Department of Nervous Diseases, S.M. Kirov Military Medical Academy, Saint Petersburg The paper gives an analysis of new diagnostic criteria for different stages of Alzheimer Х s disease (AD), which is proposed by the U.S. National Institute on Aging. It considers possibilities for the early diagnosis of AD, including its preclinical diagnosis using the laboratory and neuroimaging markers beta-amyloid, neuronal damage.

Moscow Research Institute of Psychiatry, Ministry of Health and Social Development of the Russian Federation The paper provides a historical analysis of the concept of neurasthenia with emphasis on its psychopathological heterogeneity. It considers predisposing and initiating factors in the genesis of neurasthenia. Particular emphasis is placed on its differential pharmacotherapy, by keeping in mind its predisposing factors. The results of studies confirming the efficacy of Tanakan® in different types of this abnormality are given.

Objective: to study the mechanisms of poststroke spasticity and the role of structural and functional impairments of skeletal muscles in its pathogenesis. Patients and methods. Thirty-two patients with prior hemispheric stroke and evolving spastic paresis were examined. Neurophysiological studies of upper and lower motor neuron functions and morphological, histochemical, and immunohistochemical studies of soleus muscle biopsy specimens were conducted. Results. There was diminished excitability of cortical neurons, impaired conduction along the pyramidal tracts, and hyperexcitability of the segmental apparatus of the spinal cord. The muscle exhibited myosin phenotype transformation with a preponderance of fast type II fibers, as well as a higher fiber diameter variability and a lower muscle tissue capillarization. The late periods of spasticity were marked by better conduction along the pyramidal tract, at the same time structural changes tended to increase in skeletal muscle tissue. The time course of the changes suggests that there is partial reversibility in the central nervous system and skeletal muscle, which allows elaboration of approaches to differentiated therapy for the above conditions.

Objective: to study higher mental functions (HMF) in patients with stenotic lesion of the brachiocephalic arteries (BCA) before and after carotid endarterectomy (CE). Patients and methods. Prior to and following CE, 97 patients underwent neurological examination, neuropsychological syndrome analysis described by A.R. Luria, evaluation using the Wexler verbal working memory scale, Stroop word-digital test, and Schulte test. BCA ultrasound duplex scanning and cerebral perfusion were made over time. Results. Preoperative neuropsychological study revealed abnormalities in 98% of the patients. There was most common bilateral frontal dysfunction and deep structural pathology, which were more pronounced in persons above 50 years of age and in the presence of mixed BCA stenosis. Stenosis-associated unilateral parietal and temporal dysfunctions were more frequently registered. Within 30 days after CE, the maximum HMF changes were found in patients having unilateral stenosis. There was ameliorated dysfunction of the structures blood is supplied to which by an operated vessel and the vertebrobasilar system. Poststroke patients were found to have a significant intraoperative HMF reduction in the early rehabilitation period of stroke. The syndromes having common and local mechanisms of development and different topic sites were identified among the short-term and reversible HMF impairments. Conclusion. Despite heterodirectional HMF changes in the early period after BCA reconstructive operations, the positive cognitive functional changes in all the patients at 30 days of CE confirm the rationale for and efficiency of surgical intervention.

Fatigability is a common nonmotor symptom in Parkinson's disease (PD), which worsens quality of life in patients. Objective: to analyze the association of fatigability with the duration of PD and the degree of movement and neuropsychic (depression, nocturnal sleep disorders, daytime sleepiness) disorders; to evaluate changes in the manifestations of fatigability during therapy with the dopamine receptor agonist pramipexole (Mirapex). Patients and methods. Sixty patients with PD (disease duration 6.02±3.47 years; stage 2.68±0.62) without dementia were examined using the PD fatigue scale (PFS-16), unified PD rating scale (Part 2), the Beck depression inventory, the PD sleep scale, and the Epworth sleeping scale. Results. 66% of the patients were found to consider fatigability to be one of the three most daily life-limiting manifestations of the disease. The integrated rating of fatigability significantly correlated with total depression scores and sleep scores. During pramipexole therapy, there were statistically significant positive changes in fatigability, which did not correlate with those in motor functions, depression, and sleep problems. It is concluded that fatigability substantially impairs the daily activities of patients with PD and is associated with neuropsychic symptoms to a greater extent than with the degree of movement disorders in PD. This may be due to both the common pathophysiological mechanisms of these abnormalities and their comorbidity in PD. The fact that there is no significant association of the time course of changes in fatigability with alterations in the parameters of other neuropsychic functions during therapy conceivably indicated the independent genesis of this symptom.

