[Acute transverse myelitis]

Acute transverse myelitis may be caused by many factors, however, in most cases the cause cannot be clinically found, which justifies the diagnosis of "Myelitis transversa acuta" or "myelopathia transversa acuta" in such cases. The disease is inflammatory spinal demyelination, differing morphologically from multiple sclerosis. Magnetic resonance is the examination which discloses the injury of several spinal segments. The upper limit of the lesion is higher than the clinical symptoms indicate. There is protein increase and pleocytosis in the cerebrospinal fluid. In most cases the prognosis is favourable; in 33% of patients complete regression of symptoms takes place; 33% present significant improvement and 33% show permanent disability. The frequency of relapses is high and then multiple sclerosis must be suspected. There also occur cases of monophasic multiple sclerosis and relapses of the disease without other symptoms of multiple sclerosis. The treatment of choice are steroids administered in high doses.

[Achievements, disappointments and hopes in neurological therapy in the 20th century]

Only in the second half of the 20th century a breakthrough occurred in the traditional neurological therapeutic methods based up to that time mainly on bromine with valerian extract and vitamins B. Later on in that century several great discoveries were made which improved greatly the effectiveness of the neurological therapy: psychopharmacology which began with the introduction of chlorpromazine and reserpine, the use of corticosteroids for which the Nobel award was given, levodopa introduction for Parkinson's disease, non-steroid antiinflammatory agents and the demonstration of their action mechanism /also Nobel award/, immunotherapy, botulin toxin for the treatment of dystonias and thrombolytic drugs possibly the drugs of the future. The main disappointment is the broad chasm between the progress made in diagnostic methods and the low effectiveness of therapy in strokes, amyotrophic lateral sclerosis, Alzheimer's disease and other degenerative neurological diseases. Many problems arose with the introduction of levodopa changing the course and clinical pattern of Parkinson's disease. The problem of our times are the adverse effects of pharmacotherapy. The low effectiveness of the new drugs used in epilepsy is also disappointing. A hope for the future is the new direction in therapy--the use of genes and also the use of monoclonal antibodies and neurotrophic agents. It is to be expected that in the near future medicine will find effective methods for the treatment of malignant neoplasms.

[Multiple sclerosis--certain clinical and diagnostic problems]

The diagnosis of MS is based exclusively on clinical examination disclosing at least two focal lesions, repeatedly occurring recurrences and ruling out of other causes. This is the generally accepted principle based on the diagnostic criteria of Poser. The presence of the lesions can be demonstrated in clinical examinations by magnetic resonance imaging /MRI/ or the study of evoked potentials /EP/ which detect these changes in about 90% of cases of clinically certain MS. In 10% of cases the results are negative--but can this exclude MS? It happens also that MRI or EP carried out for another reason demonstrate the presence of such lesions--is it MS in such cases? The diagnosis of SM is supported by age below 40 years and the presence of at least four focal lesions in the white matter of the hemispheres. After the age of 50 years such lesions can be the consequences of vascular disease. Contrast administration makes possible the detection of new foci and their differentiation from the old ones. In 65-85% of cases the initial phase is marked by remitting course with more or less evident worsening after each exacerbation. Out of them, in 40-70% of cases the remitting course changes to secondary progressing course. In only 10% of cases the course is progressing from the beginning. The prognosis is better if the disease begins with optic nerve involvement and is worse if pyramidal or cerebellar signs appear first. CSF examination is less important than MRI or EP. In biochemical tests no sure markers of the disease are found. In the treatment of acute exacerbations steroids are still most effective. In clinically confirmed MS interferon beta given in the first 2 years is effective in 30% of cases.

[Pain--physiological or medical phenomenon]

The word "pain" is ambiguous, symbolic and it is understood differently by the patient and by the doctor or physiologist. It describes a kind of sensation evoked by harmful stimuli which is a physiological phenomenon indispensable for protection and also suffering caused by injury or disease. The second component of the phenomenon is usually not recognized--this is the reaction to pain. The primary component is centripetal and ascending to brain centers, the second is centrifugal, descending and they both form the reflex arc. This is the pain or nociceptive reflex. Commonly, when we speak of pain we mean only the centripetal part of the reflex which cannot be objectively assessed in medical practise. This part is blocked by anaesthesia before surgical procedures. The second part is the subject of a separate consideration which begins with psychic reaction to pain and pain tolerance, and suffering depend on it. The motor reaction to pain is more spectacular and possible for recording. Three types of this reaction are discerned: flight, defense and suffering expression. Nociceptive sensation is a physiological receptor-mediated sensation, while pathological pain can derive from receptors as well as from nerves /conduction pain, neuropathic differentiation pain/ or from centres/central pain. The pathological pain has clinical features making possible the recognition of its origin, its mechanism for undertaking of appropriate measures. Neuropathic pain is the one most difficult to treat. The receptor-mediated pain continues as long as the stimulus is active, the neuropathic pain is longer lasting.

[Blepharospasm and Meige's syndrome--a contribution to it's pathogenesis]

Two cases with blepharospasm followed by Meige syndrome were described. In the first magnetic resonants revealed bilateral hypodensive foci in thalamus. During the few years general dystonia has been developed after several relapses of disease diagnosed as multiple infarcts followed by aphasia, hemiparesis and asynergia. In the other one, who died, loss of neurons in striatum, especially in caudate nuclei was found. It is concluded that blepharospasm could be a syndrome of different origin and only the phase of Meige syndrome.

