Neurology, Neuropsychiatry, Psychosomatics

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Vol 7, No 2 (2015)
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4-9 694

The possibilities of antithrombotic therapy for prevention of thromboembolic events in non-valvular atrial fibrillation (AF) have been significantly expanded after the development and introduction of new oral anticoagulants (NOACs) into clinical practice. Starting the clinical use of NOACs has opened a new page in oral anticoagulant therapy aimed at preventing thromboembolic events in AF. Dabigatran etexilate is the first NOAC that was registered in 2010. After completion of the RE-LY trial, the positive safety and efficacy profile of dabigatran has been confirmed in real practice of over 5 years of clinical use in more than 200,000 patients from nearly 100 countries. An observational cohort study of oral anticoagulants used in more than 134,000 patients was one of the largest independent studies of the Food and Drug Administration (FDA) in the Medicare system. In the dabigatran group, the risk of ischemic stroke, intracranial and intracerebral hemorrhage, and death was statistically significantly lower than in the warfarin group. The incidence of major and all hemorrhages requiring hospitalization, as well as myocardial infarction was comparable. Profuse gastrointestinal bleeding was more common with dabigatran. This study in the Medicare system has demonstrated a favorable benefit/risk ratio for this drug and this requires no additional changes in the current instructions and recommendations for its use.


10-15 1108

Objective: to study the specific features of brain bioelectrical activity in patents with poststroke apathy and depressive disorders.

Patients and methods. The investigation enrolled 175 patients (84 men and 91 women) with new-onset cerebral stroke at different sites. A total of 107 (61%) patients of them were observed to have depressive disorders (n=41 (38%)) and apathy (n=66 (62%)) within a year after disease onset. A control group included 68 (39%) patients without poststroke affective disorders. The mean age of the study group patients was 66±10 years and that of the control patients was 68±11 years. The severity and magnitude of neurological deficit were evaluated using the U.S. National Institutes of Health Stroke Scale (NIHSS). The patients underwent electroencephalography (EEG), brain computed tomography and magnetic resonance imaging. The investigators used diagnostic and statistical manual of mental disorders (DSM-IV) criteria to diagnose depression and the Hamilton depression rating scale (HAM-D) and the mini-mental status examination (MMSE) to evaluate the mental status. The basic rhythmic power indices in the affected and unaffected hemispheres were calculated, as well as anteroposterior alpha rhythm distribution coefficient and interhemispheric asymmetry coefficient. 

Results and discussion. The computer EEG analysis was shown to identify the hallmark characteristics of brain bioelectric activity in patients with different types of affective disorders in the acute, early and late recovery periods of stroke. The patients with affective disorders were found to have brain bioelectrical activity changes predominantly in the rapid frequency sub-band on EEG, suggesting midbrain structural dysfunction. In the patients with poststroke depression, depressive disorder scale scores were related to the power of bioelectric activity in the slow and alpha frequency bands manly in the acute stroke period whereas those were correlated with the EEG beta band power in the delayed period.

16-21 933

Objective: to comparatively analyze the rate and correlation of the symptoms of pathological fatigue, apathy, and depression in patients in the termination phase of an acute stroke period.

Patients and methods. The symptoms of asthenia (pathological fatigue), apathy, and depression were comparatively investigated in 105 patients at 3–4 weeks after stroke. The fatigue rating scale, apathy rating scale, and hospital anxiety and depression (HAD) scale were used to evaluate the symptoms of pathological fatigue, apathy, and depression. The level of anxiety was also estimated using the appropriate HAD subscale and the Epworth daytime sleepiness scale; the magnitude of cognitive impairments was judged from the Montreal cognitive assessment. The type, basin, and recurrence of stroke were registered. The severity of neurological deficit was evaluated using the U.S. National Institutes of Health Stroke Scale (NIHSS); limited functional capacities were estimated by the modified Rankin scale (mRS). The presence of prestroke fatigue was also determined.

