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Neurology, Neuropsychiatry, Psychosomatics

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Vol 6, No 2S (2014): Special issue "Stroke"
View or download the full issue PDF (Russian)
https://doi.org/10.14412/2074-2711-2014-2S

LECTURES

7-14 520
Abstract

Ischemic stroke (IS) prevention in non-valvular atrial fibrillation (NVAF) patients who already had IS or Transient Ischemic Attack (TIA) is the actual problem of up-to-date neurology. The article analyses methods of IS secondary prevention in AF, particularly usage of vitamin Kantagonist – warfarin and new oral anticoagulants: inhibitors of Xa factor (apixaban, rivaroxaban) and direct thrombin inhibiror – dabigatran.

Presented results ARISTOTLE study, where have defined preference apixaban vs warfarin, and AVEEROES study, where have shown preference apixaban vs ASA in AF patients. It was noted that apixaban demonstrated superiority vs warfarin in all of the 3 key outcomes:stroke/systemic embolism prevention, including recurrent, major bleeding reducing, reduction in all-cause mortality. Optimization of secondary stroke prevention in AF patients can lead to substantial reduction of morbidity and mortality in our country.

15-22 808
Abstract

Current technologies for treating ischemic stroke (IS) within the first 4.5 hours after its onset involve highly effective brain substance reperfusion techniques (thrombolytic therapy (TLT)) aimed at restoring blood flow in the affected vessel. There has been a substantial increase in the number of systemic TLT procedures after establishing stroke subdivisions as part of regional vascular centers and primary vascular departments in our country. In the past 5 years, the number of IS patients undergoing systemic thrombolysis has virtually risen 10-fold. In 2009–2013, the primary and regional centers of the Russian Federation performed 10,718 systemic TLT procedures mainly in patients with moderate stroke. The further increase in the number of reperfusion procedures in IS patients is hindered by the fact that they seek medical advice too late for acute cerebrovascular attack (ACVA) because the population has low medical knowledge (therefore education campaigns are so important for the population to increase its awareness of the signs of ACVA), prehospital delays and problems, poor organization of hospital admission (delays in diagnostic procedures).

It is important that the patients should be admitted to specialized ACVA departments as soon as possible. According to the AHA/ASA guidelines, the time between admission and TLT initiation (door-to-needle time) should not exceed 60 minutes. The major factors influencing the door-to-needle time are as follows: the time between admission and neurological examination, that between neuroimaging and its results, that of examination of necessary laboratory findings, that between admission and transfer to an intensive care unit after computed tomography. One may identify the following quality indices of the procedures (necessary diagnostic, therapeutic, and other interventions), which negatively affect the safety and efficiency of TLT: errors in determining contraindications to reperfusion, noncompliance with the protocol of thrombolysis, and further patient monitoring.

In terms of the available potential of the established stroke departments, it is absolutely real to increase the number of TLT procedures through active information campaigns among the population, which will contribute to the earliest admission of patients with ACVA to the specialized departments, and it is also necessary to make further organizational improvements of the healthcare system for stroke patients at its all stages.

ORIGINAL INVESTIGATIONS

23-27 493
Abstract

Objective: to compare a multimodal drug approach to treating poststroke cognitive impairments (CI).

Patients and methods. Eighty patients with postroke CI in the early recovery period were examined. They were allocated to 4 groups:1) secondary stroke prevention only (a comparison nontreatment group); 2) actovegin infusions; 3) cerebrolysin infusions; 4) drug therapy in combination with non-drug cognitive training using the standard procedure. Follow-ups and neuropsychological assessments were made at the inclusion in the study and 3 and 6 months after stroke. The state of cognitive functions 6 months after stroke was considered to be an endpoint of the study.