[Electromyography monitoring in the treatment of torticollis with botulinum toxin]

The new method of treatment chronic torticollis is injection into affected muscles botulinum's toxin. Some physicians in diagnostic procedure, treatment and monitoring use needle electromyography (nEMG). The aim of our study was the estimation of the value of nEMG in chronic torticollis treatment. We examined 34 patients with chronic torticollis 4 weeks after botulinum's toxin injection into affected muscles. We have been looking for denervations signs in affected muscles. We found denervations signs in 26 patients. In both muscles sterno-cleido-mastoideus and trapezius we found denervations signs in 13 patients, only in sterno-cleido-mastoideus muscles in 9 patients and in 4 patients only in trapezius muscles. 17 patients from this group improved. The overall rate of improvement in this group was 65%. In 8 patient we didn't find any denervation signs but the rate of improvement in this group was extremely high--87%.

CONCLUSION

EMG examination doesn't play deciding role in the monitoring of torticollis treatment with botulinum toxin.

[Forced normalization]

Two patients are described who had frequent epileptic seizures, one with primary generalized, the other with partly complex type, in whom after treatment EEG pattern became normal but acute psychotic disturbances appeared. In the literature this phenomenon is known as "forced normalization". The term is not precise since it reduces it to only EEG changes leaving aside seizures and psychosis as alternative of seizures. The condition occurs usually in young persons who previously had no psychotic changes, but had frequent daily seizures, usually generalized of absence type, treated usually with suximide, but in some cases the syndrome was observed in other types of epilepsy treated with other drugs. The incidence of the syndrome is estimated at 1%. Haloperidol is the treatment of choice, but sometimes psychotic episodes were so intense that anticonvulsants had to be withdrawn, as this occurred in one of the reported cases.

[Melatonin in sleep rhythm disorders after cerebral stroke]

Small doses of melatonin were administrated to 30 patients with day/night rhythm disorders, after cerebral stroke. Psychotropic drugs administrated before did not bring any clinical improvement. In evaluation of melatonin the time till falling asleep, sleep duration, anxiety and the following day activity were taken into account. Good results were observed in majority of patients, concerning falling asleep and sleep were obtained continuity. The melatonin is a safe and worth drug in sleep rhythm disorders in patients after cerebral stroke.

[Spasmodic torticollis: experience of 5 years with botulinum toxin treatment]

64 cases with spasmodic torticollis were observed during 5 years and treated with botulinum toxin (BTX). BTX was injected into dystonic muscles mostly into sternocleidomastoid then--trapezius, and splenius capitis muscle. Improvement (excellent, good and fair) was achieved in 40 patients (62%). Lack of information about 6 patient (9%). Injections were repeated every 3-4 months and in several cases even 1-2 during the year. After several injections atrophy and denervation potentials in EMG were observed in the majority of injected muscles. Neurotic syndromes coexisting with dystonia had worsening influence on therapeutic effects. Adverse events were observed in 5 cases. Treatment with BTX is very simple, easy, harmless and can be administered in outpatients.

[Treatment of vertigo with betahistine and its clinical and electrophysiological evaluation]

Betahistine was administered during 4 weeks to 31 patients with vertigo, divided into 3 groups depending on changes in neurological examination. 1 group--13 patients without abnormalities, 2 group--11 with ischemia vertebrobasilaris, 3 group--7 with lesion of VIII nerves. Significant improvement was obtained in 20 patients (65%), most evident in group 1 (in 11). BAEP examination revealed abnormalities in 12 cases before the treatment and recovery in 4 (33.3%) after 4 weeks of treatment. They were: longer latency of the 1 component (39%), and III and V components mainly in the group with baso-vertebral ischemia. It confirms the supposition that disturbances of microcirculation are responsible for the mechanism of vertigo in these cases.

[Botulinum toxin in the treatment of pain]

Botulinum toxin (BTx) has been administered for many years in the treatment of dystonias with great success. Its effectiveness is comparable with the best drugs. It was observed during spasmodic torticollis treatment that pain disappears as first before clinical improvement of dystonia. Different mechanisms of influence of BTx on pain are discussed. BTx was tried in tension headache, cluster headache, migraine, fibromyositis, painful cramps with varying results. It is possible that BTx will be useful in many other types of pain.

[Botulinum A toxin in the treatment of focal dystonias]

There are 3 clinical groups of dystonia: generalized, segmental and focal. Spasmodic torticollis, blepharospasmus, laryngeal dystonia and graphospasmus belong to the focal dystonia. The aetiology of dystonias is not clear but genetic factors are commonly accepted. Treatment with pharmacological and surgical methods is not satisfactory. Botulinum toxin A(BTX) has brought a new approach to the effective treatment of dystonias. Effectiveness of this method is estimated as 60 to 100%, depending on clinical factors, department and author. BTX acts on neuro-muscular junction and produces chemical denervation but the effect is not persistent and after 3 or more months the treatment should be repeated. The method is harmless and can be administered in out-patients practice. Adverse events are observed in 10% patients but they are not serious and transient. Details are described the methods of BTX injections in spasmodic torticollis, blepharospasmus and laryngeal dystonia.

[Botulinum toxin in the treatment of tremor]

Pharmacological treatment of essential and symptomatic tremor is not satisfactory. Introduction of botulinum toxin (BTX) has brought a new approach to tremor treatment. BTX is injected into carpal flexors and extensors about 100 i.u. into each muscle, higher doses are injected into flexors and lower into extensors. Beneficial results are observed in 50 to 67% of the patients. The author treated 5 patients with tremor of various origin with good result in 3 cases (60%), but in all cases weakness of hand muscles and middle finger dropping were observed. BTX treatment is indicated in certain cases of hand disabled by tremor.