Neurology, Neuropsychiatry, Psychosomatics

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Vol 6, No 1 (2014)


4-8 19769

Attention deficit hyperactivity disorder (ADHD) is a common neuropsychological disorder occurring in 5-8% of school-aged children. In case of late diagnosis and lack of correction, this condition may lead to intra-family problems and formation of antisocial behavior, which largely determines the relevance of the research into ADHD. The main clinical manifestations of ADHD include attention deficit, hyperactivity and impulsivity, as well as symptoms of staticolocomotory deficiency. The pathogenesis, diagnosis, and treatment of ADHD are discussed. 

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This article discusses the clinical and paraclinical aspects of pain syndromes of the lumbosacral localization. The past medical history (including the working conditions of the patient and the presence of constant stress), physical and paraclinical examination, and assessment of psychological condition are important for establishing the correct diagnosis. It should be noted that there is no strict parallelism between the presence of back pain and the results of paraclinical examination of the spine. Therefore, the comprehensive assessment of the patient's clinical status, including the state of the musculoskeletal system, has a leading value for correct diagnosis and selection of therapy.
Increasing pain when coughing or sneezing is noted in patients with discogenic pain syndromes; the development of pain along the root innervation often occurs simultaneously with the reduction of localized pain in the lumbar region.
The diagnostic value of the radiography and neuroimaging data is unquestioned; however, these methods allow one to evaluate mainly the anatomical rather than pathophysiological changes. The direct dependence between the anatomical changes and the clinical situation is not typical of back pain. Magnetic resonance imaging (MRI) is when the injury level is unclear and the clinical examination data indicate pathology of the spinal cord or soft tissues. Moreover, MRI data help either to eliminate or confirm a tumor or the inflammatory nature of the pain syndrome. MRI is also an informative method in patients who have undergone surgery for vertebral pathology. Computed tomography is an effective diagnosis method only in those cases where the symptomatology clearly indicates the injury level and the bone changes are the pain cause with a high degree of probability. Electromyography (EMG) is very informative in patients with radiculopathies; it allows one to evaluate the pathophysiological changes in such patients. However, there usually is no need for using EMG upon clinically apparent lesion of the root. In a number of cases, additional information can be obtained using blocks with an analgesics or pain-provoking agents.

The lack of close relation between the neuroimaging data and the clinical aspect of a disease may underlie the unreasonably broad application of these methods and overestimation of their results. Hence, there may emerge undue anxiety, since both the patient and the physician can set an unreasonably high value on paraclinical data, while the actual role of these results is insignificant. Upon that, an incorrect assessment of the situation results in inadequate and ineffective therapy. 


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The aim of the study was to explore condition of the nervous system in different types of childhood dysphasia (CD), to compare the brain bio-electric activity to the level of cerebral blood flow, severity of neurological disorders, and neuropsychophysiological parameters, to identify the intact links of brain organization in children with minimal brain dysfunction (MBD), sensorineural hearing loss (SNHL), and spastic forms of infantile cerebral palsy (ICP).
Patients and methods. 505 Children aged 4–8 years were examined: 218 with MBD, 73 with SNL, and 214 with spastic forms of ICP. The patients were divided into two groups: preschool age, 4–6 years (110 children with MBD, 29 with SNHL, and 116 with ICP) and early school age, 7–8 years (108 children with MBD, 44 with SNHL, and 98 with ICP). The group of preschool age children with spastic forms of ICP comprised 42 children with double hemiplegia (DHP), 36 with spastic hemiplegia (SHP), and 38 with spastic diplegia (SDP). The early school age group comprised 32 children with DHP, 37 with SHP, and 29 with SDP.
All children underwent general clinical and neurological examination, computerized electroencephalography (EEG), neuropsychophysiological and speech testing, transcranial Doppler ultrasonography, and if required, computed tomography (CT) and magnetic resonance imaging (MRI) of the brain. To clarify the mechanisms of cerebral disintegration in children with signs of epileptiform activity, in the day-time EEG recording, extended video-EEG monitoring was performed for 12–14 h with mandatory recording of nocturnal sleep. Condition of the audio-verbal sphere in children with SNL was examined using an original computer program, Speech_Audiometry.

