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Neurology, Neuropsychiatry, Psychosomatics

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Vol 6, No 3 (2014)
View or download the full issue PDF (Russian)
https://doi.org/10.14412/2074-2711-2014-3

LECTURES

4-9 2172
Abstract

Alcohol abuse and alcoholism are the leading causes of worse health and increased mortality rates. Excessive alcohol consumption is the third leading cause of the global burden of diseases and a leading factor for lower lifespan and higher mortality. Alcohol abuse decreases working capacity and efficiency and requires the increased cost of the treatment of alcohol-induced disorders, which entails serious economic losses. The unfavorable medical and social consequences of excessive alcohol use determine the importance of effective treatment for alcoholism. The goals of rational pharmacotherapy of alcohol dependence are to enhance GABA neurotransmission, to suppress glutamate neurotransmission, to act on serotonin neurotransmission, to correct water-electrolyte balance, and to compensate for thiamine deficiency. Alcoholism treatment consists of two steps: 1) the prevention and treatment of alcohol withdrawal syndrome and its complications (withdrawal convulsions and delirium alcoholicum); 2) antirecurrent (maintenance) therapy. Benzodiazepines are the drugs of choice in alleviating alcohol withdrawal and preventing its convulsive attacks and delirium alcoholicum. Diazepam and chlordiazepoxide are most commonly used for this purpose; the safer drugs oxazepam and lorazepam are given to the elderly and patients with severe liver lesions. Anticonvulsants having normothymic properties, such as carbamazepine, valproic acid, topiramate, and lamotrigine, are a definite alternative to benzodiazepines. The traditional Russian clinical practice (clearance detoxification) has not a scientific base or significant impact on alcohol withdrawal-related states in addicts. Relapse prevention and maintenance therapy for alcohol dependence are performed using disulfiram, acamprosate, and naltrexone; since 2013 the European Union member countries have been using, besides these agents, nalmefene that is being registered in Russia. Memantine and a number of other medications, including baclofen, gabapentin, pregabalin, ondansetron, modafinil, and aripiprazole, are able to decrease alcoholic needs and to alleviate the manifestations of alcohol dependence. The Russian narcological practice in using antipsychotics to suppress a craving for alcohol (as well as other psychoactive substances) contradicts the principles of evidence-based medicine and has no scientific base.

ORIGINAL INVESTIGATIONS

10-16 747
Abstract

Dizziness is a common symptom in neurological and general medical practice. In most cases it is caused by diseases of the central or peripheral vestibular system. The most common vestibular system diseases include benign paroxysmal postural vertigo, dizziness, Meniere's disease, vestibular neuronitis, and cerebrovascular diseases. One of the main treatments for the diseases accompanied by dizziness is vestibular rehabilitation that is a complex of exercises, the goal of which is to stimulate vestibular compensation. Adequate vestibular compensation allows a patient to get rid of dizziness and unsteadiness even though vestibular system injury is irreversible. Some medications are able to enhance the efficiency of vestibular rehabilitation. At the same time, the optimal duration of treatment for the most common vestibular disorders has not been
adequately explored. The paper gives the results of an observational program, whose purpose was to determine the optimal duration of vestibular rehabilitation in combination with the use of tanakan in patients with non-progressive unilateral peripheral vestibular disorder.

Patients and methods. Data on 46 patients aged 19 to 70 years who underwent vestibular rehabilitation and took tanakan for vertigo caused by vestibular neuronitis (n = 44), labyrinthitis (n =1), or Ramsay Hunt syndrome (n = 1) were analyzed. All the patients were examined four times. The symptoms were recorded and the histories of disease were considered. The degree of vestibular disorders, including vertigo, was assessed when collecting complaints. The symptoms of vertigo were objectivized using its vertigo rating scale and five-point subjective rating scale for vertigo. All the patients underwent standard somatic and neurological examinations and videonystagmography. During the first visit after diagnosis, vestibular exercises were chosen for the patients and tanakan was used in a dose of 40 mg thrice daily to accelerate vestibular
compensation. During visits 2, 3, and 4, the symptoms of the disease were recorded in the patients and the time course of treatment-induced changes in their status was estimated.

Results. The optimal duration of treatment was established to be at least 2 months. Vestibular exercises in combination with the intake of tanakan resulted in a reduction in the symptoms of vestibular dysfunction and in emotional improvement in the patients.

17-20 500
Abstract

Objective: to study the major factors that influence treatment adherence.

Patients and methods. One hundred patients aged 20 to 68 years (mean age 42.9±3.0 years for women and 43.3±5.0 years for men) diagnosed with a ≥3-year history of symptomatic epilepsy were screened. The minimal and maximal durations of the disease were 5 and 59 years, respectively (mean 20.8±3.9 years).

