[Botulin in the treatment of local dystonia]. / Botulina w leczeniu miejscowych dystonii.

Botulin A has been introduced for the treatment of local dystonia especially blepharospasm and torticollis. Three cases of blepharospasm and 5 cases of torticollis were treated with botulin injections directly into the muscles by a method presented in detail. Good effects were obtained in blepharospasm but very poor in torticollis, which may have been due to too low doses of the toxin and inadequate choice of injection points. The method is safe and in only 1 case transient weakness of the masseters was noted.

[Own experience with botulinum treatment of dystonia]. / Wlasne doswiadczenia w leczeniu dystonii botulina.

Fifty-five patients were treated with botulin injections into the muscles showing dystonia, contracture or tremor. Twenty two of them had torticollis, 21 had blepharospasm, 10 had hemifacial spasm, and 2 had tremor. In all, 112 injections were done with good result in 64%, slight effect in 27% and without effect in 9% of the cases. Similar results have been reported from other centers in the world. Adverse effects were not significant and disappeared after several days or weeks. They included ptosis, speech and deglutition disturbances, general weakness and neurotic reactions. These adverse effects developed in 12 cases. In cases of tremor the dose as well as the technique of injections must be individualized. The method is an important therapeutic advance and can be applied in outpatient clinics.

[Migraine--considerations on the achievements in medicine]. / Migrena--rozwazania na temat osiagniec medycyny.

Migraine is among the most mysterious diseases. It has been known for centuries but as yet it has resisted the advances in medicine and has not revealed its aetiology, mechanism of headache and possibilities of treatment. Various theories on the pathogenesis of migraine and arguments for and against them are reviewed here. The most convincing hypothesis seems to be that which covers all the achievements in this field, that is the neuronal-vascular theory in which serotonin is given the role of the main biochemical factor. The diagnosis of migraine is easy if its history is known, but the first attack, especially if very severe, may be difficult to diagnose and should be differentiated from meningitis or intracranial haemorrhage. The modern imaging techniques confirm the development of transient ischaemia in the brain which can explain the aura and the post-attack manifestations. The treatment includes interruption of attack and prevention of further attacks. As long as the aetiology and pathogenesis of migraine remain not fully understood, the interruption of attacks seems to be the most adequate management and here new possibilities have been demonstrated connected with the discovery of serotonin receptors. Prophylactic treatment may be justified only in severe and frequent attacks and its effectiveness is temporary. In summary it may be stated that as yet only several unshakeable facts have been established in the aetiology and pathogenesis of migraine: heritability, serotonin, vascular system of the head, trigeminal nerve, cerebral centres of inexact location and factors provoking attacks. They all are forming a chain of relationships which remains in the realm of hypotheses.

[The concept of encephalopathies -- paper for discussion]. / Pojecie encefalopatii -- artykul dyskusyjny.

The term "encephalopathy" has not yet been strictly defined. In textbooks about 20 adjectives can be found in connection with this term. All encephalopathies have certain features in common: 1. the cause of brain damage is known, 2. the neurological syndrome is diffuse or disseminated, 3. there is the syndrome of organic brain damage (most frequently with dementia). Encephalopathies can be divided into congenital and acquired. Congenital ones are: encephalopathy following perinatal injury or fetal infection. Acquired: post-traumatic, toxic, vascular (hypertensive and atherosclerotic), metabolic, postinflammatory. On the basis of analysis of clinical findings and causes the conclusion may be reached that encephalopathy is a sequela of diffuse organic brain damage, that is, it is a "status post...", but this excludes certain encephalopathies recognize as yet (hypertensive encephalopathy). In medical expertise more precise diagnosis should be required, especially for post-traumatic encephalopathy.

[Electroencephalographic studies in migraine]. / Badanie elektroencefalograficzne w migrenie

The author reviews the pertinent literature and the results of own investigations in migraine. EEG changes in migraine are observed in nearly 50% of cases during attacks as well as in the periods free of pains. Most investigations were done in the periods between attacks. The H response characteristic of migraine was found by the author in 25% of cases only. Focal changes were present in 30% of cases. They were not related to the side of the pain, its duration and the form of migraine. Seizure activity was never observed. The author regards isolation of the so-called dysrhythmic form of migraine as not justified. EEG changes suggest--according to the author--that migraine is a primary cerebral and only secondarily a vascular disorder.