Results and discussion. The rate of the motor type CD upon MBD was demonstrated to be 77.6%; the mixed type CD predominated in children with SNHL and ICP: 82.2 and 66.2%, respectively. Upon spastic forms of ICP, a combination of CD with symptoms of dysarthria and oral dyspraxia was detected in 84% of cases. A mutually aggravating effect of the main clinical manifestations on the nature and intensity of speech development disorders was revealed, especially when a child had two or more active pathological processes in the CNS. A number of clinical-neurophysiological and neuropsychological correlations with different types and versions of CD were found, which allows one to perform computerized support of rehabilitation of these children and to develop differentiated approaches to treatment. 

21-25 525

The aim of the study was to explore the most characteristic clinical manifestations of brain tumors in children, depending on their localization, and to detect the earliest of them.
Patients and methods. A total of 56 children (32 boys and 24 girls) with brain tumor, aged from 1.5 months to 15 years, were examined. The time elapsed between the onset of disease to the emergence of clinical symptoms was assessed. Neurological symptomatology was compared to the localization of a tumor diagnosed using neuroimaging techniques (computed tomography or magnetic resonance imaging) and during surgery. Surgery was performed in 18 children (in all of them, localization of the process was observed in the posterior cranial fossa, PCF). Results. The highest incidence of brain tumors was revealed in children aged 3–13 years; most patients became ill at the age between 3 and 6 years.
Tumors of the PCF predominated in terms of their localization (67.9% of cases). Intracerebral tumors of the hemispheres or vermis were observed in most (63.2%) patients with tumors of the PCF.
In 11 (61%) of the 18 operated children with subtentorial tumors, astrocytomas of various degrees of differentiation and medulloblastomas were detected using the histological examination. Tumors of the IV ventricle were ependymal. Tumors of the cerebral hemispheres (19.6%), of the pineal and chiasmosellar regions (8.9%) predominated among supratentorial tumors.
The time between the emergence of initial symptoms of a disease and admission to hospital ranged from 1 month to 3 years. The most characteristic and earliest symptoms for tumors of the PCF and brain ventricles were headache, nausea and vomiting. For tumors of the cerebellar vermis and hemispheres, these symptoms included impairment of the coordination of movements and the muscle tone change. For brain stem tumors, these symptoms included dysfunction of the cranial nerves. For tumors of the cerebral hemispheres, these were seizures and motor and sensory disturbances in the limbs. 

26-29 509

The aim of the study was to cerebral hemodynamics in patients with cognitive dysfunction associated with atrial fibrillation (AF). Patients and methods. Fifty-six patients aged 40–75 years (the mean age was 62.7±6.3 years) with nonvalvular AF caused by ischemic heart disease were examined. In 30 (53.6%) patients AF was permanent; in 26 (46.4%) patients, it was either persistent or paroxysmal. The exclusion criteria were as follows: past transient ischemic attacks, stroke or myocardial infarction, and severe somatic diseases.
All patients with AF were evaluated for cognitive functions (using the short scale for assessing the mental status), auditory memory and associative memory (using the Schulte test), and emotional background (using the Hospital Anxiety and Depression Scale). Ultrasonography of the extracranial and intracranial vessels and registration of the average linear blood flow velocity (LBFV) was performed. Results. Cognitive impairments (CI) were diagnosed in 38 patients who entered the main group; patients with AF without CI comprised the control group.
82.6% of patients of the main group were diagnosed with constrictive lesion of the carotid (CA) and vertebral (VA) arteries of various severity; the isolated lesion of the CA was observed in 23.7% of patients, the isolated lesion of the VA in 18.4%; multiple lesions of the CA and VA in 69.4%; and the hemodynamically significant lesion, in 30.3%. In patients of the control group, constrictive lesions of the extracranial arteries were observed in 65.5% of cases. Condition of the major arteries of the head (MAH) significantly affects the LBFV parameters of the intracranial arteries. In patients with multiple lesions of the CA and VA, the LBFV in the intracranial vessels was much lower than that in patients with isolated lesions of the CA and VA.

