Convulsive status epilepticus management in adults and children: Report of the Working Group of the Polish Society of Epileptology.

INTRODUCTION: The Working Group was established at the initiative of the General Board of the Polish Society of Epileptology (PSE) to develop an expert position on the treatment of convulsive status epilepticus (SE) in adults and children in Poland. Generalized convulsive SE is the most common form and also represents the greatest threat to life, highlighting the importance of the choice of appropriate therapeutic treatment. AIM OF GUIDELINE: We present the therapeutic options separately for treatment during the early preclinical (>5-30min), established (30-60min), and refractory (>60min) SE phases. This division is based on time and response to AEDs, and indicates a practical approach based on pathophysiological data. RESULTS: Benzodiazepines (BZD) are the first-line drugs. In cases of ineffective first-line treatment and persistence of the seizure, the use of second-line treatment: phenytoin, valproic acid or phenobarbital is required. SE that persists after the administration of benzodiazepines and phenytoin or another second-line AED at appropriate doses is defined as refractory and drug resistant and requires treatment in the intensive care unit (ICU). EEG monitoring is essential during therapy at this stage. Anesthesia is typically continued for an initial period of 24h followed by a slow reversal and is re-established if seizures recur. Anesthesia is usually administered either to the level of the "burst suppression pattern" or to obtain the "EEG suppression" pattern. CONCLUSIONS: Experts agree that close and early cooperation with a neurologist and anesthetist aiming to reduce the risk of pharmacoresistant cases is an extremely important factor in the treatment of patients with SE. This report has educational, practical and organizational aspects, outlining a standard plan for SE management in Poland that will improve therapeutic efficacy.

[Need for creating Polish registry of multiple sclerosis patients]. / O potrzebie stworzenia polskiego rejestru chorych na stwardnienie rozsiane.

Multiple sclerosis (MS) is the most common cause of neurological disability of young people. It is estimated that 40 000-60 000 people in the country suffer from MS, and approximately 2000 new cases are diagnosed annually. These are, however, estimated data and require verification by nation-wide research. Results published so far concern only certain regions of Poland. It is also vital to precisely describe the needs of patients in terms of immunomodulating treatment and to perform detailed pharmacoeconomical analysis. In order to estimate basic epidemiological parameters there is a need of creating, in imitation of many other countries, a national register of MS patients which would concentrate all assets concerning MS around this project. The article presented the most important of American and European databases and explained the basis of the Polish register of MS patients, which is already functioning in one of the regions.

Follow-up study of olfactory deficits, cognitive functions, and volume loss of medial temporal lobe structures in patients with mild cognitive impairment.

BACKGROUND: At 3 years after diagnosis, the risk of Alzheimer disease (AD) for patients with mild cognitive impairment (MCI) is estimated to be 18% to 30%. To improve treatment of patients at high dementia risk there is a need for a better prediction of the risk for transition from MCI to AD. Olfactory deficits are a hypothetical predictor of conversion form MCI to AD. Furthermore, several studies point at volumetric reduction of medial temporal lobe structures as predictors of conversion form MCI to AD. The primary aim of this study was to evaluate whether investigations of odor deficits in MCI combined with neuropsychological tests and MRI examinations can improve prediction of the development of dementia. METHODS: Changes in olfactory functions, cognitive functions, and volume of medial temporal lobe structures (hippocampus, parahippocampal gyrus, and amygdala) were evaluated in a 24-month follow-up study in 49 MCI patients and 33 controls. RESULTS: In the MCI group, a prediction of strong cognitive functions deterioration based on poor performance in Olfactory Identification tests shows sensitivity of 57% and specificity of 88%. The test based on cognitive functions only shows a sensitivity of 44%, and 89%, respectively. Combined tests having a criteria of poor olfactory identification performance AND poor results of neuropsychological tests showed a sensitivity of 100% and specificity of 84%. Furthermore, correlation was found between the results of Olfactory Identification tests at baseline and deterioration of cognitive functions at follow up. Odor identification threshold did not appear to be a dementia predictor. A correlation of progress of cognitive function deterioration, odor identification deterioration, and decrease of volume of the hippocampus was also observed. CONCLUSIONS: Prediction of MCI to dementia conversion can be improved by supplementing the neuropsychological tests with odor identification tests. A follow up study of hippocampus volume reduction, OI performance and cognitive functions deterioration will further increase prediction accuracy.

