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Neurology, Neuropsychiatry, Psychosomatics

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Vol 7, No 4 (2015)
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https://doi.org/10.14412/2074-2711-2015-4

LECTURES

4-10 708
Abstract
Investigations of a relationship between migraine and hypertension are being continued. In spite of numerous studies, the association of some types of migraine (migraine with aura and migraine without aura) with hypertension has not been fully elucidated. This issue is particularly relevant since these forms differ both clinically and pathophysiologically. Of even greater importance are the analysis and prediction of associations between migraine and cardiovascular diseases (ischemic stroke, myocardial infarction, coronary heart disease). The review deals with the clinical and pathophysiological features of the relationship between hypertension and migraine. There is evidence for the anatomic and functional correlation between the antinociceptive system and blood pressure (BP) regulation control. It has been speculated that the increase in pain threshold is not the result of just hypertension as a disease, but it is caused by elevated BP-related hypalgesia. The efficacy of antihypertensive drugs is the fact that supports the association between hypertension and endothelial dysfunction. Identification of groups of patients having migraine and a high cardiovascular risk will allow timely early primary prevention and therapy. Introduction of a stratification approach at diagnostic stages may cause a reduction in cardiovascular morbidity and mortality rates.

ORIGINAL INVESTIGATIONS

11-17 504
Abstract

Objective: to study the clinical features of chronic cerebral ischemia (CCI) in relation to the leading etiological factor.

Patients and methods. Examinations were made in 515 non-stroke CCI patients: 306 men and 209 women aged 58 to 75 years with hypertension and no obvious atherosclerosis of head and neck vessels (n=197); with obvious atherosclerosis of head and neck vessels and no hypertension (n=157); with obvious atherosclerosis of head and neck vessels and hypertension (n=161). In all cases, the investigators performed standard neurological examination and evaluated cognitive, affective symptoms with a set of neuropsychological scales and equilibrium and gait abnormalities with the Tinetti scale.

Results and discussion. The development of extrapyramidal syndrome was more related to hypertension or its concurrence with the atherosclerotic process. The patients with atherosclerosis and no hypertension showed a more distinct differentiation of clinical syndromes, which was associated with stenosis in the specific vascular bed; this was probably due to decreased local perfusion. A relationship was established between hypertension and the development of severe cognitive impairments (CIs) that had predominantly a dysregulation neuropsychological profile. In the patients with atherosclerosis and no hypertension, emotional disorders were more common than CI and the latter resembled Alzheimer’s disease. A differentiated prophylactic and therapeutic strategy accounting for the leading etiological factor will be able to prevent or significantly reduce functional limitations in patients with CCI.

18-22 411
Abstract

Arnold-Chiari malformation (ACM) is a group of congenital hindbrain malformations affecting the structural relationships between the cerebellum, brain stem, top cervical spinal cord, and bones of the skull base. In clinical practice, ACM types 0 and 1 are more common and types 2, 3, and 4 belong to rare severe (often fatal) congenital malformations.

Objective: to study gender differences in the incidence of ACM types 0 and 1 in outpatient neurological practice.

Patients and methods. A total 2039 case records of outpatients who had visited a neurologist of the Krasnoyarsk University clinic in 2008–2014 were analyzed. Neurological and neuroradiological (1.5 Tesla brain magnetic resonance imaging, phase-contrast spinal cerebral fluid flow imaging) diagnostic techniques were used. 3.4% (70/2039) of cases were randomized according to the criteria of inclusion and exception. An entire sample included 70 ACM patients (median age, 25 [17; 34] years) (30 (42.8–7.1%) men and 40 (57.2–7.1%) women).

Results. There was an increase in the incidence of ACM type 1 in the women than in the men. Conclusion. It is necessary to develop a new strategy for the prophylactic medical examination of patients with ACM to improve primary and specialized outpatient health care.

23-26 347
Abstract

Back pain is encountered in nearly 80–90% of the population; patient management is not only a medical, but also important socioeconomic problem.

Objective: to comparatively evaluate the efficiency of yoga and zhen-jiu (acupuncture) therapy in the combination treatment of patients with chronic nonspecific low back pain (LBP).