Results and discussion. There was a female preponderance in the treatment adherence group. The patients who had secondary special education were unemployed, disabled, and single were in both comparison groups. These data are indicative of social stigmatization in epileptic patients. Patients with severe epilepsy on multiple drug therapy were prevalent. Neuropsychological testing revealed higher levels of anxiety and depression among those who were non-adherent to therapy.

Conclusion. The sex, age, and social characteristics (education level, disability) of patients with epilepsy and its clinical picture, neurological symptoms and changes were ascertained by magnetic resonance imaging had no significant impact on therapy adherence.
The factors influencing treatment adherence should include multiple drug therapy (co-administration of two or three drugs) and the high frequency of drug use, which is more frequently observed in patients with severe treatment-resistant epilepsy. Anxiety and depressive disorders in epileptic patients resulted in impaired compliance with anticonvulsant therapy.

21-26 1184
Abstract

Objective: to reveal clinical and immunological criteria for psychogenic urticaria (PU) and to determine the therapeutic efficacy of alimemazine in this abnormality.

Patients and methods. Ninety-three patients with PU, 46 apparently healthy individuals, and 90 patients with chronic autoimmune urticaria (CAU) were examined. The methods included clinical examination; use of the Goldberg anxiety rating scale; enzyme immunoassay of serum substance P levels. The efficacy of alimemazine was evaluated in an open-label comparative randomized trial for 4 weeks.

Results and discussion. Patients with PU significantly more frequently showed a predominance of manifestations of itching over skin rashes and higher levels of anxiety disorders than those with CAU. The mean serum concentration of substance P was 0.006±0.005 ng/ml in the patients with CAU, 0.026±0.02 ng/ml in healthy individuals, and 8.46±0.95 ng/ml in the patients with PU (p<0.0001). Addition of standard therapy (second-generation antihistamines, disintoxication) with alimemazine 15–30 mg/day ensured statistically significant advantages over the control (standard therapy) in the following indicators: reductions in the severity of the disease, the degree of anxiety disorders, and the serum levels of substance P. Alimemazine was noted to be satisfactorily tolerated. Thus, the authors established the following diagnostic criteria for PU: a psychotraumatic situation; dermal manifestations after psychogeny; high anxiety; a predominance of the manifestations of itching over the dermal symptoms of urticaria; and elevated serum substance P concentrations. Standard therapy added by alimemazine versus that without the drug was found to be effective. There were reductions in the symptoms of urticaria, the degree of anxiety disorders, and the levels of substance P.

27-31 487
Abstract

Objective: to study the neurophysiological features of the visual analyzer in patients with multiple sclerosis (MS) to optimize the early diagnosis of the disease.

Patients and methods. Seventy-nine patients (57 women and 22 men, mean age 34.31±4.7 years) diagnosed as having MS were examined. The mean duration of the disease with consideration for its clinical form was 3.3±2.2 years in relapsing-remitting MS (RRMS), 9.1±4.2 years in secondary progressive MS (SPMS), and 2.7±1.9 years in primary progressive MS (PPMS).

Results and discussion. The neurophysiological examination indicated that demyelination processes in MS proceeded differently in response to dissimilar lights in the structures of the visual analyzer. The most marked significant (p<0.01) deviations in the values of visual evoked potentials (VEPs) to the black-white tessellated pattern (TP) were observed in the patients with SPMS and in those with PPMS. The latency of the P100 wave increased dramatically and differed significantly (p<0.001) from those in the control group (127.09 msec for RRMS, 128.3 msec for SPMS, 124.5 msec for PPMS, and 106.1 msec in the control). Amplitude analysis could reveal a significant decrease in the force of a N75–N100 wave response to the black-white stimulus in all the clinical groups, averaging 3.3 μW (8.5 μW in the control). The latency of the P100 wave to the red-yellow TP increased considerably and differed significantly (p<0.001) from that in the control group, by comprising
147.29±1.19 msec for RRMS, 150.23±1.49 msec for SPMS, and 144.38±2.11 msec for PPMS. There were the same changes that to the greenblack TP. Examination of 25 patients with MS established higher levels of IgG antibodies against myelin basic protein. The most significant latency increase occurs in response to the color spectrum of visible light against the black-white background, which may serve as an early diagnostic criterion for MS. These changes lead to a sharp decrease in a cortical feedback. The use of the color pattern will largely contribute to the improved early diagnosis of MS.