Three-month stroke outcome: the European Registers of Stroke (EROS) investigators.

BACKGROUND: Contemporaneous data on variations in outcome after first-ever-lifetime stroke between European populations are lacking. We compared differences in case fatality rates, functional outcome, and living conditions 3 months after stroke within the European Registers of Stroke Collaboration. METHODS: Population-based stroke registers were established in France (Dijon), Italy (Sesto Fiorentino), Lithuania (Kaunas), the United Kingdom (London), Spain (Menorca), and Poland (Warsaw). All patients with first-ever-lifetime stroke of all age groups from the source population (1,087,048 inhabitants) were included. Data collection took part between 2004 and 2006. The study investigated population variations in outcome at 3 months (death, institutionalization due to stroke, or Barthel Index below 12 points) using multivariable logistic regression analyses adjusted for age, sex, stroke severity, stroke subtype, and comorbidities. RESULTS: A total of 2,034 patients with first-ever-lifetime stroke were included. Median age was 73 years, 52% were female. The mean weighted cumulative risk of death was 21.8% (95% confidence interval 20.0 to 23.6) with a 3-fold variation across populations. The weighted proportion of poor outcome was 41.3% (95% confidence interval 39.0 to 43.7) with a 2-fold variation across populations. CONCLUSION: More than 40% of patients had a poor outcome, defined as being dead, dependent, or institutionalized 3 months after stroke. Substantial outcome variations were found between populations that were explained by case mix variables in this analysis, yet a trend toward a higher risk of poor outcome was present in Kaunas.

Rationale and design of INTERSTROKE: a global case-control study of risk factors for stroke.

UNLABELLED: Stroke is a major global health problem. It is the third leading cause of death and the leading cause of adult disability. INTERHEART, a global case-control study of acute myocardial infarction in 52 countries (29,972 participants), identified nine modifiable risk factors that accounted for >90% of population-attributable risk. However, traditional risk factors (e.g. hypertension, cholesterol) appear to exert contrasting risks for stroke compared with coronary heart disease, and the etiology of stroke is far more heterogeneous. In addition, our knowledge of risk factors for stroke in low-income countries is inadequate, where a very large burden of stroke occurs. Accordingly, a similar epidemiological study is required for stroke, to inform effective population-based strategies to reduce the risk of stroke. METHODS: INTERSTROKE is an international, multicenter case-control study. Cases are patients with a first stroke within 72 h of hospital presentation in whom CT or MRI is performed. Proxy respondents are used for cases unable to communicate. Etiological and topographical stroke subtype is documented for all cases. Controls are hospital- and community-based, matched for gender, ethnicity and age (+/-5 years). A questionnaire (cases and controls) is used to acquire information on known and proposed risk factors for stroke. Cardiovascular (e.g. blood pressure) and anthropometric (e.g. waist-to-hip ratio) measurements are obtained at the time of interview. Nonfasting blood samples and random urine samples are obtained from cases and controls. Study Significance: An effective global strategy to reduce the risk of stroke mandates systematic measurement of the contribution of the major vascular risk factors within defined ethnic groups and geographical locations.

Sleep disorderd breathing and recurrence of cerebrovascular events, case-fatality, and functional outcome in patients with ischemic stroke or transient ischemic attack.