Patients and methods. Sixty patients with chronic nonspecific LBP were examined and randomized in groups: 20 patients received symptomatic therapy only (a control group), 20 patients used yoga (Group 1) and 20 more patients had zhen-jiu therapy in addition to symptomatic therapy (Group 2).

Results. As compared to the controls, Groups 1 and 2 patients showed a significant increase in the scope of lumbar spine movements and a decrease in the degree of pain syndrome. The investigation demonstrated the efficiency of yoga and zhen-jiu therapy versus symptomatic therapy in the combination treatment of chronic nonspecific LBP, by simultaneously reducing the number of side effects.

Conclusion. It is necessary to conduct large controlled randomized studies evaluating the efficiency of yoga and zhen-jiu therapy in these patients.

CLINICAL OBSERVATIONS

27-32 328
Abstract

Wernicke’s encephalopathy (WE) is a rare but severe neurological syndrome caused by thiamine deficiency. According to the data of autopsy studies, the prevalence of WE in the general population varies from 0.4 to 2.8 per 100,000 population; the disease occurs many times more frequently in alcohol abusers than in people who lead a healthy lifestyle. These studies also showed that most cases of WE were diagnosed postmortem; less than 20% of patients with the disease were diagnosed in life. A healthy adult requires 1–2 mg of thiamine daily, depending on the carbohydrate intake. Body’s reserves of thiamine are only 30–50 mg so any malnutrition condition lasting more than 3–4 weeks can cause complete depletion of the vitamin’s stores. Classically, WE is characterized by the sudden onset of a typical triad of symptoms: an altered mental state, ophthalmoplegia, and ataxia. However, this clinical picture can be seen in only one-third of patients. The onset of the disease may sometimes look completely different: heart failure with hypotension and tachycardia; gastrointestinal symptoms (abdominal pain and nausea); hypothermia due to the involvement of the posterior hypothalamus; deafness affecting the thalamus; epileptic seizures in case of enhanced activity of the glutamatergic system.

The paper describes a clinical case of acute cerebellar ataxia that is apparently caused by Wernicke’s encephalopathy in a young woman.

33-36 285
Abstract
The paper describes subarachnoid hemorrhage (SAH) and hematomyelia resulting from bleeding from spinal hemangioblastoma. SAH is encountered in spinal pathology extremely rarely and results from bleeding from malformations in most cases. The described case demonstrates that the tumors may also cause spinal SAH even there is no clinical evidence of gradually progressive spinal cord compression in the history. Patients with hemangioblastoma are at the highest risk for clinically relevant massive bleeding in intramedullary tumors. In this case, of special attention is its clinical picture: SAH began with neck and arm pain, rather than headache, which indicates the primarily spinal level of bleeding. Head and arm pains were joined by SAH -typical headache, nausea, and vomiting in only a few minutes, which was associated with retrograde blood flow into the basal cisterns of the brain and the fourth ventricle. Primary MRI of the cervical spine was a more rational diagnostic scheme in this case.
37-41 359
Abstract
Based on the data available in the literature and their own experience, the authors give current views on the etiology, pathogenesis, classification, clinical presentations, and treatments of cerebral dural arteriovenous fistula (DAVF), one of the unusual causes of stroke. The paper describes a young male patient with the lobar localization of the focus, a concurrence of ischemic stroke and hemorrhagic stroke. It is stated that the early emergence and persistence of a considerable focus should alert the physician to the possibility of DAVF or another venous anomaly. An emphasis is laid on the leading role of multimodal imaging protocols in the early diagnosis of the disease. Selective cerebral angiography of the internal and external carotid and vertebral arteries is today the gold standard for the diagnosis and classification of DAVF.

REVIEWS

42-49 368
Abstract

Endovascular treatments for ischemic stroke (IS) are coming into clinical practice and, as shown by recent investigations, have good prospects. These treatments for IS make it possible to expand indications for revascularization and to create prerequisite for improving the outcomes of treatment.

Interventional treatments for IS should not be set off against intravenous thrombolytic therapy (ITT); it is necessary to seek their reasonable sharing. The promising directions in the development of ITT and endovascular revascularization (EVR) for IS are to upgrade tools and to choose the safest and most effective constructions, as well as to identify target patient groups needing these treatment options based on the prediction of the efficacy of these techniques with consideration for clinical findings, the pattern of a lesion, and radiological data (including estimates of perfusion, ischemic core-penumbra relationships, and collateral blood supply intensity).