32-37 516
Abstract

The early diagnosis and treatment of cognitive impairments (CIs) are presently one of the most relevant and sociomedical problems. Since 2012, a memory room that performs an outpatient reception of patients complaining of diminished memory has been working at the Department of Neurology and Medical Genetics with Course of Neurosurgery, Yaroslavl State Medical Academy. The main goals of this subdivision are to make a diagnosis and differential diagnosis of CI, to manage patients with higher brain dysfunctions, to improve quality of life, and to elaborate rehabilitation programs.

Objective: to assess the first results of work of a memory room and to study CIs in patients complaining of diminished memory at the time of their asking for medical advice.

Patients and methods. The two-year data obtained in examining the work of the memory room were analyzed. In January 2012 to January 2014, a total of 250 patients (31% men and 69% women) (mean age 52.4 years (18 to 87 years)) visited the memory room. CIs were rated using the Schulte test, studying short-term visual memory, its volume, and accuracy by mnestic tests and numbers memory tests recording the number of errors; the hospital anxiety and depression Scale and SF-36 questionnaire to estimate quality of life were applied. The efficiency of vinpocetine therapy was investigated in 20 patients (13 women and 7 men) aged 45 to 59 years (mean age 56.3±1.7 years) with moderate CIs of vascular genesis.

Results and discussion. Varying degrees of CIs were identified in 96% of the patients during their first visit to the room. The findings could estimate the approximate incidence and prevalence of CIs in the patients during different pathological processes. There was a preponderance of patients with dementia, the main cause of which was Alzheimer's disease among those who were seeking for medical advice for complaints of amnestic disorders. Vascular processes are a cause of the majority of non-dementia CIs. There are preliminary data on the association between CIs and other neuropsychiatric disorders.

38-42 727
Abstract

Spinal pain syndromes come to the forefront in the structure of referral rates for medical advice and considerably reduce quality of life in this category of patients. The paper considers the role of an edematous component in the development and chronization of pain. Occurring edema gives rise to local hemo- and lymphodynamic disorders, dysregulated vascular tone, activated thrombogenesis, and increased vascular permeability, eventually leading to the excessive irritation of nociceptors, the enhancement of a pain component, and the progression of tissue swelling.

Objective: to study the efficacy of L-lysine escinate in the combination treatment of acute non-specific low back pain.

Patients and methods. Sixty-two patients aged 21 to 53 patients (mean age 36.4±0.9 years) with acute low back pain were examined. L-lysine escinate having venotonic and anti-inflammatory activities was chosen as an agent to correct edema syndrome. The results of clinical, neurological, and manual muscular testing and assessment of the biomechanics of the vertebral column, obtained using the original soft package “Visual optic analysis” developed by the authors, were analyzed. All the patients were found to have acute non-specific low back pain or radiculopathy (entrapment syndrome) and considerable changes in the biomechanics of the vertebral column. The patients were treated in accordance with the standards of medical care for spinal pain. L-lysine escinate was additionally incorporated as an antiedema drug into the therapeutic
complex of the patients in the study group.

Results and discussion. The study patient group demonstrated a more pronounced trend towards reductions in pain syndrome and local muscle edema. It was noted that L-lysine escinate was effective in treating both acute pain syndromes and exacerbations of chronic low back pain and that additional non-drug programs should be included in order to correct an impaired motor stereotype.

43-48 1407
Abstract

The authors give the results of their investigation dealing with citicoline therapy in patients with hypertension and cognitive impairments.

Objective: to determine the efficiency of citicoline therapy on the level and variability of both systolic and diastolic blood pressures (BP) (SBP and DBP).

Patients and methods. The investigation covered 60 patients with Stage II hypertension and a goal BP of < 140/90 mm Hg within ≥3 months before their inclusion. The patients were randomized into 2 groups: 30 patients in the study group were assigned to receive a cycle of 10 injections of citicoline in a daily dose of 1000 mg dropwise intravenously, then 1000 mg/day orally for as long as 3 months. 30 patients comprised the control group.

Results and discussion. 24-hour BP monitoring indicated that during 4-week citicoline therapy there were significant (p<0.05) reductions in average nocturnal SBP (by 4.1±2.24 mm Hg), average daytime (-1.5±0.39 mm Hg) and average nighttime (-1.5±0.37 mm Hg) BP variabilities; such changes were not found in the control group. In the study group, normal daytime SBP variability at baseline (≤15 mm Hg) was seen in 15 (50%) patients; that after citicoline treatment was in 21 (70%); in the control group, this was in 15 (50% and 14 (46.7%) patients before and after 4-week therapy, respectively. In the study group, normal nocturnal SBP variability at baseline (≤ 15 mm Hg) was seen in 15 (50%) patients; that after citicoline treatment was in 23 (76.7%); in the control group, this was in 15 (50% and 16 (53.3%) patients, respectively.
Twenty-one (70%) patients in each group had baseline normal daytime DBP variability (<14 mm Hg); following 4 weeks of treatment, the number of patients with normal daytime DBP variability remained unchanged in the control group and that increased by one patient (n = 22 (73.3%)) in the citicoline group. Normal nocturnal DBP variability at baseline (<12 mm Hg) was observed in 19 (63.3%) patients in each group; that after 4 weeks was in 20 (66.7%) patients in each group.

