Neurology, Neuropsychiatry, Psychosomatics

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Vol 6, No 4 (2014)
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4-10 676

Non-drug rehabilitation in Parkinson’s disease (PD) has recently attracted the increasing attention of neurologists worldwide. Symptomatic medical treatment only prolongs the period of relative wellbeing and little affects the course of the disease, without preventing its progression. Today this raises the question of whether other or additional therapeutic approaches to rehabilitating patients with this disease should be sought. The elaboration and practical implementation of a program for multidisciplinary patient rehabilitation are most effective to date. This program includes combination therapy based on the use of current drugs and different variants of nondrug therapy. Within the current concept of medical treatment for PD, there are two strategic approaches: 1) to search for agents that are able to slow, delay, or stop its progression (the so-called neuroprotection) and 2) to develop more effective symptomatic therapies. The latter approach is presently considered to be basic. At large, more than 40-year experience in using dopaminergic and other antiparkinsonian agents indicates that this therapy cannot drastically solve the problem of PD treatment. So nondrug care methods whose improvement has become a relevant task of current therapeutic strategy in this disease are the focus of attention today. A nonpharmacological approach to treating PD is appropriate at all its stages. Here are just some of these methods: medicinal vacation, phototherapy, sleep deprivation, electroconvulsive therapy, and transcranial magnetic stimulation. Patients’ compliance to dietary advice is of significance. The experience shows that the most accessible and efficient and safe nondrug treatment is of course a package of measures to stimulate
and restore a patient’s physical activity, which encompasses special functional training programs, kinesitherapy, multisensory training,
physical exercises, etc. There is a need to further accumulate experience with nondrug therapy for PD to prove its therapeutic effectiveness and to promote its optimization.

11-18 601

Cerebrovascular diseases belong to a group of the major causes of cognitive impairments, in the elderly in particular. The paper presents current ideas on the etiology and pathogenesis of vascular cognitive impairments (VCI). The etiological factors of VCI may be divided into genetic, sociodemographic, and common risk factors for vascular and other diseases. The pathogenesis of VCI is multifactorial; cognitive function decrement results from brain damage due to cerebral circulatory disorders. Damage to the deep white matter portions and basal ganglions plays a leading role in the development of cognitive deficit in cerebral circulatory insufficiency, disrupting the connections between the frontal lobes and subcortical structures (a dissociation phenomenon). Regulatory functions are impaired; instability of volitional attention develops; the speed of thinking processes and the performance of professional and everyday skills are suffered, mnestic functions being impaired to a lesser extent. Impairments in other higher cortical functions, such as speech, gnosis, praxis, thinking, generally occur in the later stages of cognitive deficit. The comprehensive approach to examining patients with cognitive dysfunctions, which encompasses physical examination with a mandatory evaluation of neurological symptoms, neuropsychological testing, laboratory studies, instrumental diagnostic methods, and structural and functional neuroimaging techniques, are most justified now. VCI therapy is a challenging task requiring the specific features of different types of cognitive deficit to be analyzed, by providing a rationale for the choice of medications. Therapeutic effectiveness may be enhanced by rational combined multimodal therapy, by keeping in mind a variety of factors for the pathogenesis of VCI.


19-25 499

The capabilities of antithrombotic therapy to prevent systemic thromboembolic events in nonvalvular atrial fibrillation (AF) are substantially extended after clinically introducing novel oral anticoagulants (NOACs), such as dabigatran, rivaroxaban, and apixaban. World clinical experience with NOACs in AF has confirmed their efficacy and safety in both primary and secondary stroke prevention. At the same time, apixaban additionally reduces the risk of fatal outcomes and it is the safest among the NOACs against hemorrhagic events. The low risks of intracranial hemorrhage typical of NOACs should be taken into account when choosing oral anticoagulant therapy after hemorrhagic stroke in patients at
high risk for thromboembolic events due to AF. Whether NOACs may be used in acute myocardial infarction and during coronary stenting in the presence of nonvalvular AF, left ventricular thromboses, and cardiomyopathies is considered. In real clinical practice, nonvalvular AF may be accompanied by different cardiovascular diseases, by creating the situations where there are no specific guidelines for the use of NOACs. The results of comparing the clinical efficiency of different antithrombotic therapy regimens, the subanalysis of randomized trials, and experts’ opinions may assist a physician to substantiate their decisions. Thus, just a few NOACs that are similar and/or superior to warfarin in efficacy and safety have emerged to date. There are grounds to believe that many physicians will prefer direct anticoagulants to warfarin not only because of their proven efficacy, but also the rapid onset of their anticoagulant effect, neither interaction with a number of foods or drugs, and above all, nor need for regular laboratory blood testing. World post-marketing
surveillance and new clinical tests will be helpful in better estimating the benefits and risks of treatment with NOACs and in expanding indications for their use, which will considerably enhance the possibilities of preventing thromboembolic events in cardiac pathology in the period ahead.