[Cholinergizing treatment in hyperkinesis]. / Cholinergizujace leczenie w hiperkinezach.

Hyperkineses are a clinical and pathogenetic counter-part of parkinsonism (MP). Their underlying cause is increased activity of the dopaminergic system or insufficiency of the cholinergic system. Treatment inhibiting the dopaminergic system, similarly as anticholinergic treatment is of little effectiveness in MP. A trial of substitutive treatment was undertaken activating the cholinergic system with a precursor of acetylcholine (dimethyl-amino-ethanol-deanol--Bimanol) with simultaneous inhibition of cholinesterase with prostigmin. The results of this treatment were compared with previously applied antidopaminergic treatment (Haloperidol) and with the effects of L-dopa. This treatment was given to 11 patients with Huntington's chorea (ChH), 4 with faciolingual dyskinesis (DFL), 3 with torticollis spasmodicus (TS), 3 with maladie des tics (MT) and 8 with dyskinesia following treatment with L-dopa (MP). Cholinergizing treatment gave better results than antidopaminergic treatment in TS and ChH, and worse in MT. In dyskinesia following L-dopa cholinergizing treatment gave also no effects reported by others. Differences in the results of cholinergizing and antidopaminergic treatment may indicate non-homogenous pathological mechanism of these hyperkineses. Cholinergizing treatment in hyperkineses is based on a similar principle as L-dopa treatment in MP and this approach seems to be proper but more effective preparations should be sought for.

[New attempt at treating Huntington's chorea (preliminary report)]. / Próba nowego sposobu leczenia plasawicy Huntingtona (doniesienie wstepne)

In Huntington's chorea the biochemical disturbances are to some degree a reverse of those observed in Parkinson's disease and a failure of the cholinergic system is prevalent. Former attempts at treatment were based on blockade of the dopaminergic system. The author suggests that the general line of treatment should be -- similarly as in Parkinson's disease -- not blockade of the predominant system but enhancing the cholinergic activity by administration of acetylcholine precursors and agents blocking cholinesterase. Eight patients were treated in this way and significant improvement was achieved in half of them. Further therapeutic trials along these lines are justified theoretically and the main problem will be to find substances crossing the blood-brain barrier and acting more strongly.

[Sleep disturbances in multi-infarction dementia and trials of treatment with caffeine]. / Zaburzenia snu w otepieniu wielozawalowym i próba leczenia kofeina.

Atherosclerotic cerebrovascular lesions leading to repeated ischaemic strokes produce a wealth of clinical symptoms and signs with dementia. Sleep disturbances are frequent and take the form of difficult falling asleep and shifting of the sleep/waking rhythm to late night and morning hours. Hypnotic drugs produce often a paradoxical effect with complete reversal of the circadian sleep rhythm. These observations gave the inspiration to a trial of reversed treatment: with administration of analeptics in the evening and sedative drugs during the day. Sixteen patients with this dementia and pronounced disability were treated by this method. Before the treatment they spent most time in bed, their age was 51-81 years, 9 were males and 7 females. In 10 cases a significant improvement was obtained with shifting of the sleep rhythm by 4 hours on average towards normal rhythm. Further studies would be necessary for explaining this effect.

[Spasmodic torticollis: experience of 5 years with botulinum toxin treatment]. / Krecz karku. 5 lat doswiadczenia w leczeniu toksyna botulinowa A.

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.

[Achievements, disappointments and hopes in neurological therapy in the 20th century]. / Osiagniecia, rozczarowania i nadzieje w leczeniu neurologicznym XX wieku.

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.

[Pain--physiological or medical phenomenon]. / Ból--fizjologia czy objaw medyczny.

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.

[Multiple sclerosis--certain clinical and diagnostic problems]. / Stwardnienie rozsiane--niektóre problemy kliniczne i diagnostyczne.

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.

[Apomorphine in treatment of Parkinson's disease with fluctuations]. / Apomorfina w leczeniu choroby Parkinsona z fluktuacjami. Doniesienie wstepne.