Conclusion. Following 4-week citicoline treatment, there were significant decrease in average nocturnal SBP and average daytime and average nighttime SBP variabilities and an increase in the number of patients with normal average daytime and average nighttime BP variabilities.

REVIEWS

55-60 661
Abstract

Stroke is one of the top three causes of death in the population and a leading cause of disability in the elderly; ischemic stroke (IS) constitutes a major portion (70–85%) of all strokes so its prevention  s a relevant problem of modern medicine. Among the risk factors  RFs) of stroke, nonvalvular atrial fibrillation (AF) is of great  ignificance, which occurs in persons over 70 years of age in  pproximately 5–10% of cases and increases the risk of IS 3–4-fold.
The review analyzes RFs for stroke in AF. The CHA2DS2-VASc scale encompassing several RFs is noted to be informative and easy-to-use. There are data of large-scale randomized trials that show that novel oral anticoagulants (dabigatran, rivaroxaban, apixaban) are as good as warfarin or offer an advantage over the latter, by more substantially decreasing the risk of stroke and reducing the likelihood of profuse bleeding, intracranial hemorrhage in particular. There is evidence for the efficacy of rivaroxaban in the secondary prevention of stroke. The authors provide their experience with patient management to prevent recurrent cardioembolic stroke.
In our country, most patients who have sustained IS or transient ischemic attack in the presence of AF do not take warfarin due to the fact that it is difficult to regularly monitor the international normalized ratio (INR). It is noted that the administration of the novel anticoagulants, which differs from that of warfarin, does not require INR monitoring and can increase the number of patients on anticoagulant therapy and therefore reduce the incidence of stroke in the presence of AF.

61-68 1538
Abstract

Systemic thrombolysis using recombinant tissue plasminogen activator is the most effective and safe therapy option for ischemic stroke (IS) in the first 4.5 hours after onset of the disease. The safety and efficiency (or inefficiency) of perfusion therapy in patients with IS may be affected by a multitude of factors associated with the time of the therapy, patient age, the presence and size of a brain region with potentially reversible changes, the location of a cerebral lesion region, the specific features of systemic and local hemodynamics, and the degree of blood-brain barrier impairment. The hemorrhagic transformation of a brain lesion focus in IS is a serious complication of thrombolytic therapy (TT). The analysis and detection of predictors for hemorrhagic complications, TT in terms of the clinical and pathogenetic features of the disease, the location of a lesion focus and the degree of early neuroimaging signs, and data of additional studies will contribute to the safer and more effective
use of this treatment in patients with IS.

69-74 981
Abstract

The paper considers different aspects of neuroplasticity in patients with stroke. It underlines the dynamism of this process and the ambiguity of involvement of the structures of the contralateral cerebral hemisphere in the restorative process. It considers the periods after onset of stroke and the activation of different brain regions (of both the involved and intact hemisphere) in the poststroke period. Particular emphasis is placed on the issues of neurorehabilitation in this category of patients. Delay in rehabilitation measures leads to a worse outcome, the patients must be at hospital longer. It is emphasized that the neurorehabilitaton measures should use strategies aimed at improving plasticity processes at the level of synaptic transmission and neuronal communications. At the same time, of great importance are the processes of structural and functional remodeling of neuronal communications with the involvement of surviving neurons that are located in the peri-infarct area and partially damaged during ischemia. To recover stroke-induced lost motor functions, measures are implemented to modulate the ipsilateral motor cortex, contralateral motor cortex, and sensory afferentation. Remodeling processes, one of the manifestations of neuroplasticity, vary with the size and location of an ischemic focus. The specific features of this process with subcortical and cortical foci are considered. It is stressed that there are genetically determined neurotrophic factors that may enhance remodeling processes in the peri-infarct area, as well as factors that inhibit these processes. The sensory system is noted to have a high potential of compensation, which is appreciably associated with the considerable extent of sensory fibers even at the level of the cerebral cortex.