Results and discussion. The symptoms of asthenia were observed in 56% of the patients and associated with the severity of poststroke disability. The symptoms of apathy were detected in 10.5% of the patients; those of depression were present in 18% and determined by the magnitude of neurological deficit and the degree of poststroke disability and cognitive impairments. All the three phenomena were correlated with the magnitude of anxiety, daytime sleepiness, and between them. This suggests that they may complicate a reciprocal course in some cases. The symptoms of depression, asthenia, and apathy may also develop on their own, which is borne out by their different rates and correlations. Each of these phenomena requires an individual approach to diagnosis and treatment.

Conclusion. The symptoms of pathological fatigue are most common and least specific in patients with mild poststroke neurological deficit. Apathy may be also associated with depression or develop on its own. Further investigation of mechanisms for the development of poststroke pathological fatigue and apathy is important for developing effective methods to correct these abnormalities.


56-60 784

Betahistine hydrochloride is the drug of choice for the treatment of vestibular vertigo in the presence of benign paroxysmal positional vertigo, Meniere's disease, and vestibular neuronitis. Effective combination therapy regimens that contain, along with drugs from other pharmacological groups, betahistine hydrochloride that improves blood circulation in the vestibular structures, accelerates vestibular compensation, and prevents recurrent dizzy spells, have been elaborated to treat central vestibular vertigo in migraine-associated dizziness and in acute cerebrovascular accident. Of great importance is a combination of drug therapy and the current rehabilitation methods for vestibular diseases, which contribute to prompter and complete recovery of vestibular function. Biofeedback instrumental rehabilitation techniques using a stabilographic platform
are highly effective. Successful treatment depends on the correctness of the established diagnosis. The diagnosis of peripheral and central vestibular vertigo frequently poses challenges. The essential reason for this is physicians’ unawareness about outpatient methods for the diagnosis of major vestibular diseases when the patient is at a doctor. It is important to follow a vestibular system study protocol since the use and correct assessment of diagnostic tests in most cases make it possible to estimate the degree of vestibular analyzer injury and to make an accurate diagnosis. The paper describes the diseases that are the most common causes of vestibular vertigo. The most effective methods for their treatment and current rehabilitation methods are discussed.

61-66 1539

In vitro and in vivo studies have provided sufficient evidence of the neurotoxicity of general anesthetics and their ability to cause postoperative cognitive dysfunction (POCD). The latter is one of the undesirable phenomena associated with general anesthesia. Recently, the prevention of postoperative cognitive impairments has been of particular relevance because of their high incidence, longer length of hospital stay, higher cost of treatment, worse quality of life in patients, and no approaches to drug correction and prevention. The review gives data on the negative effects of general anesthesia in patients of different age groups, highlights the pathogenetic mechanisms of POCD, and proposes its possible drug prevention and treatment strategies: identification of patients at high risk for POCD and both pre- and postoperative neuropsychological testing; intraoperative POCD prevention using a package of measures and, if inefficient, drug correction of found cognitive impairments just in the early postoperative period.

67-74 678

Vibration disease (VD) (pneumatic hammer disease) is a leader among occupational diseases. The prolonged use of vibrating tools is a high occupational health risk. The clinical picture of VD caused by local vibration includes sensorineural and upper extremity locomotor impairments that are polymorphic, polysyndromic, and not always specific. The International List of Occupational Diseases (2010) defines VD using the terms «vibration-induced white finger» (VWF) and «hand-arm vibration syndrome» (HAVS). VWF as a manifestation of secondary Raynaud’s syndrome is the most noticeable vascular injury in HAVS. According to the recommendations of the International Labor Organization (2011) and the order of the Ministry of Health of Russia (2012), the clinical manifestations of local vibration include upper extremity polyneuropathy, secondary Raynaud’s phenomenon, and carpal tunnel syndrome (CTS). The paper considers approaches to differentially diagnosing CTS and HAVS, primary and secondary Raynaud’s syndrome, as well as clinical, laboratory, and electrodiagnostic studies. Prolonged exposure to vibration may affect the large myelinated (Ab) fibers responsible for tactile touch, pressure, and vibration. Patients with VWF are frequently found to have hyperresponsiveness of the sympathetic nervous system, which affects digital vascular tone and appears as lower fingertip skin temperature. The paper discusses some possible mechanisms for the pathogenesis of vibration neuropathy (e.g. demyelination
of peripheral nerve fiber), as well as the involvement of plasma endothelin-1 in vascular response to cold as one of the components of the pathogenesis of vascular disorders. The central nervous system (cortical reorganization, plasticity phenomenon) is believed to be implicated in the development and maintenance of vibration neuropathy.