Ninety one patients with stroke or transient ischemic attack (TIA) were screened for sleep-disordered breathing (SDB). Case fatality, rate of recurrence of cerebrovascular events, and functional outcome were analyzed during a 2-year follow-up. The patients were stratified into groups: without (AH < or =5) and with SDB (AHI >5). SDB was present in 61 (67.7%) patients with stroke or TIA. The rate of recurrence of TIA or stroke in patients with SDB was significantly higher (12 patients, OR=1.52, P<0.05) as compared with patients without SDB (3 patients) within two years of observation. Case-fatality rates were not significantly different (4 patients with SDB and 2 patients without SDB). Our data show that SDB significantly increases the incidence of recurrent cerebrovascular events in patients with TIA or stroke in a two-year follow-up. SDB in patient with stroke or TIA did not influence functional outcome of stroke during the long-term observation.

Sleep related breathing disorders in patients with ischemic stroke and transient ischemic attacks: respiratory and clinical correlations.

Fifty five patients with ischemic stroke and 15 patients with transient ischemic attacks (TIA) were screened for sleep related breathing disorders (SRBD). Apnea-hypopnea index (AHI) and desaturation index (DI) were analyzed. The clinical status was assessed with National Institute of Health Stroke Scale (NIHSS). The patients with stroke were stratified into groups: without (AHI10). SRBD were present in 36 patients with stroke and in 10 patients with TIA. There were significant differences in the clinical status on admission, as quantified with NIHSS, between stroke patients with mild and moderate or severe SRBD. AHI positively correlated with NIHSS on admission in stroke patients (r=0.54, P<0.01). The final NIHSS score was significantly greater in patients with moderate or severe SRBD than in those with mild SRBD: 3.4+/-1.9 and 1.8+/-1.2, respectively. Our data suggest that the severity of SRBD is related to the clinical status on admission and it influence the clinical outcome after ischemic stroke.

The incidence of sleep apnea in patients with stroke or transient ischemic attack.

Disorders of breathing during sleep are defined as cessation or reduction of air flow thorough the upper airway, accompanied by a decrease of oxygen saturation. The results of many studies underline the association between sleep-disordered breathing (SDB) and cerebrovascular disorders. SDB, mostly obstructive sleep apnea syndrome (OSAS), is believed to be an independent risk factor of stroke and is related to poor outcome and increased long-term stroke mortality. The present study evaluated the frequency of SDB in patients with stroke or transient ischemic attack transient ischemic attack. We studied 43 patients (mean age 68.5 +/-11.0), which included 35 males and 8 females, with acute stroke (n=37) and transient ischemic attack (n=6). The assessment included body mass index (BMI), age, cardiovascular risk factors, and localization of stroke. All patients underwent all-night screening for SDB with a portable 8-channel recorder. The apnea/hypopnea index (AHI) for the whole group was 13.3 +/-15.2. AHI <5 was found in 16 patients. Overall, SDB was present in 27 (62.8%) patients with stroke and transient ischemic attack, stratified into those with AHI 5-10, (10 patients), 10-20 (8 patients), and AHI>20 (9 patients). In 15 patients, there was an increase in AHI >or=5 on assuming the supine position. The patients' mean BMI was 27.8 +/-4.7. The analysis of BMI, age, and localization of stroke was not sufficient to identify patients with high risk for SDB. We submit that overnight screening for SDB should be routinely performed in every patient after stroke and transient ischemic attack and it should become a diagnostic tool in neurological departments.

Differences in risk factors for dementia with neurodegenerative traits and for vascular dementia.

In 229 patients with dementia and in 144 control subjects, polymorphisms of apolipoprotein E (ApoE), low-density-lipoprotein (LDL)-receptor-related protein, alpha(2)-macroglobulin, interleukin (IL) 1beta, angiotensin-converting enzyme and of methylene tetrahydrofolate reductase genes were investigated. In plasma, antibodies against Chlamydia pneumoniae and lipids were determined. Dementia was classified as probable Alzheimer's disease (AD), probable dementia of vascular origin (VaD) and mixed dementia (MD). An association of the disease with ApoE and IL-1beta polymorphism and increased levels of LDL cholesterol were observed in AD and in MD but not in VaD.