75-79 495
Abstract

Myalgia is not a definite nosological entity and fixes the attention of neurologists, rheumatologists, and physicians in other specialties. This is first of all associated with the high incidence of chronic pain syndrome that leads to long-term disability mainly in young and middle-aged persons. One of the most common reasons for seeking advice from a therapist and neurologist is low back pain that may be due to the involvement of three key anatomical players: facet joints (arthrosis treatment should make an emphasis on  hondroprotectors), intervertebral disks (in case of discopathy, clinicians tend to favor nonsteroidal anti-inflammatory drugs – NSAIDs), and a muscular frame. In this case, two thirds of patients with pain syndromes in the trunk and limbs are found to have myofascial dysfunction that is defined as impaired function of one or
other muscle, which occurs with its overload and manifests itself as muscle spasm and the presence of painful muscle infiltrations or local muscle hypertonus and trigger points in the tense muscles. Ignoring this fact gives rise to the irrational use of analgesic and anti-inflammatory drugs and further to the increase of their doses because the treatment is ineffective. Modern-day therapy for myofascial syndrome is multimodal and encompasses physiotherapic and manual procedures and the use of myorelaxants rather than NSAIDs. To prescribe myorelaxants, it is necessary to understand their mechanisms of action and the effects of different agents in this group.

80-84 976
Abstract

The main goal of therapy for Parkinson's disease (PD) is to correct dopamine deficiency in the nigrostriatal system. Levodopa preparations and dopamine receptor agonists (DRAs) that are prescribed with regards to patient age and disease severity are mainly used now. Notwithstanding the fact that levodopa preparations are the gold standard of therapy, their long-term use gives rise to complications as motor fluctuations and drug-induced dyskinesias. The currently available DRAs are the drugs of choice for the therapy of early-stage PD as they are as effective as levodopa preparations. In extensive-stage PD, DRAs are used to enhance the therapy and correction of developed motor fluctuations and dyskinesias. Pramipexole is one of the most commonly used representatives of non-ergoline DRAs. The paper analyzes the efficacy of the medication used as both monotherapy and part of combined therapy, its effect on tremor and depression in PD. A novel extended-release formulation of pramipexole is considered separately. Both immediate- and extended-release pramipexole formulations contain the same active ingredient and have the same dopamine-receptor interaction profile, but differ in the tablet release rate of the active ingredient. The advantages of the novel formulation are its more steady-state plasma concentration and 24-hour action, which ensures continuous dopaminergic stimulation of
postsynaptic receptors to prevent and treat already developed motor complications. The once-daily extended-release formulation of the drug makes its treatment regimen easier and patient compliance higher.

CLINICAL OBSERVATIONS

49-54 1030
Abstract

Parainfectous limbic encephalitis (PILE) associated with viruses of the Herpesviridae family is one of the forms of chronic herpes encephalitis characterized by limbic system dysfunction and a prolonged course with frequent exacerbations. There are two types of the course of the disease: latent autoimmune limbic encephalitis (LE) progressing to mesial temporal sclerosis and pseudotumorous granulomatous LE. The latter (inflammatory pseudotumor or granuloma) is characterized by the formation of a polymorphic inflammatory infiltrate with the elements of fibrosis, necrosis, and a granulomatous reaction and by myofibroblast cells. This is a slowly growing benign pseudotumor that contains much more plasma cells than inflammatory ones. The diagnosis of pseudotumorous LE is difficult and requires the participation of a neurologist, an immunologist, an oncologist, and a neurosurgeon. Perfusion computed tomography, magnetic resonance imaging, and magnetic resonance spectroscopy give proof to the adequacy of the term inflammatory pseudotumor because it is histologically difficult to characterize the lesion as a tumor or inflammation. When a chronic lesion in the central nervous system is lately diagnosed, the prognosis of the disease may be poor and complicated by the development of resistant symptomatic focal epilepsy and emotional, volitional, and cognitive impairments. It was differentially diagnosed from brain tumors (astrocytic, oligodendroglial, and mixed gliomas, ependymal, neuronal, neuroglial, and embryonal tumors, meningiomas, cholesteatomas, dermoid cysts, teratomas, and cysts), other reactive and inflammatory processes (leukemic infiltrations, systemic lupus erythematosus, multiple sclerosis, encephalomyelitis), hypoparathyroidism, Addison's disease, vitamin A intoxication, and the long-term use of glucocorticoids and contraceptives. The authors describe a clinical case of the pseudotumorous course of chronic PILE in a 28-year-old woman. They discuss difficulties in differential diagnosis and the specific features of the clinical course and treatment of the disease. Inflammatory pseudotumor is an indication for surgery, but realizing the fact that this false tumor may avoid an unnecessary radical operation in some cases, which demonstrates the given clinical observation.



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