Neurology, Neuropsychiatry, Psychosomatics

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Vol 15, No 5 (2023)
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4-12 163

Neck pain (NP) is one of the most common complaints of patients in outpatient practice and is predominantly non-specific (musculoskeletal) in nature. When examining a patient with NP, it is necessary to rule out a specific cause of the condition. The diagnosis of nonspecific NP (NNP) is based on a clinical examination that excludes signs of specific NP (“red flags”). If there are no signs of specific NP (“red flags”), early (in the first 4 weeks) magnetic resonance imaging is not indicated. It is recommended to inform the patient with NNP about the favorable prognosis of the disease, its risk factors, avoidance of prolonged excessive static and physical activity, incorrect (non-physiological) positions and postures, the effectiveness of therapeutic exercises (kinesiotherapy) and the advisability of maintaining physical activity. Non-steroidal anti-inflammatory drugs and muscle relaxants can be used to relieve NNP. For subacute and chronic NNP, kinesiotherapy, manual therapy in combination with psychological therapy methods (for depressive and anxiety disorders, pain catastrophizing, pain behavior), and antidepressants are recommended. Radiofrequency denervation may be effective for chronic NNP associated with cervical facet joint pathology. There are no convincing data on the efficacy of electrotherapy, ultrasound, traction, and wearing a cervical collar in the absence of orthopedic indications. For preventive treatment of NNP, kinesiotherapy and an educational program to avoid excessive static and physical activity, incorrect positions and postures are recommended. The issues of duration and frequency of therapeutic exercises for the treatment and prevention of NNP need further investigation.


13-19 275

Stroke in the arteries of the vertebrobasilar system is characterized by a variety of nonspecific symptoms, many mimickers, and often atypical clinical presentation, which, together with the low sensitivity of CT and MRI of the brain, leads to incorrect and untimely diagnosis. This article addresses in detail the issues of differential diagnosis of this disease with Guillain–Barre syndrome, myasthenic crisis, central pontine myelinolysis, multiple sclerosis, Wernicke encephalopathy, vestibular neuronitis, Meniere's disease, and vestibular migraine.


20-34 149

Functional dizziness (FD) is one of the most common causes of chronic dizziness for which there is no effective drug therapy, highlighting the importance of searching for new treatment technologies.

Objective: to evaluate the efficacy and safety of Vespireit® (INN buspirone) prolonged-release tablets 15 mg2 (JSC “Valenta Pharm”, Russia) compared with placebo in the treatment of patients with autonomic dysfunction syndrome accompanied by FD.

Material and methods. The clinical trial (CT) included a total of 268 patients with autonomic dysfunction syndrome accompanied by FD and a DHI (The Dizziness Handicap Inventory) dizziness scale score of 36 to 52 inclusive, who were randomly divided into 2 groups and treated in a double-blind fashion. 135 patients (Group 1) received Vespireit® prolonged-release tablets 15 mg at a dose of 15 mg (1 tablet) once daily for 28 days. 133 patients (Group 2) received placebo at the same dosage regimen. Treatment was given against a background of vestibular gymnastic exercises. The primary outcome of the clinical trial was assessment of patient response rate (proportion of responders), i.e., a ≥50% reduction in total DHI for dizziness score at Visit 5 (day 28±1) compared with baseline (Visit 1, day 1). Secondary efficacy measures included assessment of: 1) treatment response rates (≥50% reduction in DHI total score compared to Visit 1) at Visits 2, 3, and 4; 2) DHI total score at Visits 2, 3, 4, and 5; 3) changes in DHI total score at Visits 2, 3, 4, and 5 compared to Visit 1; 4) proportion of patients with a 30% or greater reduction in DHI scale dizziness compared with baseline at Visit 2, 3, 4, and 5; 5) time elapsed until total DHI score decreased by ≥50% compared to baseline; 6) time elapsed until total DHI score decreased by ≥30% compared to baseline; 7) changes in Digital Rating Scale (DRS) score from Visit 1 to Visit 2, 3, 4, 5; 8) scores on the DRS at Visits 2, 3, 4, 5; 9) proportion of patients with different response to treatment on the Likert scale at Visits 2, 3, 4, and 5. Additional secondary criteria of efficacy were also assessed: total Hamilton Depression Rating Scale (HDRS) score at Visits 4 and 5; change in total Hamilton scale score at Visits 4 and 5 compared to Visit 1. The safety criterion assessed in the clinical trial was monitoring of adverse events (AEs), clinically significant deviations in vital signs, laboratory parameters, and ECG parameters.