Results and discussion. At the inclusion in the study, the mini-mental state examination and the frontal lobe dysfunction scale showed no statistical differences in cognitive functions in different patient groups. At a 3-month follow-up, the cognitive status in the neuronal plasticity stimulation groups was significantly better than in the comparison group (p≤0.05). At a 6-month follow-up, there was a significant cognitive improvement in the combined stimulation group versus the drug-therapy and comparison groups (p≤0.05). Day-to-day activities and independent functioning also improved significantly more promptly in the patients receiving drug or combined therapies. More complex instrumental activities of daily living recovered significantly better during combined cognitive function stimulation than during pharmacological stimulation only. There was evidence that the drugs with proven stimulating effects on neuronal plasticity and nondrug cognitive training were effective in treating CI in the early recovery period of stroke. The combined drug and nondrug poststroke CI treatments reflecting the multimodal approach versus drug therapy were found to be most effective in these patients.

28-33 471
Abstract

Objective: to study the epidemiology, risk factors, clinical course, and outcomes of ischemic stroke (IS) on the basis of a 20-year follow-up of patients in Surgut (Khanty-Mansi Autonomous District (KMAD)).

Patients and methods. About 9 thousand patients with IS were followed up during the study. The follow-up results obtained in 1990, 2000, and 2012 were compared. The study was conducted in accordance with the procedure described in the Register of Stroke, by using the records of neurological hospitals of the town, its emergency service, urban polyclinics, and forensic medical examination bureau.

Results. The incidence of IS significantly increased in Surgut in the examined period: there were about 300 primary and secondary IS cases in 1990; about 600 in 2000, and above 1,000 in 2012; the increment being nearly 100% per decade. The rise in the incidence of IS was due to the higher prevalence of its major risk factors: hypertension (by 42%), atherosclerosis (by 24%), diabetes mellitus (by 101%), and cardiac arrhythmia (by 18%). Major cerebral artery (MCA) stenosis and occlusion were identified in 162 (43.2%) of 375 IS cases with their neuroimaging diagnosis. The rate of MCA stenotic lesions was not high, increased with age, and assumed considerable significance in patients over 51–55 years of age. There was a seasonal non-uniform pattern of morbidity, its peak (about 70% of IS) occurred in May-June (this is a spring in the KMAD) when there was a dramatic interdiurnal variability in major meteorological factors. The clinical course of stroke was characterized by relatively favorable outcomes, low mortality rates that declined from 14.5% in 1990 to 6.7% in 2012, which stemmed from the improved delivery of health care.

34-41 584
Abstract

Objective: to study the course of free radical processes (FRP) and the role of glycolytic disorders in patients with stroke and transient ischemic attack (TIA) developing in the presence of several vascular diseases (vascular comorbidity).

Patients and methods. The study enrolled 141 patients aged 28–94 years (mean age 65.48±13.44 years) with stroke and TIA developing in the presence of vascular comorbidity. Ischemic stroke was diagnosed in 87 (61.7%) patients, hemorrhagic stroke and TIA were in 35 (24.8%) and 19 (13.5%) patients, respectively. Their neurological and functional status was evaluated over time using the U.S. National Institute of Health stroke scale, the Barthel index, and the Rankin scale. Plasma FRP was investigated over time from the oxygen and lipid peroxide markers of oxidative stress. After hospital discharge, the patients were followed up for 6 months to 6 years. Survival and recurrent cardiovascular event rates were estimated.

Results. In the patients with prior stroke, the severity of vascular comorbidity correlated with the rise in death rates that within 6 years after hospital discharge were 42.9% and 8.3% in patients with 4 cardiovascular diseases (CVD) and 1 CVD, respectively. Vascular comorbidity correlated with the outcome of the disease. Emphasis was laid on the role of hyperglycemia in the breakdown of adaptive processes in stroke. The low level of malonic dialdehyde and the high antiperoxide activity of secondary plasma in the stroke patients are markers for good in-hospital functional recovery and reduced poststroke mortality rates during a long-term follow-up.

Conclusion. Stroke and TIA develop in the presence of obvious vascular comorbidity that predetermines the severity of the disease. The FRP values correlating with dysenergetic processes are significant prognostic markers in both acute and chronic stroke.