The paper discusses the present status and prospects of EVR of cerebrovascular arteries, its indications, and basic procedures.

50-56 834
Abstract
The incidence of dysphagia after stroke accounts for 20 to 64%, which makes swallowing disorder one of the most common sequels of acute cerebrovascular accident. Dysphagia may cause life-threatening complications, such as aspiration pneumonia, cachexia, and dehydration. The paper gives international algorithms for the clinical and instrumental evaluation of swallowing function and the diagnosis of aspiration. It sets forth basic principles for managing patients with dysphagia, as well as dietary recommendations for these patients. The authors show the advantages of fast-dissolving oral medicines used in the therapy of patients with dysphagia after stroke. The currently available experience of drug and non-drug treatments for dysphagia in patients after stroke is analyzed.
57-64 547
Abstract

Hypertension is one of the most common vascular diseases. The brain as target organs in hypertension is damaged more often and earlier. Neurological complications due to hypertension are frequently hyperdiagnosed in Russian neurological practice. Thus, headache, dizziness, impaired recall of recent events, nocturnal sleep disorders, and many other complaints in a hypertensive patient are usually regarded as a manifestation of dyscirculatory encephalopathy. At the same time headaches (tension headache and migraine) in hypertensive patients are predominantly primary; headache associated with dramatic marked elevations in blood pressure is encountered in only a small number of patients. The role of cerebrovascular diseases in the development of dizziness in hypertensive patients is also overestimated. The vast majority of cases, patients with this complaint are in fact identified to have benign paroxysmal postural vertigo, Mеniеre’s disease, vestibular neuronitis, or vestibular migraine. Psychogenic disorders or multisensory insufficiency are generally responsible for non-systemic vertigo in hypertensive patients. Chronic cerebral circulatory insufficiency may cause non-systemic vertigo as a subjective equivalent of postural instability.

Cognitive impairments (CIs) are the most common and earliest manifestation of cerebrovascular lesion in hypertension. In most cases, CIs in hypertension were vascular and associated with cerebrovascular lesion due to lacunar infarcts and leukoaraiosis. However, mixed CIs frequently occur when hypertensive patients are also found to have signs of a degenerative disease, most commonly in Alzheimer’s disease.

65-70 336
Abstract

The paper reviews the data available in the literature on the pharmacokinetic and pharmacodynamic properties of cyticolin and its use in cognitive impairments (CIs).

It assesses trials investigating the effect of cyticolin on cognitive functions, including its possible role in increasing Sirtuin 1 (SIRT1) expression. The results of the latest multicenter trials of the drug used to treat dementia syndrome are analyzed in elderly patients with clinical presentations of mental confusion (the VITA trial) and mild vascular CIs (the IDEALE trial).

Cyticolin is able to potentiate neuroplasticity and is a natural precursor of phospholipids, mainly phosphotidylcholine that serves as a source of choline in the metabolic pathways of acetylcholine biosynthesis. The VITA and IDEALE have shown that the parenteral and oral administrations of cyticolin are effective and safe in the treatment of moderate vascular CIs and dementia with clinical presentations of mental confusion. Cyticolin therapy is used to reduce the risk of side effects and to delay of loss of the therapeutic effects of levodopa preparations. Cyticolin has been noted to have a positive effect on cognitive functions in patients with Alzheimer’s disease if it is used as an additional therapy.