The relation between the rate and severity of constrictive lesions of the MAH and the presence of AF accompanied with CI was noted in patients. Cerebral hypoperfusion, stenosis of the MAH, and lesions of the small cerebral arteries play an important role in pathogenesis of CI in patients with AF. Changes in the cerebral hemodynamics were stronger pronounced in patients with cognitive dysfunction associated with AF. To prevent the development and progression of vascular dementia, patients with AF need complex treatment by a cardiologist and a neurologist. 

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The aim of the study was to explore the effect of Thiocetam (combination of pyracetam and thiotriazoline) on recovery of neurological functions, social adaptation and improvement of the mental and emotional states of patients with ischemic stroke.
Patients and methods: The study involved 250 patients (132 females and 118 males) aged 38 to 85 years (mean age 68.3 years) after an ischemic stroke. All patients received treatment aimed at preventing recurrent stroke (antithrombotic and antihypertensive drugs, statins) and restoring the lost functions (therapeutic exercise, etc.). Additionally, 125 patients received intravenous infusion of Thiocetam at a dose of 30 ml for 14 days, then 1 tablet TID for 1 month (group 1); the second group included 125 patients who received no Thiocetam (control group).
Results: Thiocetam facilitated recovery of neurological functions and social adaptation, normalized the emotional state of patients after a stroke. Further randomized, placebo-controlled studies of Thiocetam efficacy in patients with ischemic stroke are required. 


48-53 547

Possibilities of antithrombotic therapy in prevention of cardioembolic stroke (CES) in patients with nonvalvular atrial fibrillation (AF) were significantly broadened after new oral anticoagulants (NOC) have been designed and launched into clinical practice (rivaroxaban being one of these agents).

In real-life clinical practice, nonvalvular AF can be combined with various cardiovascular pathologies in patients who have had CES, thus giving rise to situations when there are no specific recommendations for NOC.

The article analyzes the most common comorbid clinical situation in vascular neurology and evaluates the potential of rivaroxaban as an alternative to warfarin. Rivaroxaban is shown to be a promising drug for widespread use in angio-neurological practice for treating combined cardiovascular pathology. 

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Timely diagnosis and the early start of therapy for cognitive impairments (CI) are extremely important. Unfortunately, there is a serious problem of belated CI diagnosis (it is often diagnosed only at the stage of severe dementia). The article discusses the current CI classification by the severity level. Special attention is paid to clinical symptoms, diagnostic criteria, and the basic principles of managing dementia patients. The differences in the severity levels of dementia are discussed in detail; special attention is given to severe dementia. It is noted that the presence of severe dementia in the patient is indicated by permanent dependence on physical assistance. The demand for structuring the clinical assessment of the state of cognitive functions and of the CI influence on daily activity is emphasized. For this purpose, it is recommended that special clinical scales listing cognitive symptoms that are most typical of various stages of cognitive deficit are used. The Clinical Dementia Rating (CDR) Scale is one of the well-proved scales. The main approaches for managing patients with severe dementia, including modern drugs for correction of CI and behavioral disorders, are discussed. The possibility and advisability are discussed for treating severe dementia with acetylcholinesterase inhibitors and/or a competitive blocker of the NMDA-receptor, memantine. Special attention is paid to behavioral disorders in patients with severe dementia. These disorders require both the medication correction and psychological support from relatives. The critical significance is emphasized for the proper patient care and for the correction of associated disorders, including pelvic disorders. Neurogenic inappropriate urination often accompanies the manifestations of CI and other neuropsychiatric disorders in patients with severe dementia. The main groups of medications that are used for drug therapy of this condition, as well as possibilities for using modern absorbents and care agents, are discussed. 

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The current knowledge on epidemiology, diagnosis, and treatment of Alzheimer's disease and dementia of the Alzheimer type are presented.

Various approaches to therapy based on current understanding of the pathogenesis of the degenerative process are discussed with allowance for the clinical features of the disease (psychopathologic symptoms and stage of the disease). Special attention is paid to compensatory therapy aimed at compensating for the deficit in cholinergic and glutamatergic neurotransmission. 