Taste responses in patients with Parkinson's disease.

OBJECTIVE: Preclinical studies indicate that dopaminergic transmission in the basal ganglia may be involved in processing of both pleasant and unpleasant stimuli. Given this, the aim of the present study was to assess taste responses to sweet, bitter, sour, and salty substances in patients with Parkinson's disease (PD). METHODS: Rated intensity and pleasantness of filter paper discs soaked in sucrose (10-60%), quinine (0.025-0.5%), citric acid (0.25-4.0%), or sodium chloride (1.25-20%) solutions was evaluated in 30 patients with PD and in 33 healthy controls. Paper discs soaked in deionised water served as control stimuli. In addition, reactivity to 100 ml samples of chocolate and vanilla milk was assessed in both groups. Taste detection thresholds were assessed by means of electrogustometry. Sociodemographic and neuropsychiatric data, including cigarette smoking, alcohol consumption, tea and coffee drinking, depressive symptoms, and cognitive functioning were collected. RESULTS: In general, perceived intensity, pleasantness, and identification of the sucrose, quinine, citric acid, or sodium chloride samples did not differ between the PD patients and controls. Intensity ratings of the filter papers soaked in 0.025% quinine were significantly higher in the PD patients compared with the control group. No inter-group differences were found in taste responses to chocolate and vanilla milk. Electrogustometric thresholds were significantly (p = 0.001) more sensitive in the PD patients. CONCLUSIONS: PD is not associated with any major alterations in responses to pleasant or unpleasant taste stimuli. Patients with PD may present enhanced taste acuity in terms of electrogustometric threshold.

Factors predicting early stroke fatality in Poland. Preliminary report of the Polish National Stroke Registry.

Poland has one of the highest rates of death due to stroke in Europe, which, in contrast to many industrialized countries, has not changed since at least 1984. To improve this unfavorable situation, the entire approach to stroke management needs to be recognized. For this purpose, an analysis of stroke epidemiology regarding regional differences was one of the the strategic points of the Polish National Project of Stroke Prevention and Treatment. The Polish National Stroke Registry was maintained from 1 January to 31 December 2000 in 59 Neurological Department in all 16 districts of Poland. In total 11,107 patients were included: 11% with intracerebral hemorrhage, 63.4% with ischemic stroke, and 25.6% with unclassified stroke. Computed tomography (CT) was performed in 73.6% of patients. Analysis of in-hospital deaths showed great differences between the centers (from 8% to 36%). According to multifactorial analysis, not only well-known predictors of early death (decrease in consciousness at the onset of stroke, decrease in functional state prior to stroke, and severity of stroke) influence the prognosis. In centers with high risk of death, CT, especially CT on admission, was performed significantly less often (4.2% vs. 62.6%), early rehabilitation was delayed (38.3% vs. 73.4%), and secondary prevention treatment was prescribed to fewer patients (antiplatelettherapy 36.4% vs. 77.4%; antithrombotic therapy 4.9% vs. 13%).

Dynamics of LDL oxidation in ischemic stroke patients.

OBJECTIVE: Oxidative modification of human low density lipoprotein (LDL) plays an important role in the development of atherosclerosis. The aim of this study was to evaluate the oxidative modification of LDL in the group of patients with ischemic stroke. MATERIAL AND METHODS: In the group of 43 patients 3 months after ischemic stroke and in the age and sex-matched control group, the kinetics of LDL oxidation and level of vitamin E were estimated. The susceptibility of LDL to oxidation was evaluated in isolated LDL exposed to in vitro oxidation. In 26 patients, after diet change, clinical and laboratory investigations were repeated 9 months later. RESULTS: In the patient group, susceptibility of LDL to oxidation was enhanced, lag phase was significantly shorter in comparison with the control group. After a change in diet, significant elongation of the lag phase was observed. CONCLUSION: Diet change improves LDL resistance to oxidation and may influence prognosis in stroke patients.

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.