Results. The proportion of responders with a ≥50% reduction in DHI total score at Visit 5 (Day 28±1) compared to baseline (Visit 1, Day 1) was 68.7% (n=92) in Group 1, which was 52.9% more than in Group 2 – 15.8% (n=21) (p<0.0001). Evaluation of all secondary (including additional) efficacy criteria also showed a statistically significant benefit of therapy in Group 1 compared to Group 2 (p<0.0001). A total of 61 AEs were recorded in 46 (17.2%) patients: 30 AEs in 21 (15.6%) patients in Group 1 and 31 AEs in 25 (18.8%) patients in Group 2. There was no significant difference between treatment groups in the number of patients with AEs (p=0.5196). In both groups, there were no patients with AEs with severity ≥3, serious AEs (SAEs), SAEs with fatal outcome, or SAEs that led to discontinuation of study therapy. No clinically significant abnormalities were noted during assessment of vital signs, laboratory parameters, or ECG parameters

Conclusion. The superiority of Vespireit® prolonged-release tablets (PR) 15 mg therapy over placebo in reducing FD in patients with autonomic dysfunction syndrome was confirmed. The drug demonstrated a favorable safety profile comparable to placebo.

35-38 92

Cervical dystonia (CD) is common in outpatient practice but in many cases is diagnosed at late stages. The efficacy of long-term botulinum therapy (BT) in CD has been poorly studied.

Objective: to analyse the typical practice of treating patients with CD and the efficacy of long-term BT therapy (three years).

Material and methods. Sixty-three patients (43 women and 20 men) diagnosed with CD (mean age 51 [42; 63] years) participated in the study. We performed an analysis of typical practice of managing patients with CD before starting BT. The mean duration of disease at the time of referral was 6 [4; 10] years. Patients received repeated injections of BT at 10–20 week intervals; BT was administered under electromyographic control and ultrasound navigation. The severity of CD was assessed using the Toronto Western Spasmodic Torticollis Rating Scale (TWRSTW), quality of life using the EuroQol-5D questionnaire (EQ-5D) questionnaire, and anxiety level using the Generalized Anxiety Disorder Questionnaire scale-7, GAD-7). Patients' condition was assessed at baseline, 1 month after BT, and after 3 years against the background of regular BT. The severity of the disease before BT was 36.71±3.6 points. The control group consisted of 46 healthy subjects (39 women and 7 men, mean age 53.8±12.3 years).

Results. The diagnosis of CD was made on average 2.3±1.1 years after the onset of the first symptoms, BT was started on average 5±2.6 years after diagnosis. At the first visit to the physician, CD was detected in only 32% of cases. In the CD group there was an increase in the severity of anxiety up to 9.93±4.7 points (in the control group – 4.28±3.5 points; p≤0.05) and a decrease in quality of life down to 62.53±12.1 points (in the control group – 86.38±6.4 points; p≤0.05). One month after BT, a significant decrease in the severity of the disease was observed – from 36.7±13.6 to 13.3±10.8 points (p≤0.05). After three years of regular BT the severity of the disease decreased to 12.7±10.5 points (p≤0.05), the level of anxiety decreased to 5.2±3.7 points (p≤0.05), the patients' quality of life increased up to 77.93±8.4 points (p≤0.05).

Conclusion. CD is still underdiagnosed in practice, and BT is not prescribed until several years after the onset of the disease. Regular and longterm use of BT not only reduces the severity of CD, but also reduces the severity of anxiety disorders and improves patients' quality of life.


39-45 74

The article presents a review of the literature and a description of a clinical case of osmotic demyelination syndrome manifested by pontine and extrapontine myelinolysis in a 36-year-old woman after her third surgical preterm delivery. The reasons for the development of a demyelinating lesion of the central nervous system are discussed, and clinical cases described in world literature sources are presented. An analysis of the pathogenesis of the development of this disease in women during pregnancy, childbirth, and lactation is provided. The importance of this period in a woman's life as an independent significant risk factor for the development of osmotic demyelination syndrome is discussed.