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This review focuses on the possible mechanisms of sleep disorders in patients with cognitive impairment (CI) of different severity. The interrelation between CI, emotional disorders and insomnia, as well as the dependence of CI severity on the degree of sleep disorders, are discussed.

The issues related to treatment of sleep disorders in patients with CI, the advantages and disadvantages of modern somnogenic medications are studied. Recommendations on management of patients with a combination of sleep disorders and CI are provided. Data on the use of Egb 761 to treat CI no dementia and melatonin-based drugs to treat sleep disorders in patients with CI are presented. 

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Vascular pathology of the brain is the second most common cause of cognitive impairment after Alzheimer's disease. The article describes the modern concepts of etiology, pathogenetic mechanisms, clinical features and approaches to diagnosis and therapy of vascular cognitive impairment (VCI).

Cerebrovascular accident, chronic cerebral circulatory insufficiency and their combination, sometimes in combination with a concomitant neurodegenerative process, are shown to be the major types of brain lesions leading to VCI. The clinical presentation of VCI is characterized by the neuropsychological status dominated by impairment of the executive frontal functions (planning, control, attention) in combination with focal neurological symptoms.

The diagnosis is based on comparing of the revealed neuropsychological and neurological features with neuroimaging data. Neurometabolic, acetylcholinergic, glutamatergic, and other vasoactive drugs and non-pharmacological methods are widely used to treat VCI. 

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pathy in Parkinson's disease (PD) patients is one of the least studied manifestations of a broad range of neuropsychic disorders. According

to numerous researchers, the rate of apathy in PD patients is 17–80%. The structural and neurochemical changes associated with PD have been considered to be the leading pathophysiological factors of apathy. The possible general pathophysiological mechanisms are discussed for apathy and hypokinesia, depression, executive (frontal) cognitive functions, and sleep disorders in PD patients. The pathophysiological commonality of apathy, hypokinesia, and executive functions is probably based on bilateral disorders of functional links of the striatum and dorsolateral, medial parts of the prefrontal cortex. A combination of apathy and depression in PD patients may be due to dysfunction of the structures of the limbic system and medial orbital prefrontal cortex, which are responsible for the motivationally driven behavior.

Variability of relationships of apathy with hypokinesia, depression, cognitive impairments, sleep disorders at different stages of PD may be associated with the phenomenological heterogeneity of apathy.
Apathy reduces quality of life, makes a significant contribution to disturbances of both everyday and social adaptation of PD patients. A study of the possibility for apathy correction using dopaminergic therapy is rather promising. Twenty patients with PD (the middle stage according to the Hoehn and Yahr scale, 2.5) received pramipexole (1.5–3.0 mg/day) to correct motor disorders. A statistically significant positive trend in the time course of apathy, according to the overall assessment by the Starkstein apathy scale (AS), was noted after 4–6 weeks of the therapy. Based on the results, no statistically significant correlation was observed between the dynamics of the overall apathy score and the dynamics of motor symptoms of PD on the unified rating scale for PD assessment («Motor functions»). We believe that this fact demonstrates the independent effect of pramipexole therapy against motivational disorders. 

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We present a review of literature devoted to epidemiology, and the nosological and syndromal structure of back pain in children. The data of our own study of school-aged children with back pain are presented.
The structure of back pain syndromes in 105 children has been analyzed using the medical aid appealability data. The results of a comprehensive clinical and instrumental study demonstrated that the children mostly had lumbosacral pain (52.4% of cases); neck pain was observed in 29.5% of cases; while thoracic pain syndromes were observed in 18.1% of cases. Congenital defect of the connective tissue was diagnosed in 16.19% of children; congenital abnormalities of the spine, in 15.2%; scoliosis (idiopathic and secondary), in 8.6%; and Scheuermann-Mau's disease, in 5.71%.
The conclusion has been made about the high prevalence of back pain in schoolchildren. Muscular tonic syndromes were prevailing in the clinical structure in children; radicular syndromes were less frequent. Musculoskeletal disorders were the main causes of back pain. Congenital defect of the connective tissue was often observed, which was revealed as functional instability of the vertebral motor segment, spondylolisthesis due to weak ligaments, and disc protrusions. Congenital abnormalities of the spine, scoliosis, and Scheuermann-Mau' disease were observed less often. 