[Headache concurrent with the onset of ischemic stroke]. / Ból glowy towarzyszacy wystepowaniu udaru niedokrwiennego mózgu.

The aim of the study was to assess the occurrence of headache in acute ischaemic stroke and its association with type, aetiology and localization of stroke. 342 patients with stroke were analysed. Their average age was 70.8 +/- 13.1. Headache was observed in 17.8% stroke patients. There was no correlation between headache and size of ischaemic lesion in CT. Headache was observed in 43.1% of patients with small foci localized in deep structure, and in 33.3% of large cortical-subcortical foci. The analysis between the frequency of headache and type of stroke according OCSP classification revealed that headache occurred statistically significant more frequent in POCI.

A comparison of the costs and survival of hospital-admitted stroke patients across Europe.

BACKGROUND AND PURPOSE: Policy makers require evidence on the costs and outcomes of different ways of organizing stroke care. This study compared the costs and survival of different ways of providing stroke care. METHODS: Hospitalized stroke patients from 13 European centers were included, with demographic, case-mix, and resource use variables measured for each patient. Unit costs were collected and converted into US dollars using the purchasing power parity (PPP) index. Cox and linear regression analyses were used to compare survival and costs between the centers adjusting for case mix. RESULTS: A total of 1847 patients were included in the study. After case-mix adjustment, the mean predicted costs ranged from $466 [95% CI 181 to 751] in Riga (Latvia) to $8512 [7696 to 9328] in Copenhagen (Denmark), which reflected differences in unit costs, and resource use. The mean length of hospitalization ranged from 8.3 days in Menorca (Spain) to 36.8 days in Turku B (Finland). In the 3 Finnish centers at least 80% of patients were admitted to wards providing organized stroke care, which was not provided at the centers in Almada (Portugal), Menorca, or Riga. Patients in Turku A and Turku B were less likely to die than those in Riga, Warsaw (Poland), or Menorca. The adjusted hazard ratios were 0.18 [0.10 to 0.32] for Turku A, 0.18 [0.10 to 0.32] for Turku B, 0.68 [0.48 to 0.96] for Warsaw, and 0.56 [0.33 to 0.96] for Menorca, all compared with Riga. CONCLUSIONS: The cost of stroke care varies across Europe because of differences in unit costs, and resource use. Further research is needed to assess which ways of organizing stroke care are the most cost-effective.

[Atherosclerotic changes in the aorta of patients with ischemic and hemorrhagic stroke]. / Zmiany miazdzycowe aorty u chorych w udarze niedokrwiennym i krwotocznym mózgu.

Clinico-pathological analysis of 207 patients dying after stroke was performed. The occurrence of atherosclerotic lesions in the aortic arch, thoracic and abdominal parts of aorta were compared in patients dying of ischaemic and haemorrhagic stroke. Advanced atherosclerotic lesions in the arch of aorta were rare in patients with ischaemic and haemorrhagic stroke. Moderate atherosclerotic lesions in the aortic arch were observed more frequently in ischaemic than in haemorrhagic stroke. Advanced atherosclerotic lesions in thoracic and abdominal part of aorta occurred with the same frequency in ischaemic and haemorrhagic stroke.

[Determination of lipoprotein (a) [Lp(a)] in patients with ischemic stroke. Preliminary communication]. / Oznaczanie lipoproteiny (a) [Lp(a)] u pacjentow z niedokrwiennym udarem mozgu. Doniesienie wstepne.

The aim of this work was the determination of apolipoprotein(a) [Lp(a)] in the patients three months after the onset of ischaemic stroke. A group of 56 patients was investigated. Stroke was diagnosed as caused by atherosclerotic changes in main cerebral arteries in 32 patients and in 11 by changes in cervical arteries. In 13 persons a lacunar stroke was recognised. The mean Lp(a) level and the median value were significantly higher in the group of patients after stroke as compared with 45 controls. A more frequent occurrence of Lp(a) level over 30 mg/dl considered as pathological was observed more often in the patients. No correlation was seen between Lp(a) and the resistance of LDL to oxidation nor between Lp(a) and the amount of products of LDL oxidation in vitro.