75-79 704

The authors give the data available in the literature and the results of their investigations of the gender features of depressive disorders in women. They analyze the results of studies relating to gender differences in the neurohormonal system from the embryonic period, as well as those in the lateralization of neuromorphofunctional provision of emotions. Based on their clinical observations, the authors discuss the varying roles of menopause in the etiopathogenesis of climacteric, psychogenic, and endogenous depression; in these forms of depression, menopause may be a cause, ground, or trigger, respectively. The influence of endocrine and sociopsychological factors on the development of postpartum depression is considered. The authors unveil the diagnostic and predictive value of premenopausal syndrome with depressive disorders at different stages of a depressive episode: the prediction of depression when depressive symptoms appear in the premenopausal period, as well as the reduction of premenopausal depressive disorders as evidence of intermission. Based on the data available in the literature, the authors consider the clinical features of depression in women: earlier onset; more frequent depressive episodes; greater presentation of atypical symptoms (anxiety, fatigue, increased appetite, weight gain, hypersomnia, and signs of somatization), as well as rarer suicidal tendencies as compared
to men. It is concluded that the gender features of depression in women are due to the whole complex of gender factors, such as neurophysiological, neuroendocrine, and sociopsychological ones.

80-85 802

The paper reviews the present-day Russian and foreign literature on neuromuscular disorders in chronic alcohol intoxication. The most common manifestations of alcohol disease include alcoholic polyneuropathy (PNP) and alcohol-induced skeletal muscle injury. The clinical polymorphism of alcoholic PNP is discussed. The paper considers a chronic sensory automatic form due to the direct toxic effects of ethanol and its metabolites during long-term alcohol intoxication, as well as acute/subacute sensorimotor neuropathy, the basis for the pathogenesis of which is B group vitamins, predominantly thiamine, deficiency that develops in the presence of drinking bouts concurrent with malnutrition and/or alcohol-related gastrointestinal tract diseases. In addition to nonuse of alcohol and a properly balanced diet, antioxidant therapy with alphalipoic acid and neurotropic B group vitamins is considered to be pathogenetic therapy for neuropathy. The most common and least studied clinical
form of alcohol-induced musculoskeletal injury is chronic alcoholic myopathy (AM), the diagnostic standard for which is morphometric
and immunohistochemical examination of a muscle biopsy specimen. The morphological base for this form of myopathy is predominantly type 2 muscle fiber atrophy caused by impaired protein synthesis and a decreased regenerative potential of muscle fiber. The efficacy of antioxidants and leucine-containing amino acid mixtures in the treatment of chronic AM is discussed.

