfilling criteria of the National Program for Stroke Prevention and Therapy and European Stroke Initiative guidelines), (ii) class B (conditionally fulfilling criteria), (iii) class C (not fulfilling criteria), and (iv) departments without SU. Only class A units are eligible for implementing thrombolysis. We obtained response from 194 of 222 (87.4%) departments; 90 (46.4%) declared having an SU. According to criteria, 20 class A, 56 class B, 14 class C. During one year, 71 208 patients were admitted to hospitals; 69,982 (98.2%) to neurological departments. A total of 10,959 (15.4%) were treated in class A SU, 23,650 (33.2%) in class B, 5153 (7.2%) in class C, whereas 30,220 (42.4%) in neurological departments without SU. Our survey showed that only 15.4% stroke patients in Poland are admitted to high-quality SU, where thrombolysis may potentially be administered. Improvement of SU quality in Poland is necessary for wide implementation of new methods of stroke therapy.

Late onset of Wilson's disease. Report of a family

Five cases of Wilson's disease were diagnosed in a family of eight siblings. All of them had Kayser-Fleischer rings. The first neurologic symptoms appeared in one person at age 46 years; in another, psychotic symptoms appeared at age 38 years; and in one patient, jaundice was noted at age 40 years. Two other persons, aged 53 and 43 years, were still without hepatic, neurologic, or psychiatric symptoms of the disease at the time of writing. The family described is very atypical with regard to the age at onset of Wilson's disease.