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Neurology, Neuropsychiatry, Psychosomatics

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Vol 7, No 3 (2015)
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https://doi.org/10.14412/2074-2711-2015-3

LECTURES

4-9 412
Abstract

The paper describes spinal dural arteriovenous fistulas (SDAVF), the most common type of spinal cord vascular anomalies. SDAVFs account for 60–80% of the spinal cord vascular anomalies. The causes of SDAVFs, the specific features of their hemodynamics, and their classification remain the subject matter of disputes.

SDAVFs form in dura mater tissue, on the dorsal surface of radicular cuffs. The pathogenesis of neurological disorders in SDAVF has determined the name «venous hypertensive myelopathy», a spinal cord injury occurring in their presence. Pain and paresthesias, cacesthesia (more commonly in their distal parts), and motor disorders as flail legs are observed at the onset of SDAVF in typical cases. On average, 12 to 44 months elapse to establish its diagnosis. In addition of motor and sensory disorders, sphincter impairments and sexual dysfunction are detected in the patients at the time of diagnosis. By this time, most patients have already neurological disability.

The paper presents the history of studying SDAVF, the existing classifications of arteriovenous malformations and fistulas, the clinical manifestations of venous hypertensive myelopathy in SDAVF, neuroimaging findings, and treatment options.

ORIGINAL INVESTIGATIONS

10-14 471
Abstract

Objective: to evaluate the efficiency of epilepsy therapy in the two periods 2006–2007 and 2013–2014 due to drug provision-related changes: the use of antiepileptic drugs (AEDs) in accordance with their international nonproprietary name.

Patients and methods. The continuous sample survey enrolled patients aged 18 years and older, who had been seen by an epileptologist at the Moscow Regional Research Clinical Institute in 2006–2007 (n=1200) and 2013–2014 (n=1450). The patients who had received initial therapy (n=384) were divided into 2 groups in accordance with the type of drug provision. Group 1 (n=124) had recommended AEDs. In Group 2 (n=260), there was switching between AED analogues in 80% of the patients. Therapeutic efficiency was comparatively analyzed in relation to the AEDs used and treatment policies.

Results. In 2013–2014 versus 2006–2007, the rate of remissions and the number of respondents was halved. The analysis demonstrated significant differences (p<0.05) between Groups 1 and 2 in the following indicators: the number of respondents (75:52%), remission rates (58:38%), pharmacoresistance (25:47%), the frequency of use of brand (54:34%) and generic (45:65%) AEDs, and that of switching between AED analogues (0:80%).

15-20 385
Abstract

The quality-of-life indicators are integral characteristics of treatment and diagnostic measures in modern epileptology.

Objective: to assess the social adaptation and quality of life in reproductive-aged women with epilepsy.

Subjects and methods. A sociological survey using the Quality of Life Satisfaction questionnaire and the European Quality of Life-5 Dimensions (EQ-5D) was carried out in 352 women living in the Krasnoyarsk Territory.

Results. At the time of the study, 21.3% of the patients were unemployed. Disability related to epilepsy was in 13.1% of women, mainly in those with cryptogenic (22.3%) and symptomatic (14.4%) epilepsy. Most of the women were unsatisfied with their job activity (55.1%), financial status (64.6%), and physical health (65.3%). Mainly the patients with symptomatic epilepsy reported dissatisfaction with their psychological status. The patients had employment problems (12.5%), inability to work in their specialty (12.5%) and to get the desired specialty (10.3%), and labor maladaptation (8.8%). There was a preponderance of women with higher education (40.3%) and 21.3% continued their studies. Warm family relations and help from relatives and friends (65.4%), hope for their recovery (50.7%), contacts with their friends (30.1%), and plans for future (34.6%) were important for the women to control the disease.

Conclusions. The findings suggest that family, personal, maternity problems are more important causes of social maladaptation in epileptic women.

21-27 374
Abstract

Objective: to investigate the efficacy/tolerability of topiramate in reproductive-aged women.

Subjects and methods. A group of 58 patients in fertile age (18–35 years) with a long history of focal (n=44) or idiopathic generalized (n=14) epilepsy (FE and IGE) who received mainly combined therapy with 2 antiepileptic drugs (AEDs) was analyzed. 82.8% of the patients were overweight; 51.7% had one or other menstrual cycle disorders; however, the women had been followed up by a gynecologist in exceptional cases.