[EEG value in cases of epileptic seizures in early phase of stroke]. / Wartosc badania EEG u pacjentów z napadami padaczkowymi we wczesnej fazie udaru mózgu.

The aim of our work was to assess the usefulness of EEG in patients with seizures in acute phase of stroke. EEG patterns of 54 patients with epileptic seizures at the onset of stroke were evaluated: 45 of ischaemic, 6 of haemorrhagic origin and 3 with lacunar stroke as confirmed by CT or MR examination. Out of 40 patients, who had a single or multiple seizures at the onset of stroke, EEG revealed focal slow waves in 90% and in 22.5% they were accompanied by interictal epileptiform discharges. None of those patients had recurrent seizures during the time of hospitalisation irrespectively of applying antiepileptic drugs. In the remaining 14 patients prolonged disturbances of consciousness were observed. EEG examination revealed simple partial status epilepticus (SE) in 10 and complex partial SE in 4 of them. In 11 of those patients EEG disclosed fragments of periodic lateralized epileptiform discharges (PLED) interrupted by seizure activity. The findings indicate that in patients with seizures in the acute phase of stroke EEG examination is very helpful in making the proper therapeutic decision by recognizing the SE. The introduction of antiepileptic drugs is generally not necessary in stroke patients with single seizures.

[Comparison of neurological status in patients treated in a stroke unit with those treated in classical care model]. / Porównanie stanu neurologicznego u chorych leczonych w oddziale udarowym z chorymi leczonymi w klasycznym modelu opieki.

140 patients with stroke (69 men and 71 women) aged 71.7 +/- 12.4 treated in the general neurology were compared with 102 patients (46 men, 56 women) aged 71.5 +/- 11.2 treated in the stroke unit during the period 1.11.95 to 31.10.97. Neurological status and state of environmental dependency during the discharge time were similar in both groups, but the state of motor performance was significantly better in the group of patients treated in the stroke unit. In the stroke unit collaboration between nurses and rehabilitants makes it possible to increase the time of rehabilitation and to introduce the elements of exercises which can be done by patients under control of nurse.

[In vitro oxidation of low density lipoproteins in patients after ischemic stroke]. / Utlenianie in vitro lipoprotein niskiej gestosci u osób po przebytym niedokrwiennym udarze mózgu.

The aim of this work was the evaluation of low density lipoprotein (LDL) susceptibility to oxidation in the survivors of ischaemic stroke. The investigations were performed in 65 individuals at least three months after the onset of acute symptoms. In 24 patients stroke was caused by alterations in main cerebral arteries, in 19 by considerable narrowing of carotid artery, in 15 by alterations in small cerebral arteries with often accompanying hypertension and/or diabetes (lacunar stroke) and in 7 by embolism of cardiac origin in individuals with cardiac arrhythmia and coronary artery disease. The control group comprised 25 age matched persons without pathological symptoms. Plasma lipids and apolipoprotein B levels were determined as well as two antioxidants: alpha-tocopherol level and superoxide dismutase activity. The evaluation of lipid peroxidation was performed by determining thiobarbituric acid reacting substances (TBARS) and lipid peroxides (LPO) increase after 5 hours oxidation of isolated LDL in vitro in the presence of copper ions. The level of IgG directed against modified LDL was also evaluated. In the patients decreased HDL cholesterol level was observed as well as increased apolipoprotein B. In the group of thrombotic strokes high triglycerides were observed. alpha-tocopherol level was decreased in the group of cerebral strokes. The amounts of oxidation products did not differ between the whole group of patients after stroke and the controls. A significant increase concerned only the group of lacunar strokes. The evaluation of LDL susceptibility to oxidation in patients after stroke by measuring absorption at 234 nm and determining the time period necessary to the onset of intensive LDL oxidation will be the subject of a separate publication.