REVIEWS

42-49 709
Abstract

This review analyzes the pathogenetic factors of cryptogenic stroke, the results of investigations into secondary prevention, and current approaches to diagnostic criteria for this condition. The rate of cryptogenic stroke (stroke with no unspecified or identifiable cause) is 20 to 40%. A great deal of etiological factors leading to the development of cryptogenic stroke determine the extraordinary heterogeneity of this patient cohort; at the same time there is no universally accepted opinion as to the identification of cryptogenic stroke, its risk factors, and medical treatment. The conception of ischemic stroke with no identifiable cause of embolism and with clearer diagnostic criteria will be able to perform special studies in this group of patients, which will contribute to more differentiated and effective therapy and secondary prevention.

50-55 843
Abstract

The paper reviews the literature on the identification of the causes of ischemic stroke and transient ischemic attacks in intracranial atherosclerosis. Symptomatic intracranial atherosclerosis is the cause of an ischemic focus in not only the cortical and subcortical structures due to hypoperfusion or arterio-arterial embolism, but also in the deep structures of the cerebral hemispheres and brainstem. Major artery dolichoectasia may make an accurate diagnosis and treatment choice difficult.

Progress in the treatment of patients with symptomatic intracranial atherosclerosis depends on the availability of current brain and vessel imaging techniques and cranial artery angioplasty and stenting methods. The efficiency of aggressive medical prevention, primarily blood pressure reduction and different combinations of antiplatelet drugs, is being intensively investigated.

56-61 679
Abstract

This article considers the pathogenetic mechanisms of stroke in arterial hypertension (AH) with special emphasis on comorbid neurological and cardiac disorders. It presents the cardiac and neurological aspects of the current strategy of medical therapy within the secondary prevention of poststroke cardiovascular events. The secondary prevention of cardiovascular events in patients who have sustained ischemic stroke in the presence of AH involves the use of not only antihypertensive drugs, but also adequate antiplatelet therapy and statins. The most important part is assigned to the prevention and treatment of cognitive impairments, which also promotes increased patient treatment adherence and improved poststroke prognosis, including longer survival and better quality of life.

62-68 533
Abstract

The paper discusses concepts, such as cognitive reserve (CR) and cognitive impairments (CI). It presents the controlled and uncorrectable factors that influence CR and considers the factors of increasing CR and reducing the risk of dementia. The mechanisms responsible for the development of vascular CIs and the role of vascular factor in the occurrence of neurodegenerative disease, primarily Alzheimer's disease and Parkinson's disease, are covered. The issues of correcting CIs in cerebrovascular and neurodegenerative diseases are discussed. The conception of CR is shown to be of value in the planning of management tactics for each patient to prevent dementia by drug and non-drug treatments.

69-74 484
Abstract

The paper discusses the possibilities of using the NMDA receptor antagonist memantine in patients with vascular cognitive impairments (CIs). The author gives the data available in the literature and the results of her investigations into the efficiency and safety of treatment in patients with vascular dementia and moderate vascular CIs. The paper presents the results of a Russian multicenter trial of the efficacy and safety of akatinol memantine in patients with CIs, which enrolled 240 patients (mean age 69.5±5.5 years) with moderate CIs or mild dementia (the total Mini-Mental State Examination (MMSE) scores were 22–28). A study group included 148 patients who took akatinol memantine during a follow-up; a comparison group consisted of 92 patients who did not. Therapeutic effectiveness was evaluated using the quantitative neuropsychological scales and from changes in the somatic and neurological status and in the magnitude of emotional disorders at the inclusion in the study (before treatment initiation) and at 1.5, 3, and 6 months of therapy. During akatinol memantine therapy, there were significant reductions in the degree of CIs (lower total MMSE scores; p<0.00000), abnormalities in programming, generalization, and control over performed actions (a change in the total frontal lobe dysfunction battery scores;p<0.00000), and memory disorders, a significant increase in speech fluency (p<0.00000) and attention level (p< 0.00000), and a decrease in the degree of visuospatial deficits (p<0.00000). The effect of the therapy showed itself at its 3 months and continued to rise later on. The performed trial has indicated that akatinol memantine is an effective symptomatic drug to treat both moderate CIs and mild dementia.



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