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Most reports on vascular pathology of the brain have been devoted to arterial blood flow, while morphometric studies of the brain have demonstrated that approximately 85% of the vascular bed of the brain accounts for venous vessels, 10% accounts for the arteries, and about 5% accounts for capillaries. Nevertheless, only a few studies regarding venous pathology of the brain have been published. Many authors admit that the arterial and venous segments of the vascular bed represent a complex interdependent system, where the venous segment is considered to be a highly organized reflexogenic zone responsible for the development of complex, physiologically important, compensatory reactions that provide the constancy of cerebral blood flow.
Venous circulation disorders, cerebral venous dyscirculations (CVDs), as well as thromboses of the intracranial veins and sinuses, comprise a significant part of vascular lesions of the brain. The etiologic and pathogenetic aspects of CVD, as well as of thromboses of the intracranial veins and sinuses, have been analyzed. The issues of diagnosis and management of patients with cerebral venous disorders have been considered. Clinical manifestations and characteristics of progression of this pathology have been presented. Cerebral venous thromboses and CVP are often severe, but potentially treatable diseases. Knowledge of the main clinical symptom complexes makes it possible to timely diagnose this pathology and perform effective differentiated pathogenetic and symptomatic therapy in these patients. 


35-43 617

Paraneoplastic cerebellar degeneration (PCD) is a rare form of the paraneoplastic neurological syndrome (PNS). PCD is an autoimmune disease of the central nervous system (CNS) affecting the Purkinje cells and possibly other cells of the cerebellum. PCD is characterized by a rapid onset resulting in disability for a few days or weeks; a slow progredient increase in cerebellar symptomatology is observed less often. PCD develops in 1–3% of cancer patients; its fraction accounts for 25% of all forms of PNS. The mean incidence rate of PCD is about
2 cases per 1,000 cancer patients. PCD develops in patients with cancer of the ovary, uterus and fallopian tubes, with small cell lung cancer and Hodgkin's lymphoma. The incidence rate among females is 3 times higher than that among males. Females aged 50–65 years are most likely to suffer from PCD. PCDs are divided into four main subgroups that differ in terms of prognosis and range of associated antineuronal antibodies. In the last decade, different classes of anti-onconeuronal antibodies associated with PCD have been described; 9 of them have been best studied. Anti-Yo and anti-Hu antibodies are most frequently detected upon PCD. PCD can be also diagnosed without anti-onconeuronal antibodies associated with it or their titer in the blood can be low. Differential diagnosis of PCD is complex and is conducted for a wide range of CNS diseases. No single approach to treating PCD currently exists. Surgical removal of the tumor, the source of production of anti-onconeuronal antigens, followed by radiotherapy and/or chemotherapy, does not solve the problem completely, but may reduce severity of the clinical manifestations of PCD or stabilize the pathological process. This explains the need for rapid and profound search for a tumor in patients suspected with PCD. The authors described a clinical case of an acute debut of PCD in 47-year-old female, 6 months after which, the patient was diagnosed with breast cancer. The problems of PCD diagnosis by neurologists are discussed. The importance of the interdisciplinary approach to diagnosis and follow-up monitoring of patients with this nosology is noted. 

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In outpatient practice, neurologists often face patients diagnosed with dyscirculatory encephalopathy (DEP). Sleep disorders, headaches, rapid and unexplained fatigability, and irritability are predominating, which poses a number of complex medical issues. A case report of a 69 year-old patient, who was being followed up for a long time because of DEP diagnosis is reported. However, examination of the neu-ropsychic status revealed the depressive disorder with somatoform complaints, which was verified by a psychiatrist. Psychotherapy and antidepressant therapy led to significant improvement.
The differential diagnosis and treatment of depressive disorders in outpatient practice are discussed. 

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