The paper analyzes the use of movalis (meloxicam) in 150 patients with nonspecific back pain in the outpatient setting. Movalis was given in a single daily oral dose of 15 mg throughout the follow-up; the oral use of the drug was, if required, preceded by a 3-day course of its intramuscular administration (15 mg). The mean cost of treatment (medical services - pharmacotherapy) was 6670 rbl. (range 4601-479 rbl.) in the entire group, 6074 rbl. (range 4367-156 rbl.) in the acute subgroup (n = 112), 8951 rbl. (range 6662-0195 rbl.) in the subacute pain (n = 20), and 9904 rbl. (range 5436-2070 rbl.) in the chronic pain group (n= 18). In patients with subacute and chronic pain as compared to those with acute pain, the cost of treatment was 2121 rbl. (95% CI, 698 to 4744) and 2817 rbl. (95% CI, 701 to 4932) higher, respectively, during much longer treatment. Comparison of the cost of drug therapy and common practice involving manual therapy has demonstrated the benefits of movalis treatment.

Objective: to estimate the significance of parameters of transcranial magnetic stimulation (TMS) of the brain and somatosensory evoked potentials (SSEPs) in the prediction of recovery of motor functions after ischemic stroke. Patients and methods. The study enrolled 63 patients (29 women and 34 men aged 41-5 years) in the acutest period of middle cerebral artery (MCA) basin infarct with evolving hemiplegia. In the first 5 days after stroke, TMS was performed in the projection of the motor cortex of the involved hemisphere, by recording a motor evoked response (MER) from m. tibialis anterior and m. pollicis brevis in hemiplegia; and SSEPs were recorded when stimulating n. medianus and n. tibialis in hemiplegia. The outcomes were assessed a year after stroke: muscle strength on a scale from 0 to 5 e and the Rivermead mobility index were studied. Results. A year later, there was either partial or full recovery of active lower and upper limb movements in 73.3 and 58.2%, respectively. With good and poor motor outcomes, the parameters of MCA rather than SSEPs differed significantly. The optimal threshold amplitude for MER from the lower and upper limbs was 0.25 and 0.3 mW, respectively; the time of central motor conduction was 22 and 19 msec for the lower and upper limbs, respectively. At the same time, TMS findings were insufficient for predicting a patient's mobility. The prognosis was determined by the data of TMS and the results of SSEPs: the best outcomes in movement recovery were noted when the prognosis was positive according to the data of TMS in combination with the preserved parameters of SSEPs in the study of cortical projections of the lower limb. Conclusion. It is expedient to perform TMS to estimate the probability of muscle strength recovery. The SSEPs method cannot determine the prognosis of muscle strength recovery; however, its results are of importance for estimating the promises of recovering a patient's mobility. Therefore, comprehensive neurophysiological examination is warranted.

The authors determined the individual profile of functional interhemispheric asymmetry (IPFIA) in 70 patients (28 men and 42 women) with Parkinson's disease (PD), by using the examination protocol comprising 48 assignments, its association with clinical asymmetry and effect on electroencephalography (ECG) readings. Right-sided PD onset was significantly more frequently observed in patients with a right IPFIA than in those with mixed and left IPFIAs (p<0.05). Left-sided PD onset was significantly more common in patients with mixed and left IPFIAs than in those with a right IPFIA (p<0.05). EEG showed that the generator of pathological slow wave activity was on the side contralateral to that of the affected extremity and had a clearer lateralization in the initial involvement of the dominant hemisphere in the pathological process.