26-30 2548

Dizziness is one of the common reasons for visits to physicians of various specialties; the data of foreign investigations show that benign paroxysmal positional vertigo (BPPV) is most frequently encountered.

Objective: to study the causes of dizziness, to analyze the frequency of BPPV and the efficiency of its treatment in outpatient practice.

Patients and methods. The investigation enrolled 80 patients, including 55 (68.7%) women and 25 (31.3%) men, aged 18 to 75 years (mean age 53.8±12.8 years), who complained of dizziness and sought for medical advice in the Therapeutic-and-Diagnostic Unit, A.Ya. Kozhevnikov Clinic of Nervous System Diseases, I.M. Sechenov First Moscow State Medical University.

Results. The most common causes of dizziness in outpatient practice were BPPV (46.2%) and postural phobic vertigo (35%). The diagnosis of VPPV, if special positional testing (Dix-Hallpike and McClure-Pagnini tests) was carried out, was shown to create no significant difficulties. The diagnosis was not established in the majority (97.5%) of the patients; effective treatment was performed in one of the patients. Combined treatment, by performing the positional tests and using betaserc for 2 months, led to complete resolution of positional vertigo in most (97.3%) patients.

Discussion. The findings indicate the efficiency of examining patients with complaints of dizziness, by using the special otoneurological tests to detect BPPV. The purposeful questioning of patients with BPPV can suspect this disease in the majority of cases. Our investigation shows the high efficiency of rehabilitation maneuvers for BPPV, which agrees well with the data of other authors. Physicians’ poor awareness of BPPV among physicians and the high efficiency of its treatment in outpatient practice are noted.

31-39 970

Objective: to determine the clinical and electroencephalographic (EEG) signs of dopaminergic deficiency (DD) when recovering consciousness in patients with severe brain injury (SBI).

Patients and methods. Thirty-five patients (23 men and 12 women; mean age 29±13 years), who had experienced SBI accompanied by coma (mean duration 17±6 days) and treated at the Acad. N.N. Burdenko Research Institute of Neurosurgery, were examined. The comprehensive examination included neurological and mental status evaluation and EEG with dynamic assessment of the pattern.

Results and discussion. The authors defined a constellation of neurological symptoms as increased extrapyramidal muscle tone, resting tremor, and specific autonomic dysfunction, which was characteristic of autonomic status and some forms of mutism, and, in accordance with the data available in the literature, was defined as DD syndrome. The latter accompanied by characteristic EEG changes: its pattern’s higher synchronized β-activity (13–14 Hz) enhanced in the frontal and anterior temporal regions. The administration of amantadine sulfate was followed by an increase (even as compared with the normal value) in the dynamics of the power of mainly of β3 (at frequencies of 17–23 Hz) and θ2 (5.9–7.4 Hz) bands along the anterior regions more frequently on the right; by the amplification of intrahemispheric connections (in the occipitotemporal regions) in the β3 band (more often on the right) and θ one (5.9–7.4 Hz) in the right occipitotemporal region. The agent had no significant effect on the SBI outcome assessed 12 months after injury, but it affected the clinical symptoms of DD.