46-53 94

Compression of nerve roots by herniated intervertebral discs (IVD) is a major cause of lumbosacral radiculopathy and often causes problems in patient management. We present a case report of a patient whose initial pain was axial discogenic in nature, probably due to a fissure of the annulus fibrosus, and who later developed LIII–IV radiculopathy. The timing of formation of a sequestered IVD hernia was recorded on MRI. There was no prolonged gradual formation of IVD hernia (bulging, fissure, protrusion, extrusion/sequestration), an acute formation of disc herniation occurred. Conservative treatment, including nonpharmacological (McKenzie gymnastics, educational program) and drug treatment (nonsteroidal anti-inflammatory drugs, anticonvulsants), as well as minimally invasive measures (epidural administration of local anesthetics and glucorticoids), allowed rapid regression of clinical symptoms and improvement of functional and emotional status. MRI of the lumbar spine performed six months after onset showed complete resorption of the IVD hernia. The patient follows ergonomic recommendations and performs therapeutic exercises (Nordic walking); no deterioration was observed within 9 months.


54-64 131

Depression is one of the most common medical causes of disability and mortality in patients of all ages. Depressive disorders are common in the practice of physicians of a variety of specialties, including psychiatrists, neurologists, and physicians. This paper provides a summary review of the literature on modern ideas about the epidemiology, classification, and clinical picture of depression. Current approaches to the diagnosis and treatment of depressive disorders in neurological and psychiatric practice are discussed. Modern pharmacotherapeutic strategies for the treatment of depression in various patient populations are described in detail. Current clinical practice indicates the high importance of an interdisciplinary approach in the diagnosis and management of patients with depressive symptoms in Russia. The paper suggests organizational and educational strategies that can be recommended to improve the effectiveness of medical care for patients with depressive disorders.

65-71 165

Visual snow syndrome (VSS) is a visual perception disorder characterized by persistent positive visual symptoms described by patients as “tiny dots, pixel vision, interference as on TV”. To date, the prevalence of VSS may be as high as 2.2–3.7% of the population, which significantly increases the interest not only of physicians but also of medical researchers. In addition, patients may have other visual symptoms as well as tinnitus, migraine, dizziness, tremor, fibromyalgia, paresthesias, depersonalization, derealization, anxiety, and depression. VSS may affect quality of life, educational, professional and social activities. The article discusses the criteria for diagnosis, pathogenesis, differential diagnosis, clinical cases, and approaches to the treatment of VSS.

72-78 125

To date, inflammatory mechanisms are known to be involved in neuronal damage and increased risk of associated mental disorders, but most previous work has focused primarily on cytokines and other inflammatory markers that are difficult to replicate and not economically feasible for use in routine clinical practice. Other extremely important indicators of the systemic inflammatory process are circulating blood cells and changes in their number, composition, and ratio. Hematologic indices of systemic inflammation (HISI) are already used in somatic specialties: neutrophil-lymphocyte (NLR), monocyte-lymphocyte (MLR) and platelet-lymphocyte (PLR) ratios, as well as the Systemic Immune Inflammation Index (SII) and the System Inflammation Response Index (SIRI). In the context of psychopathology, the HISI require additional investigation, which makes it necessary to pay more attention to the possible mechanisms underlying their changes. The article provides data on the contribution of each cellular element to the mechanism of neuroinflammation and neurodegeneration and on their role in the development of psychopathological processes.

79-86 98

Since the appearance of the first antidepressants, ideas about the goals of long-term treatment of depression have changed considerably. The prevailing priority in the 1960s to 1980s of relieving current depressive symptoms and ending the current episode – shifted to achieving remission in the early 1990s and functional recovery in the mid-2010s. The general recognition of a new approach to the treatment of depression is reflected in the inclusion of functional disorder in the ICD-11 diagnostic criteria for a depressive episode. The paradigm shift in therapy has been driven by advances in the field of psychopharmacology that have led to the development of antidepressants with a fundamentally new mechanism of action that provides a broader therapeutic effect combined with a more favorable tolerability profile. Agomelatine provides a harmonious and complete reduction of depression symptoms, including those resistant to other antidepressants, and a stable clinical and functional remission of high quality, i.e., it allows the achievement of all three therapeutic goals.

87-93 112

Headache and dizziness are the two most common complaints with which patients turn to physicians of various specialties. A thorough examination often reveals a combination of these two symptoms. Currently, the term “vestibular migraine” (VM) is recognized by the worldwide community of otoneurologists and neurologists as the most appropriate for the combination of vestibular vertigo and migraine headaches. The difficulties in diagnosis and differential diagnosis are related to the lack of possibility to confirm the disease (and to detect) instrumentally and to the fact that the dizziness may be different in different VM episodes, even in one patient. The complexity of therapy is in the need to choose a relatively individualized treatment regimen and in the lack of an ideal vestibular suppressant (which quickly suppresses dizziness and has no significant side effects). In this context, finding the most effective drugs for emergency and elective treatment of patients with VM is undoubtedly important. For patients with VM, the use of the drug Arlevert (dimenhydrinate 40 mg + cinnarizine 20 mg) can be recommended for the relief of acute vestibular crisis at home, since the drug is highly effective and well tolerated. In addition, and most importantly, Arlevert has no known interactions with other medications used for migraine prevention.