Objective: to study the clinical and psychoemotional characteristics in patients with systematic and nonsystematic vertigo and to optimize therapy. Patients and methods. The clinical features were analyzed in 25 patients with systematic vertigo and 25 patients with psychogenic vertigo. Their psychoemotional sphere was studied using the Beck depression inventory, the Spielberger-hanin personality- and situation-related anxiety inventory, and the vestibular inventory. Results. There were statistically significant clinical differences and a higher degree of anxiety-depressive disorders in the patients with psychogenic vertigo. Drug therapy in combination with stabilometric platform exercises based on the biological feedback principle was stated to be effective in patients with different types of vertigo, in those with psychogenic dizziness in particular.

Patients with atrial fibrillations (AF) and comorbid mental disorders were examined. Two patient groups differing in the structure of psychosomatic ratios were identified. Group 1 comprised patients with AF and signs of reactivity lability that manifested itself as psychopathological reactions to the primary manifestations of AF; Group 2 included those who had developed mental disorders mainly in end-stage cardiovascular disease (predominantly a permanent form of AF) in the presence of such events as chronic heart failure (CHF). The results of the study suggest that the patients with AF have frequently anxiety and hypochondriacal disorders, which agrees with the data available in the literature. In addition, end-stage AF is marked by depressive syndromes caused by the severe course of cardiovascular diseases resulting in CHF.

Objective: to evaluate the cerebral circulation in idiopathic arterial hypotension (IAH) in relation to neurological and neuropsychological disorders. Patients and methods. Sixty-five patients (mean age 40.2 [8, 14] years) with prolonged IAH were examined. Neuropsychological examination was made using the procedure adapted by A.R. Luria; different psychic functions (memory, speech, gnosis, praxis, thinking, attention, counting, writing, and reading) were studied. Cerebral hemodynamics was investigated using duplex scanning of the brachiocephalic arteries (BCA), middle cerebral arteries (MCA), internal jugular (IJV) and vertebral veins (VV). The patients were assigned to 2 groups: 1) 19 (29%) patients with somatoform disorders, 2) 46 (71%) patients with signs of the initial manifestations of chronic cerebrovascular insufficiency. Group 2 patients were older and had a longer history of IAH. Results. In all the patients, cerebral blood supply in the carotid system showed moderately lower arterial blood inflow with a compensatory vascular resistance decrease and balanced venous outflow reduction with increased vascular resistance. Group 2 patients had a substantial (to the lower normal range) blood flow decline in the vertebral artery along with increased peripheral resistance in the VV. The degree of neuropsychological derangement was inversely proportional to blood flow velocity in BCA and MCA and to blood outflow in IJV and VV.

Reperfusion and neuroprotection are two present-day therapy strategies for patients with acute stroke. The paper reviews currently available drugs used for neuroprotection in ischemic strokes in the context of evidence-based medicine.

Cognitive impairments (CIs) are a highly common type of neurological disorders particularly in elderly patients. Choice of a therapeutic strategy for CI is determined by the etiology of abnormalities and their degree. Measures to prevent CI progression and dementia: adequate treatment of existing cardiovascular diseases, prevention of stroke, balanced nutrition, moderate physical and intellectual exercises, and combatting overweight and low activity are of basic value in treating mild and moderate CIs. According to the data of a number of investigations, the above measures reduce the risk of dementia, including in the genetically predisposed. Pharmacotherapy for mild and moderate CIs generally comprises vasoactive, neurometabolic, and noradrenergic agents. The indication for the use of memantine and/or acetylcholinergic agents, i.e. basic therapy for the most common forms of dementia (Alzheimer's disease, Lewy body dementia, vascular, and mixed dementia), hepatic colics is severe CIs. The long-term use of memantine and/or acetylcholinergic agents alleviates the cognitive and behavioral symptoms of dementia, enhances self-dependence in patients, and prolongs their active lifetime.