Apomorphine is a non-specific dopamine agonist, most similar to it, with a strong action on D2, D3, D4 receptors and weaker action on D1 and D5 receptors. It has been known since 100 years, and in Parkinson's disease it was used first in 1970 by Schwab and Cotzias. Apomorphine is used in Parkinson's disease with high-grade fluctuations of symptoms which cannot be controlled by oral drugs, especially in off" periods resistant to levodopa. After subcutaneous administration it changes the "off" to "on" period within 5-10 minutes. Unfortunately, its effect is short-lasting and wears off after 40-90 minutes. Apomorphine is administered in repeated single subcutaneous injections or in continuous subcutaneous infusion, if more than 7-9 single injections are required daily. Before beginning of treatment the optimal dose of apomorphine should be determined. For counteracting its emetic action domperidon (Motilium) is given additionally 20 mg t.d.s. Apomorphine produces no tolerance and is not losing its effectiveness with continued treatment. The most frequent adverse effects during long-term treatment are local cutaneous reactions, increased intensity of dyskinesia during the "on" period, visual hallucinations whose illusory character is clear to the patient, psychoses, orthostatic hypotension. The authors treated 8 patients with marked fluctuations in Parkinson's disease treated with levodopa. In 7 cases the effects was good--6 of them received 2-3 mg s.c. 3-4 times in 24 hours for 7-12 days. One patient has been treated 9 months with good result. In one case the intensity of dyskinesia made impossible treatment continuation.

[Cerebrolysin in treatment of acute ischemic stroke]. / Cerebrolizyna w leczeniu niedokrwiennych udarów mózgowych.

Cerebrolysin is composed of low molecular peptides and free amino-acids and as a nootropic drug it administered in various diseases of central nervous system. In an open clinical trial patients with acute ischaemic stroke in the region of the middle cerebral artery, were treated. Cerebrolysin was administered as intravenous infusion in daily dose of 15 ml during 21 days. Recovery in 10 patients and improvement in 3 was obtained and only one patient died. The results were compared to the large group of 108 patients treated earlier with other drugs. Therapeutic effect was similar in all groups.

[Acute transverse myelitis]. / Myelitis transversa acuta.

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.

[Long-term steroid therapy in multiple sclerosis]. / Dlugotrwala "pulsacyjna" terapia steroidowa w stwardnieniu rozsianym.

Corticosteroids have a firm place in the treatment of ms, but as yet no generally accepted regimen of this therapy exists. It is not known either, how to achieve the greatest effectiveness of these drugs and avoid side effects. Many clinicians advocate high intravenous doses of methylprednisolone in a short time of 5-7 days. This method is more effective and leads to less adverse effects. The studied patients received prednisone (Encorton Polfa) in short course of 3 days every month. The dose of Encorton in each course depended on the clinical condition but never exceeded 200 mg. The regimen was used in 18 patients who were followed up at least one year. Evident improvement or stabilization was obtained in 11 cases. No adverse effects were noted. These results are comparable to those achieved with methylprednisolone. It may be supposed that every regimen of corticoid treatment in ms is usefull if it causes no adverse effects. The treatment by method of long-term pulse therapy with corticoids is applicable in outpatients.

[Piracetam treatment in ischemic stroke]. / Leczenie piracetamem niedokrwiennego udaru mózgowego.

The increase of interest in piracetam in the treatment of stroke has been noticed lately. The reason of that is the unique double-action of this drug which depends on: 1. its effect on vascular system, and 2. improving of the metabolic process in a nerve cell. The purpose of our work was the evaluation of the therapeutic action of piracetam in comparison with other drugs, which are applied in treating stroke. 171 patients were examined, and piracetam was given to 40 of them. The effects of the treatment were evaluated after 14 days of using piracetam in dose of 12.0 g i.v. The authors estimate, that this drug is efficient in ischaemic stroke. However, its definite superiority over other drugs has not been firmly stated.

[Botulinum A toxin in the treatment of focal dystonias]. / Leczenie dystonii ogniskowych toksyna botulinowa A.

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]. / Toksyna botulinowa w leczeniu drzenia.

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.

[Botulinum toxin in the treatment of pain]. / Toksyna botulinowa w leczeniu bólu.

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.