86-92 1602

The paper considers the main causes of falls. Whatever their cause is, falls may lead to severe maladjustment in everyday life. In nearly 1 out of 10 cases, they are accompanied by severe injuries, including fractures (most commonly those of the proximal femur and humerus, hands, pelvic bones, and vertebrae), subdural hematoma, and severe soft tissue and head injuries. This process is emphasized to be multifactorial. Particular emphasis is laid on the involvement of the cerebellum and its associations, which may be accompanied by falls. This is clinically manifested mainly by gait disorders. Walking is a result of an interaction of three related functions (locomotion, maintenance of balance and adaptive reactions). In addition to synergies related to locomotion and balance maintenance, standing at rest and walking are influenced by
the following factors: postural and environmental information (proprioceptive, vestibular, and visual), the capacity to interpret and integrate this information, the ability of the musculoskeletal system to make movements, and the capability to optimally modulate these movements in view of the specific situation and the ability to choose and adapt synergy in terms of external factors and the capacities and purposes of an individual. The clinical signs of damage to the cerebellum and its associations are considered in detail. These structures are emphasized to be involved not only in movements, but also in cognitive functions. The major symptoms that permit cerebellar dysfunction to be diagnosed are given. Symptoms in cerebellar injuries are generally most pronounced when suddenly changing the direction of movements or attempting to start walking immediately after a dramatic rise. The magnitude of ataxia also increases in a patient who tries to decrease the step size. Falling tendencies or bending to one side (in other symptoms characteristic of cerebellar diseases) suggest injury of the corresponding cerebellar hemisphere. Management tactics for patients for cerebellar disorders are considered.

93-100 935

The paper gives an update on the pathogenesis, clinical presentation, and pathomorphology of cognitive impairments (CIs) in different autoimmune, endocrine, and infectious diseases: systemic lupus erythematosus, Sjögren’s syndrome, Behchet’s disease, primary angiitis of the central nervous system, polyarteritis nodosa, cryoglobulinemic vasculitis, hypothyroidism, herpetic lesion, and neurosyphilis. It is noted that treatment for CIs should be individual in terms of virulence factors. In vascular CIs, therapy should be aimed primarily at modifying risk factors and eliminating or reducing chronic brain ischemia. The prevention of progressive CI encompasses antihypertensive and antithrombotic therapies and surgical correction of atherosclerotic great artery stenosis. Control of hyperlipidemia, hyperglycemia and treatment of other somatic diseases are also of great importance. Such patients are usually given cetylcholinesterase inhibitors, acetylcholine precursors, antiglutamatergic agents, and metabolic and vascular drugs. By taking into account brain ischemia/ hypoxia in the above diseases, it is shown to be advisable to use antioxidants, cerebral active agents in particular, which have a complex neurometabolic effect. 


22-27 716

The paper gives the data available in the literature on meningiomas and their psychopathological manifestations that occupy a central position in the clinical picture in almost every 5 patients with these tumors. The authors provide a clinical and psychopathological analysis of a female patient with multiple meningiomas in the right hemisphere: a giant meningioma in the posterior third of the falx, a large meningioma in the temporal region, and three small meningiomas in the frontal and parietal regions. The disease started as headache; however, psychopathological symptoms remained missed by physicians, such as emotional lability; personality changes leading to family dissension; lower criticism; spatial orientation problems; hypomnesia; left-sided visual inattention,
occurred in parallel. Surgical treatment was performed by stages: the two largest meningiomas were removed at an 11-day interval, which presented a means of observing psychopathological changes after each operation. It is concluded that greater attention should be given to the psychopathological manifestations of the disease, which is important to make a primary diagnosis and to define further treatment policy.

28-34 1255

Herpesviruses can directly affect the structure of the nervous system, resulting in encephalitis, and also induce immune-mediated disorders of the peripheral nervous system as sensory-predominant chronic inflammatory demyelinating polyneuropathy (CIDP). Patients with immunodeficiency may simultaneously develop two pathological processes, determining the severity of the condition. Parainfectious limbic encephalitis (PILE) associated with viruses from the family Herpes viridae is a form of chronic herpes encephalitis, which is characterized by dysfunction of the limbic system and by a long-term course with exacerbations. CIDP is a dysimmune disease leasing to peripheral nervous system involvement, which belongs to a class of myelinopathies. The paper describes two clinical cases of a concurrence of chronic PILE and CIDP in middle-aged men who have symptomatic status epilepticus and iatrogenic complications. It characterizes difficulties in diagnosis and the clinical features of chronic herpes infection involving the central and peripheral nervous systems. The given clinical cases suggest that not only neurologists
and epileptologists, but also resuscitation specialists and ngiosurgeons should be particularly alert to the pathology in question.