Results. Switch from one of the parent AEDs to topiramate or its incorporation into a treatment regimen as an additional drug substantially improved the course of the disease: remission at 12 months was achieved in 59.1% of the patients with FE and 78.6% of those with IGE. 29.3% of the patients receiving dual therapy, the second medication of which was topiramate, were observed to have lost weight not only if those had high baseline body mass index (BMI), but also if those had normal BMI at baseline. 8.6% of all the patients and 16.7% of those with menstrual cycle disorder achieved normalization of menstrual function. Topiramate was discontinued only in 1 (1.7%) patient because of critical weight loss (BMI<15). In addition to substantial improvement, topiramate used in mono- or dual therapy for FE and IGE may normalize weight and a menstrual cycle. Menstrual function is indicated to be monitored in epileptic women.

28-34 439
Abstract

Objective: to investigate the specific features of epilepsy that manifests itself in the presence of chronic cerebrovascular disease.

Patients and methods. A total of 304 patients (a study group of 174 patients with new-onset seizures developing in the presence of cerebrovascular disease and a control group of 130 patients with cerebrovascular disease and no seizures) were examined. They underwent clinical neurological examination, electroencephalography (EEG), ultrasonic duplex scanning of extra- and intracranial arteries with functional tests, and visualization of brain structures.

Results. Focal seizures were prevalent in the patients with cerebrovascular disease and epilepsy. It was found that there was a preponderance of left-sided localization of EEG foci of abnormal activity and a tendency to more commonly detect subcritical and critical stenoses in the left carotid bed in the patients with epileptic seizures. Diminished perfusion reserves in the posterior circulation system were more frequently observed in the patients with seizures in the presence of cardiovascular diseases. Moreover, the patients with seizures displayed a more profound degree of brain ischemia with the frequent cortical and subcortical localization of dyscirculatory foci. Thus, a study of perfusion reserves, localization of vascular foci, and degree of occlusive changes in the wall of brachiocephalic vessels allows identification of risk factors for epilepsy in the patients with cerebrovascular disease and promotes the prediction of the course of the disease.

35-39 444
Abstract

Objective: to make a pharmacoeconomic comparison of the administration of first- and second-line drugs in the treatment of multiple sclerosis through cost, cost-effectiveness, and budget impact analyses using the 2015 state prices.

Material and methods. A pharmacoeconomic analysis was carried out on the basis of the data available in the literature on trials of the effects of the drugs on the rates of exacerbations and disability. On calculating, the authors took into account the current standards for the out- and inpatient management of patients with this nosological entity in accordance with the compulsory health insurance (CHI) program; prices for state drug purchases in March 2015; prices for medical services in compliance with the CHI standards in Moscow in 2015; the average sizes of minimum wage, salary, and disability grants with consideration for a discount rate of 3%. The cost-effectiveness and budget impact analyses were performed for intramuscular interferon (INF)-β1a (avonex, 30 μg), subcutaneous INF-β1a (rebif, 44 μg), subcutaneous INF-β1b (ronbetal, 8,000,000 IU), subcutaneous INF-β1b (betaferon, 9,600,000 IU), subcutaneous glatiramer acetate (copaxone, 20 mg), intravenous natalizumab (tyzabri, 300 mg), and oral fingolimod (gilenya, 0.5 mg).

Results and discussion. The second-line drug tyzabri outperforms the first-line agents for cost-effectiveness. The first-line drugs betaferon and copaxone is slightly exceeded in this indicator by tyzabri; the other both first- and second-line agents compared are all the more inferior in this indicator. The budget impact analysis has shown that the cost of the second-line drugs was higher than that of the first-line ones.

CLINICAL OBSERVATIONS

40-45 403
Abstract
Subcortical laminar heterotopia (double cortex syndrome) is an orphan disease with an incidence of 1 to 200,000 people in the population. The cause of the disease is mutation of the gene DCX (synonyms: DBCN, XLIS) in chromosome Xq22.3-q23. The type of inheritance is X-linked dominant. Correct diagnosis requires a high degree of skills of a neurologist/epileptologist and a radiologist. The paper describes a clinical case of the late diagnosis of double cortex syndrome in a 36-year-old woman with a long history of resistant atonic seizures and mental retardation.
46-50 429
Abstract

The data available in the literature on the role of melatonin in the regulation of circadian rhythms and sleep disorders in the population and in patients with mental diseases are analyzed. The cause of insomnia may be circadian rhythm disorders due to the age-related decline in the elaboration of the endogenous hormones that are responsible for the quality and duration of sleep, one of which is melatonin.