40-45 729

Lumbago is one of the most common lower back pain syndromes in medical practice, which is benign in the vast majority of cases and caused by spinal osteochondrosis, injury, and muscle strain or spasm. The primary task of examining a patient with lumbago is to be certain that the pain is musculoskeletal and unassociated with a potentially dangerous spinal disease requiring emergency special therapy.

Objective: to analyze the efficiency of treatment in outpatients with chronic lumbago.

Patients and methods. One hundred and four patients followed up by us in the Smolensk Kinesitherapy Center were examined. A study group comprised 84 patients (34 men and 50 women; mean age 44.2±1.29 years) with dorsalgia (pain duration ≥3 months; mean 7.6±6.83 years);a control group included 20 persons (10 men and  10 women; mean age 31.9±1.88 years) without pain in the back. Neurological examination and magnetic resonance imaging revealed nonspecific lower back pain in 67 (79.8%) patients and radiculopathy in 17 (20.2%). Combination treatment including pharmacotherapy and kinesitherapy was proposed in all the patients.

Results. 2.5–3 months after the initiation of therapy, pain regressed completely in 29 (34.5%) patients and was considerably alleviated in 27 (32.1%). Quality of life after therapy improved in the majority of patients. The patients in whom therapy was ineffective (n = 26; 31%) did not attend kinesitherapy classes and were cautious towards physical rehabilitation.

Discussion. The findings indicated the high efficiency of a comprehensive approach to treating chronic lumbago, which is largely associated with rational psychotherapy, early patient activation, and adaptive behavior training.

46-50 688

Objective: to study the efficiency of psychotherapeutic correction of mental disorders in pregnant women with threatened miscarriage.

Patients and methods. Psychotherapy for mental disorders and prenosological conditions was performed in 84 pregnant women aged 18 to 41 years with threatened miscarriage. The efficiency of performed measures was evaluated using the quality of life questionnaire, Spielberger–Hanin’s scale, and a therapy efficiency assessment scale in patients with borderline states. Delivery outcomes were analyzed in relation to management tactics in this cohort of pregnant women. The health status of newborn infants was assessed by the neonatologists of maternity hospitals.

Results and discussion. After psychotherapeutic correction, the quality-of-life indicators in the pregnant women with threatened miscarriage from the study group were significantly higher than in those from the comparison group. The level of reactive and personality anxiety significantly decreased in the pregnant women in the study group. The pregnant women with the asthenic variant of prenosological conditions and those who had ICD-10 diagnoses F40-48 were most successful in the context of psychotherapeutic rehabilitation. Sporadic cases of incomplete recovery were noted when psychotherapeutical support was got. In the study group, pregnancy resulted in full-term babies in 100% of the women. In the pregnant women with prenosological conditions and mental disorders from the study group, parturition proceeded significantly
more rapidly than in those from the comparison study. Significantly higher physical quotients were found in the newborn babies from the study group parturients. The psychotherapy that supplements the complex system of therapeutic measures has been shown to be highly effective in the women with threatened miscarriage accompanied by mental disorders.

51-58 791

The paper gives an update on the occurrence and development of Alzheimer’s disease (AD), a condition manifesting itself as a steady reduction in memory. AD is common in the modern population. The reason for its higher incidence rate is the specific features of the current information sphere. Genetic factors that both directly lead to the development of AD and indirectly influence its occurrence are also imperative. At the present time, the genetic bank of mutations associated with the development of AD contains information on more than 300 different mutations. Genetic predetermination of this disease has a negative impact on prognosis and prospects for patient treatment.

Patients and methods. The distribution of hereditary forms of AD in a Russian population was analyzed at the Clinic of Nervous System Diseases, I.M. Sechenov First Moscow State Medical University. The investigation enrolled 46 patients (13 men and 33 women) who met the international criteria for AD; all had its proven hereditary history. The patients' mean age was 73.7±8.3 years in the men and 73.4±8.5 in the women; the mean disease duration was 29.6±12.4 and 28.0±18.8 months, respectively. The incidence of AD was estimated depending on age, comorbidity, degree of cognitive impairments, and pattern of the disease. Its history was rated using a questionnaire. No genome mapping was carried out.