94-101 125

Depressive disorders and anxiety are the most common mental disorders in the perinatal period, occurring in 14–23% of women. Antidepressants from the selective serotonin reuptake inhibitor (SSRI) group are considered the drugs of choice for the treatment of these disorders. Although SSRIs are the best-studied antidepressants used in pregnant women, there are still conflicting opinions about their effect on pregnancy course and outcomes of pregnancy. At the same time, the risks associated with their use in pregnant women are often exaggerated, while the risks of untreated mental disorders are underestimated. SSRI use during pregnancy has been associated with a modestly increased risk of adverse events, including postpartum haemorrhage, miscarriage, preterm birth, cesarean delivery, fetuses small for their gestational age and low birth weight, low Apgar scores, and increased rates of neonatal hospitalization to intensive care units. However, depressive and anxiety disorders in the mothers themselves also contribute to similar outcomes, so it is not always possible to distinguish the contribution of medication and illness. Comparative data on the effects of different SSRI medications on outcome for the mother and fetus during pregnancy are limited, but paroxetine and fluoxetine are reported to pose the greatest risk to the fetus/neonate. Information on the safety of citalopram and escitalopram during pregnancy and lactation is limited. Citalopram has the highest concentrations in amniotic fluid of all SSRIs. According to current data, sertraline has the most favourable safety profile during pregnancy and lactation, which is explained by its low penetration through the placenta. Sertraline concentrations in the fetus are approximately 1/3 of those in maternal plasma. Sertraline has the lowest concentrations in breast milk of all SSRIs and is associated with a low risk of adverse effects in a baby, making it the drug of choice for nursing mothers. In conclusion, sertraline is one of the best studied SSRIs and has a favourable safety profile for both the mother and the fetus/neonate.

102-108 88

Sex hormones have a significant influence on the course of migraine in women. Perimenopause is accompanied by unstable cycle length, vasomotor, urogenital and other symptoms, while the course of migraine usually worsens. In postmenopause ovarian follicular function decreases, and the course of migraine improves in most cases. However, a number of studies have shown that the course of migraine does not change or even worsen after menopause. Perimenopausal and postmenopausal migraine patients are also more likely to suffer from vasomotor symptoms. Hormone replacement therapy is prescribed to relieve vasomotor symptoms, which may worsen the course of migraine. In this review, the influence of perimenopause and postmenopause on the course of migraine, the use of hormone replacement therapy, and methods to relieve and prevent attacks in patients with migraine are examined in detail.

109-116 72

Pharmacologic symptomatic treatment of headache attacks is an essential strategy for effective management of patients with migraine. Choosing a medication requires an individualized approach and consideration of patient profile, characteristics of ictal manifestations of migraine, and personal experience in headache relief. Among the recommended medications, triptans are the first choice therapy. The pharmacologic differences among triptans allow selection of the most effective drug depending on the individual needs of the patient. Considering the primary importance of characteristics such as speed and duration of pain relief, as well as the consistency of effect in interrupting successive attacks, the choice of rizatriptan may be optimal for migraine patients.

117-124 86

Among the various syndromes in the post-stroke period, asthenic disorder plays an important role, the presence of which is associated with unfavourable course of the disease. Post-stroke fatigue is, on the one hand, the result of organic brain lesions and, on the other hand, a person's emotional reaction to the clinical manifestations of stroke and its consequences. Affective and cognitive disorders are common comorbidities of fatigue after stroke. To correct asthenic manifestations, a holistic approach with pharmacological, physical, and psychological treatments is used. The main components in the pathogenesis of fatigue are hypoxia and energy imbalance, so it seems reasonable to include in the complex therapy of post-stroke fatigue the drug Cytochrome C, which is a key peptide of the mitochondrial respiratory chain. Considering the frequent combination with cognitive disorders of different modality, the use of bovine cerebral cortex polypeptides in patients with post-stroke fatigue is pathogenetically reasonable. Inclusion of drugs with a complex mechanism of action on hypoxia, oxidative stress, energy deficiency, and neuroplasticity processes in the therapeutic algorithm may increase the effectiveness of treatment.


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ISSN 2074-2711 (Print)
ISSN 2310-1342 (Online)