Sustained-release melatonin is a synthetic analogue of the endogenous human pineal hormone melatonin. According to clinical findings, the main proven clinical effects of sustained-release melatonin 2 mg are a reduction in the latency of sleep, improvement of its quality, and lack of daytime sleepiness. The drug causes no dependence on its long use and rebound symptoms (increased insomnia symptoms), positively affects cognitive functions, and lowers nocturnal blood pressure in hypertensive patients.

The paper describes a clinical case of a female patient with recurrent depressive disorder, in whom sustained-release melatonin 2 mg has demonstrated high efficacy and good tolerability in the combination therapy of sleep disorders in the pattern of depression.

51-56 373
Abstract

To manage patients with low back pain is an urgent problem of modern medicine. The paper considers the main causes of chronic nonspecific lumbago and the principles of its diagnosis and treatment in the context of evidence-based medicine. Medical treatment using analgesics (nonsteroidal anti-inflammatory drugs (NSAIDs), weak opioids), antidepressants, therapeutic exercises, and cognitive-behavioral therapy as components of a multidisciplinary treatment is noted to be highly effective. The efficacy and side effects of NSAIDs, the high efficiency and safety of using meloxicam in different dosage forms are outlined.

The authors set forth their experience in treating 85 patients with chronic low back pain and an observation of a female patient who has concurrent chronic migraine and abuses analgesics.

57-61 470
Abstract
Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) syndrome is a congenital small-vessel disease running with recurrent lacunar infarcts and leading to gradually progressive subcortical, pseudobulbar, and cerebellar syndromes and dementia. Neuroimaging reveal multiple lacunar infarcts in the basal ganglia, thalamus, pons Varolii, and cerebral hemispheric white matter, as well as cerebral atrophy. The specific feature of the disease is white matter lesion adjacent to the temporal horns of the lateral ventricles and to the external capsules. The paper describes a patient with CADASIL syndrome. The latter runs a progressive course and includes the following neurological disorders: cognitive, pyramidal, extrapyramidal, and axial ones. This clinical case was differentially diagnosed with multiple sclerosis, including with consideration for neuroimaging findings. The CADASIL syndrome is a rare potentially menacing neurological condition that is observed in young patients and requires a detailed examination using current diagnostic techniques.

REVIEWS

62-69 332
Abstract

Vascular cognitive impairments (CIs) are heterogeneous in the mechanism of their occurrence and may develop in different extent of brain damage, in different locations, and the number of foci. Their etiological factors are various. The mechanism for the development of CIs may be associated with impairments of both per se the structures responsible for cognitive functions (frontal cortex, subcortical-cortical interactions, and hippocampus) and deafferentation of the cortex and limbic structures due to periventricular white matter lesion or local lesion of the basal ganglia and thalamus. The pattern of CIs depends on the predominant involvement of cortical or subcortical regions or their combinations. The progression of CIs is also variable. In chronic cerebral circulatory insufficiency, CIs develop gradually over several years. Poststroke CIs manifest themselves acutely or subacutely. 6-27% of patients are diagnosed with dementia 3 months after acute cerebrovascular accident. The risk of subsequent dementia is 7% within the first year and 48% after 25 years.

The paper reviews the most important trials of citicoline used in CIs. The drug has a multicomponent activity spectrum that permits its use in CIs of varying genesis. By taking into account its good tolerability and safety, the drug may be recommended for a wide circle of patients, including for elderly patients with comorbidity.