Results and discussion. The patients were divided into two groups: 1) presenile AD (age at its onset less than 65 years; n=8) and 2) senile AD (age at its onset more than 65 years; n=38). There was a preponderance of patients with mild dementia in both groups; however, in the patients with senile AD, the latter was diagnosed at the stage of moderate cognitive impairments in 7.9% of cases. Comorbidity was mild in all the patients. Depression and behavioral disorders were noted in half of the patients with AD; at the same time, behavioral and emotional disorders were significantly more common in the presenile and senile AD groups, respectively. The prevalence of senile AD was shown to be 4.7 times
greater than that of presenile AD, as shown by our data). The performed investigation could reveal some features of the course and clinical presentation of both genetically determined AD as a whole and its senile and presenile forms in particular.

59-64 624

Parkinson’s disease (PD) is the second most common human neurodegenerative disorder. Genetically, PD may be considered as both a monogenous and multifactorial disease. At the moment, much consideration is being given to a search for genetic markers for the LRRK2 6055G>T mutation in exon 41, which plays a role in the development of both monogenous and sporadic cases of PD. The paper presents the results of a 4-year epidemiological study of PD in the town of Zheleznogorsk (Krasnoyarsk Territory).

Objective: to study the epidemiology and clinical and genetic features of PD.

Patients and methods. There were three observation groups: 1) 135 patients with PD, including 72.6% with previously diagnosed PD and 27.4% with new-onset PD; 2) 44 patients (75% of women and 25% of men) with PD who underwent molecular genetic examination; 3) 30 healthy volunteers (66.7% of women and 33.3% of men) – a control group. The observation groups were matched for gender and age (p>0.05). The study included a retrospective analysis of medical documentation, a prospective clinical and epidemiological study, and a cohort study of genetic predictors for PD.

Results and discussion. The weighted mean prevalence of PD in Zheleznogorsk was 124.2 per 100,000 population; morbidity, 13.8 per 100,000 in 2013; mortality was minimal (0 case per 100,000 in 2010 and 2012 and 1.1 case in 2012 and 2013. The genetic markers rs1427263, rs11176013, and rs11564148 of the LRRK2 6055G>T mutation linked to the PARK8 locus on chromosome 12q12 were unassociated with the development of PD among the dwellers of Zheleznogorsk. The frequency of the genetic marker rs7966550 (the homozygous genotype C/C) in the group of PD patients was higher than in that of healthy volunteers (44.5% vs 16.5%). No specific features were found in the pattern and clinical presentations of PD with regard to single-nucleotide polymorphism markers.


65-71 1370

The paper considers the etiology, pathogenesis, clinical presentations, diagnosis and treatment in children with febrile infection-related epilepsy syndrome (FIRES) and the aspects of identifying this disease as an individual nosological entity. It details a study of the possible etiological factors of FIRES, such as metabolic, genetic, and immunological disorders, aseptic inflammatory processes, as well as a search for a certain infectious agent by inoculations of different biological environments of the body and by polymerase chain reaction; the diagnostic characteristics of FIRES at the present stage, including the use of electroencephalography, positron emission tomography, and magnetic resonance imaging; different approaches to drug therapy for FIRES at the onset stages of its clinical manifestations, protracted status epilepticus, and drugresistant epilepsy. The issues of the predictable outcome of this disease, including survival and the probability of further development of epilepsy and maintenance of cognitive functions, are also viewed. Diagnostic criteria for the syndrome, such as age at its onset 3 to 15 years in previously healthy children; acute onset as fever to develop high-frequency focal seizures several days later; the absence of the identified disease pathogen detected by the examinations of cerebrospinal fluid, serum, and other environments of the body; the development of drug-resistant epilepsy and severe permanent cognitive and motor deficits after the completion of an acute period in most cases are presented. The paper is clinically exemplified by the authors’ observation of an 11-year-old boy who meets the above criteria for the syndrome, but has a relatively favorable course, without developing severe drug-resistant epilepsy.