35-41 702

Chronic daily headache (CDH) is one of the top 10 causes of adult disability and one of the 5 most common causes of female disability. To treat patients with CDH is one of the most difficult tasks in neurological practice. Difficulties in managing patients with CHD are associated with the high prevalence of comorbid mental disorders, analgesic abuse, pain syndromes at another site, and misconceptions of a patient about his/her disease. A combination of drug and non-drug therapies is the mainstay of the current approach to treating patients with CDH. Standard, alternative, and auxiliary therapies are identified. The paper describes different types of current auxiliary and alternative therapy used in the world’s leading headache centers and clinics. It describes experience with cerebrolysin used as auxiliary and alternative pharmacotherapies for CDH.

42-46 668

The paper describes a 44-year-old male patient with an about 6-year history of hypertrophic pachymeningitis. The major clinical symptoms were characterized by headache, exophthalmos, and blindness in one eye. The data for differential diagnosis of the disease are given. The current literature on the clinical manifestations of hypertrophic pachymeningitis, its differential diagnosis, and the results of magnetic resonance imaging (MRI) is reviewed. Diagnostic difficulties at the stage of a clinical observation are due to the nonspecificity of neurological manifestations and the need for a comprehensive examination to detect a somatic disease. MRI can diagnose the disease-specific phenomenon of damage to the meninges, which calls for further careful differentiation. Clinicians must be familiar with alternative differential diagnosis, as a rapid specific therapeutic approach will help avoid long-term or irreversible neurological complications.

47-51 2824

Differential diagnosis of new-onset acute vestibular vertigo is chiefly made between vestibular neuronitis and stroke. Dizziness in stroke is usually accompanied by other focal neurological symptoms of brainstem and cerebellar involvement. However, stroke may appear as isolated vestibular vertigo in some cases. An analysis of history data and the results of neurovestibular examination and brain magnetic resonance imaging allows stroke to be diagnosed in patients with acute isolated dizziness. The treatment of patients with stroke-induced dizziness involves a wide range of medications for the reduction of the degree of dizziness and unsteadiness and for the secondary prevention of stroke. Vestibular rehabilitation is an important component of treatment. The paper describes an observation of a patient with poorly controlled hypertension, who developed new-onset acute systemic dizziness. Vestibular neuronitis might be presumed to be a peripheral cause of vestibular disorders, by taking into account the absence of additional obvious neurological symptoms (such as pareses, defective sensation, diplopia, etc.) and the nature of nystagmus. However, intention tremor in fingernose and heel-knee tests on the left side, a negative Halmagyi test, and results of Romberg’s test could suggest that stroke was a cause of

52-55 681

The paper describes an observation of a female patient with acute non-specific low back pain (LBP). It gives current recommendations for the 
treatment of acute LBP and evaluates the clinical efficiency of these methods. The management of patients with acute nonspecific LBP encompasses: 1) correct information about the nature and prognosis of the disease; 2) recommendations for daily activities; 3) a short-term rational therapy with paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), and/or myorelaxants. The role of NSAIDs, ketorol in particular, in treating patients with acute nonspecific LBP is discussed.


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The paper gives information on the Interuniversity Scientific and Practical Conference on Psychosomatic Medicine in Russia: Advances and prospects, held in Moscow on March 26, 2015, which was a continuation of a series of the similar measures arranged by the Department of Psychiatry, Psychotherapy, and Psychosomatic Pathology, Faculty of Advanced Training Peoples’ Friendship University of Russia. The conference was focused on a wide range of specialists (psychiatrists, narcologists, psychotherapists, cardiologists, gastroenterologists, therapists, family doctors, plastic surgeons, cosmetologists, etc.), its participants were more than 180 practitioners, and researchers. The program included the discussion of diverse aspects of a relationship between mental and somatic diseases in different fields of medicine.

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