70-74 333
Abstract
Ischemic stroke in the vertebrobasilar system (VBS) is characterized by the high rates of death and disability; reperfusion therapy in patients with a lesion focus in the VBS is safe and effective beyond the 4.5-hour therapeutic window. Actively developed current methods for the endovascular treatment of acute ischemic stroke enable one to increase recanalization rates and hence to improve the degree of functional recovery in this group of patients. Considering that there are no significant differences in the outcomes of systemic and selective thrombolytic therapy in patients with occlusion of the basilar arteries, the urgent problem is to increase the time from the onset of the disease to reperfusion therapy, therefore combined reperfusion therapy may be an optimal option. This approach would make it possible to initiate the therapy in a shorter period of time and to use the advantages of both reperfusion techniques. Intravenous thrombolysis as the rapidest and technically simplest method may be performed in the first step of therapy in the clinics unequipped with an X-ray surgical service, with the patient being further transported to a specialized endovascular center if the intravenous injection of a thrombolytic agent has no effect. Taking into account the fact that reperfusion therapy may be performed in patients with vertebrobasilar stroke in the wider therapeutic window, a similar organizational chart with multistep therapy for this disease might become the treatment of choice.
75-79 441
Abstract
The paper gives a brief clinical characterization of hereditary cerebellar ataxias running with polyneuropathy. Particular attention is paid to the pathogenesis, clinical presentation, and treatment of gluten ataxia. A mutant gene and concurrent symptoms are indicated. The differential diagnosis of cerebellar ataxias should be started by ruling out the hereditary nature of the disease, which is verified by molecular genetic testing. In recent years, some genetic diseases manifesting themselves by a concurrence of ataxia and polyneuropathy have been replenished by a description of new hereditary syndromes. The knowledge of the nature of inheritance, age at disease onset, and concurrent manifestations will assist a practitioner in presuming the diagnosis of a rare disease and in referring a patient for medical genetic testing. Only a precise diagnosis will be able to assess prognosis and to use specific treatment.
80-85 1683
Abstract
The paper gives an update on the epidemiology, etiology, pathogenesis, prevention, and treatment of Alzheimer's disease (AD). It points out the role of acetylcholine and glutamatergic components of neurotransmission in the pathogenesis of the disease, as well as their interactions, which is important to keep in mind to have a potentiated response to therapy that includes both these components. Different approaches to AD therapy are considered on the basis of the current ideas on the pathogenetic mechanisms of a degenerative process and with regard to the clinical features of the disease (the nature of the psychopathological symptoms of the disease and its stage). Particular emphasis is placed on compensatory therapy for deficient cholinergic and glutamatergic neurotransmission. Whether psychopharmacological agents may be used and psychotherapeutic work with the relatives of patients with AD should be done are also highlighted. Data on the efficiency of replacement therapy for different dementia stages, which promotes a delay in degenerative processes and a definite stabilization of the mental status, are presented.
86-92 477
Abstract
The paper gives an update on the pathogenesis, clinical presentation, and pathomorphology of cognitive impairments (CIs) in different autoimmune, endocrine, and infectious diseases, such as systemic lupus erythematosus, Sjögren's syndrome, BehНet's disease, primary angiitis of the central nervous system, polyarteritis nodosa, cryoglobulinemic vasculitis, hypothyroidism, herpetic lesion, and neurosyphilis. These patients are observed to have ischemic-hypoxic brain damage, the causes of which are free radical-induced cell injury, oxidative stress, excitation toxicity, cell necrosis and/or apoptosis, inflammation and immune disease, molecular sequestration, and cell death. There is enhanced imbalance in the pro-oxidant and antioxidant systems as cerebrovascular insufficiency progresses; as this takes place, the nerve cells are most susceptible to the induction of free radical reactions. In these cases, antioxidants that block the effects of free radicals and may potentially improve brain perfusion, by assisting the coupling of neurons and vessels, are first-choice drugs. To improve the cognitive status and to prevent the progression of CIs, it is important to build a cognitive reserve in a patient; this is largely favored by the preservation of a proactive approach to life and social bonds, as well as intellectual work.

PHARMACOTHERAPY

93-97 482
Abstract
Levodopa remains the most effective drug for the treatment of Parkinson's disease. The paper considers the mechanism of action, recommended levodopa doses, the time of therapy initiation, and risk factors for motor complications. A few dosage forms of levodopa are currently being used. The results of comparative trials of levodopa-benserazide and levodopa-carbidopa and the clinical experience with Levodopa/Benserazide-Teva are given. An open-label multicenter trial of Levodopa/Benserazide-Teva has shown its high efficacy and good tolerability.

REVIEWS

98-99 284
Abstract
Хронические цереброваскулярные заболевания, инсульт и его последствия являются наиболее острым вызовом современной медицине. С увеличением средней продолжительности жизни сосудистые заболевания нервной системы все чаще становятся причиной смерти и нарушения трудоспособности, неуклонно растет число больных, пострадавших от инсульта.

IN MEMORY OF OUR TEACHER

100 274
Abstract
25 сентября исполнилось бы 90 лет одному из самых значительных неврологов России Давиду Рувимовичу Штульману. Не обладая ни административным влиянием, ни громкими академическими званиями, Давид Рувимович оказал неизгладимое влияние на формирование нескольких поколений отечественных неврологов.


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