72-75 582

Despite being thoroughly studied, senile aortic stenosis (AS) remains a disease that is frequently underestimated by Russian clinicians. Meanwhile, its manifestations can not only deteriorate quality of life in patients, but can also be poor prognostic signs. The most common sequels of this disease include heart failure and severe arrhythmias. However, there may be also rare, but no less dangerous complications: enteric bleeding associated with common dysembriogenetic backgrounds, infarctions of various organs, the basis for which is spontaneous calcium embolism, and consciousness loss episodes. The latter are manifestations of cardiocerebral syndrome. Apart from syncope, embolic stroke may develop within this syndrome. There is evidence that after syncope occurs, life expectancy averages 3 years. Global practice is elaborating approaches to the intracardiac calcification prevention based on the rapid development of new pathogenetic ideas on this disease. In particular, it is clear that valvular calcification is extraskeletal leaflet ossification rather than commonplace impregnation with calcium salts, i.e. the case in point is the reverse of osteoporosis. This is the basis for a new concept of drug prevention of both calcification and the latter-induced heart disease. But the view of senile AS remains more than conservative in Russia. The paper describes a clinical case of a rare complication as cerebral calcium embolism and discusses the nature of neurological symptoms of the disease, such as vertigo and syncope.


76-80 5163

Wernicke’s encephalopathy and Korsakoff’s psychosis are the acute and chronic phases of Wernicke–Korsakov syndrome, a neurodegenerative process that is caused by thiamine deficiency and predominantly develops in persons with severe alcohol problems. In accordance with classical descriptions, Wernicke’s encephalopathy is manifested by a triad of the following major symptoms: ophthalmoplegia (or nystagmus), ataxia, and clouding of consciousness. The predominance of the subtle forms of Wernicke’s encephalopathy, which hinders its timely recognition and treatment, presents a serious problem. When left untreated, Wernicke’s encephalopathy is characterized by a high risk for a fatal outcome
and transition from acute reversible disorders to chronic irreversible cerebral structural changes associated with the occurrence of memory consolidation. The main manifestation of Korsakoff’s syndrome is the absence of or significant reduction in the ability to store new information with the relative preservation of other psychic functions. Effective care for patients with Wernicke’s encephalopathy and prevention of Korsakoff’s psychosis require that high-dose thiamine should be administered parenterally in good time. Alpha-lipoic acid along with thiamine is used in the treatment of polyneuropathy accompanied by Wernicke–Korsakoff syndrome. Untreated Wernicke’s encephalopathy is considered to lead to Korsakoff’s psychosis in above 80% of cases and to death in almost 15–20%. There is complete recovery from Korsakoff’s psychosis in approximately 20% of cases; with the lapse of time there may be a significant recovery of cognitive functions in 25% of cases.

81-86 914

As of now, somatization of disorders when its physical symptoms may be caused by mental, psychological, or emotional factors is an extremely common event in clinical practice. The somatization is considered to mean the conversion of mental stress to somatic symptoms. The mechanisms and specific features of somatization disorders within generalized anxiety disorder and panic disorder are of interest. One of the theories about the causes of somatization disorders proposes that somatization is as a way of avoiding psychological stress: it serves to protect from psychological pain, which allows the label of a psychiatric diagnosis to be circumvented in the majority of cases. Some patients unconsciously substitute the
experienced symptoms of anxiety or depression for the development of physical symptoms; anxiety disorders are one of the most common mental disorders. Among various forms of anxiety disorders, panic attacks and generalized anxiety disorders are most often met with neurologists. In some patients, the clinical picture is characterized by a concurrence of both the permanent and paroxysmal symptoms of anxiety, which is not only important to analyze the individual course of the disease, but also responsible for the addressness of a therapeutic approach to a greater extent.
There are data of clinical trials and current algorithms for the therapy of generalized anxiety and related disorders reflecting the complexity of a therapeutic approach. The trials of the therapeutic effectiveness of these or those psychopharmacological agents demonstrate the importance of different groups of drugs in relation to the clinical features of detectable disorders. A number of trials indicate that the use of benzodiazepines (such as phenazepam) may be considered irreplaceable as an emergency care on an exacerbation of anxiety and exceptional therapeutic orientation by using selective antidepressants not always can solve diverse clinical problems.