Basic directions in the primary prevention of ischemic stroke are presented. Population and high-risk strategies are identified in the system of primary prevention of stroke. The population strategy proposes the use of diverse medical, social, and educational measures that promote the elimination of the negative impact of lifestyle, nutrition, and environment on the incidence of stroke. The high-risk strategy implies individual preventive management in patients at high risk for cardiovascular events. Adequate antihypertensive therapy with blood pressure goals being achieved; antithrombotic therapy with a drug being rationally chosen; normalization of lipid metabolic parameters; and substantiated surgical intervention into the carotid arteries are able to substantially reduce the risk of primary stroke.

The authors have made a generalized analysis of earlier published PARUS program studies covering (2327 patients in different nonmental health care facilities). It has ascertained that depressions in these patients cannot be qualified in Chapter V of ICD-10 (“Mental Disorders” and “Behavioral Disorders”). It has been shown that depressions can be most commonly regarded as mental symptoms of a somatic or neurological disease. This concept best explains the high prevalence of such depressions, as well as their masked, somatized pattern. At the same time this concept is in conflict with the prevailing medical approach contemplating the differentiation between somatic (neurological) diseases and mental disorders.

The paper reviews the data available in the literature on the use of ketorolac in clinical practice. Ketorolac is a highly effective analgesic that has proven to be the best drug in the treatment of pronounced acute pain (during monotherapy and combination analgesic therapy) in the postoperative period or after serious injuries. The drug is excellently combined with narcotic analgesics, which permits reductions in the dose of opioids and in the risk of their adverse reactions. When given in standard doses and used for a short period, Ketorolac is reasonably safe, which makes it the drug of choice to relieve acute pain in therapeutic practice. It may be successfully used in cases of acute lower back pain, toothache, migraine, renal and hepatic colics, and in many other situations requiring prompt and potent analgesia, but it is inexpedient to administer narcotic analgesics. Ketorolac should be regarded as a good alternative to metamizole (analgin) that is still popular in our country.

The paper gives data on the use of the nonsteroidal anti-inflammatory drug (NSAID) aceclofenac (Airtal) for nonspecific back pain and other diseases. Aceclofenac is noted to be as effective as the most known nonselective NSAIDs (diclofenac, naproxen, indomethacin), at the same time it causes much lower rate of adverse gastrointestinal reactions, including hemorrhage. The authors also provide an analysis of serious side effects of NSAIDs in several countries, which shows that aceclofenac is one of the safest NSAIDs.

Neck pain is frequently encountered in clinical practice. In most cases, it is unassociated with a serious problem and ends with complete recovery. Nonspecific (mechanical, axial) pain is most common; posttraumatic pain associated with whiplash injury is less frequently encountered; compression (radicular and myelopathic) syndromes are much less frequent. Analysis of complaints and medical histories and neuroorthopedic and neurological examinations allow one to define the major source of pain. Additional studies are indicated in cases of suspected serious pathology, ineffective standard medical therapy, elective manual therapy or neurosurgery. Paracetamol, nonsteroidal anti-inflammatory agents, and myelorelaxants are the drugs of choice in treating acute pain. If these are ineffective, blocks with local anesthetics and glucocorticoids, including diprospan, are used. Early activation and manual therapy are effective. Psychotherapy, therapeutic exercises, manual therapy, and the use of antidepressants and anticonvulsants are indicated for chronic pain. Surgical treatment has limited indications.

The paper reviews the literature on the use of L-lysine aescinate in the treatment of central nervous system (CNS) diseases. It describes the positive experience of neurologists of Ukraine in using L-lysine aescinate for stroke, brain and spinal cord injuries. It shows that it is necessary to conduct multicenter placebo-controlled trials of the efficacy and safety of the drug in CNS diseases.