87-93 608

The paper reviews the literature related to the investigations of neck pain (cervicalgia) in patients with headache (cephalalgia). Neck pain is second to lower back pain as a reason for considerable socioeconomic damage to society. The prevalence of cervicalgia in the population ranges from 5.9 to 38%; the annual incidence is 10.4–21.3%; 14.2 to 71% of people report to have neck pain at some time in their lifetime. Neck pain is concurrent with cephalalgia in 70% of cases. In patients with cervicalgia, the prevalence of headache is 20–40% higher than in those with musculoskeletal pain at another site. Neck pain is as a major risk factor for migraine and tension headache (TH). Neck pain in TH progresses with the increased intensity, frequency, and strength of headache. There is a direct relationship of the quality of life worsening associated with
cervicalgia to the frequency of migraine attacks and the risk of its chronization. Neck pain is noted in cervicogenic headache belonging to secondary headaches. The identification of mixed headache in a patient with cervicalgia allows the prescription of a treatment option that may be effective in relieving both headache and neck pain. The paper discusses the causes and pathogenesis of cervicalgia in patients with headache, examination methods, and main approaches to drug and nondrug therapies in relation to the leading pathophysiological mechanism, as well as new possibilities for the effective and safe relief of pain syndrome in this category of patients. Nonsteroidal anti-inflammatory drugs, myorelaxants,
and their combination are observed to be effective in treating patients with cervicalgia and cephalalgia.

94-100 927

Ever-increasing attention now focusses on dementia caused by small vessel damage when considering cerebrovascular disease leading to cognitive impairments (CIs). Stroke is one of the most important risk factors (RFs) of vascular CI, including vascular dementia. Experienced stroke increases thrice the risk of dementia. Diffuse changes in the cerebral white matter (leukoaraiosis) due to fluctuating blood pressure (BP) and cerebral small vessel damage in most cases play an important role in the genesis of vascular CIs. Executive dysfunctions frequently concurrent with delayed psychomotor speed are the leading clinical manifestations of subcortical vascular dementia. Severe memory impairments are not
typical for subcortical dementia, its early stages in particular. The basis for the pathogenesis of CIs is the dissociation phenomenon that disrupts connections between the frontal lobes and subcortical structures and other cerebral cortical areas. Inadequate hypertension correction at a middle age is responsible for more than one fourth of cases of dementia developing in the elderly. The detection and further elimination of vascular RFs can reduce the risk of developing dementia in elderly and senile patients. Correction of elevated BP in the middle-aged is regarded as an effective method to prevent dementia in the future, but no premium is placed upon antihypertensive therapy in the elderly to lower elevated BP that is an inherent characteristic of this category of patients. Medications affecting RFs and those improving cerebral metabolism and blood
flow, including nicergoline are widely used to treat PD.

101-105 612

Stroke heads the list of all causes of disability in middle-aged and elderly people. In recent years, there have been about 30% of morbid events among able-bodied persons (less than 65 years of age). The major post-stroke incapacitating disorders are motor and speech defects, cognitive and psychoemotional disorders, and pelvic organ dysfunctions. The patients’ quality of life largely depends on the degree of recovery of lost functions. In turn, the degree of their recovery depends on the start, proportioning, and continuity of initiated rehabilitation measures and on whether the patient has cognitive, speech, and psychoemotional problems and pelvic organ dysfunctions. Unfortunately, after discharge from a specialized unit, only a small number of post-stroke patients are admitted to specialized rehabilitation centers. The responsibility of caring for
these patients rests with their relatives and outpatient physicians.
The main tasks in the early and late recovery periods following stroke are, in addition to the prevention of recurrent stroke, the implementation of rehabilitation programs to correct motor and speech disorders and cognitive impairments, the stabilization of emotions, and the provision of proper and qualitative general care for patients with severe motor defects and pelvic organ dysfunctions. The paper considers the main principles of patient management in the early and late post-stroke recovery periods. The authors give rehabilitation recommendations and main errors in routine practice (their relatives and junior medical staff have no speech contact with patients having speech disorders; psychoemotional disorders are underestimated and uncorrected; proper general care for patients with pelvic organ dysfunctions is absent).

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