71-77 487
Abstract
The management of patients with headache (cephalgia) concurrent with neck pain (cervicalgia) remains an urgent problem of modern medicine. Concurrent cervicalgia in cephalgia substantially lowers quality of life in these patients and is encountered in more than half the patients. Cervicalgia is considered as a risk factor of migraine and tension headache attacks. Cervicogenic headache is assigned to one of the most common forms of secondary cephalgias. It is shown that patients with daily headache have functional insufficiency of the antinociceptive system that plays an important role in the maintenance and chronization of neck pain. The diagnosis of different cephalgic syndromes and the identification of causes of cervicalgia commonly raise problems in a physician; the rate of misdiagnoses and hence inadequate treatment has been high so far. The detection of various comorbid conditions, including cervicalgia, in a patient with cephalgia makes it possible to use effective treatment and to achieve good results.
78-82 400
Abstract
All general anesthetics routinely used in clinical practice are noted to have a neurotoxic effect on the brain in different animal species including primates. The negative effects observed both in young and sexually mature animals include apoptotic neuronal cell death, suppression of neurogenesis and gliogenesis, neuroinflammation, as well as learning and memory impairments. A number of epidemiologic surveys have established an association between anesthesia in patients younger than 3 to 4 years and subsequent learning disabilities and language disorders whereas others have not found this link. In middle-aged and elderly patients, anesthesia is frequently associated with the development of postoperative cognitive dysfunction. The key component of its pathogenesis (general anesthesia itself or other factors, such as operative injury, an inflammatory response, pain syndrome, intraoperative complications, underlying disease in a patient) remains unelucidated. It is concluded that there is a need for additional experimental and clinical studies of the pathogenesis of these undesirable phenomena to be prevented and corrected.
83-91 418
Abstract
The important task of nevrology is to improve the diagnosis of chronic progressive degenerative and vascular brain diseases – to detect them at the earliest stages. The paper presents current views on the non-dementia stages of brain diseases: moderate, mild, and subjective cognitive impairments. It sets forth data on their prevalence and clinical features and types, as well as international diagnostic criteria. There is evidence for the expediency of the earliest neuroprotective therapy to prevent dementia. A methodology for neuroprotective therapy is discussed; the available data on the long-term effect of intermittent treatment cycles with the vasotropic and neurometabolic drug tanakan are given.
92-100 508
Abstract
Neurotrophic therapy with brain extract-based drugs has been performed for decades. The basis for their neurotrophic activity is amino acids and neuropeptides. However, incomplete information on the composition of these drugs precludes a detailed description of mechanisms through which their pharmacological effects occur. The review considers the results of the most recent molecular pharmacological investigations and the mechanisms of therapeutic action of cerebrolysin.
101-109 1500
Abstract
In the current biopsychosocial model of back pain, there are biological (anatomic sources of pain), psychological and social components that promote its occurrence and maintenance. Nonspecific (musculoskeletal, mechanical) pain that is diagnosed, with a serious disease and radicular symptoms being ruled out, is encountered most commonly (in 85% of cases) in clinical practice. A group of patients with nonspecific back pain is very heterogeneous and needs differential treatment. The most common sources of back pain are abnormally changed discs, facet and sacroiliac joints, and muscles; however, it is often difficult to determine the main source of pain. International guidelines for the management of acute and chronic back pain have been elaborated, which assign an important role to the clarification of the benign pattern of pain to patients; their training; and recommendations for the maintenance of day-to-day activity. Medical treatment involves both nonselective and selective nonsteroidal anti-inflammatory drugs and myorelaxants as the drugs of choice. Non-drug treatments are actively used; these are manual therapy for acute pain, cognitive behavioral therapy, manual therapy, therapeutic exercises, reflex therapy, and yoga exercises for subacute and chronic pain. Whether blockades, ablations, minimally invasive neurosurgery, which are aimed at eliminating the main source of pain, is discussed if the treatment is ineffective.
110-115 386
Abstract

The efficacy of naftidrofuryl in treating cerebrovascular diseases is analyzed on the basis of a review of the Russian and foreign literature. Naftidrofuryl is a seroton 5-HT2 receptor antagonist and acts on brain energy metabolism mainly during hypoxia or ischemia. The results of preclinical studies proving the antispasmodic and neuroprotective properties of the drug and its capacity to normalize microcirculation in hypoxia are briefly considered. Experimental findings served as a basis for further studies of the efficacy of naftidrofuryl in patients with stroke, chronic cerebral ischemia, or vascular dementia. The use of naftidrofuryl (dusopharm) was demonstrated to statistically significantly enhance the efficiency of rehabilitation in post-stroke patients and to be followed by significant psychoemotional improvement. According to a Cochrane review, the naftidrofuryl-treated patients with vascular dementia showed a tendency towards better executive and cognitive functions, behavior, and mood. The drug was noted to have a positive effect on the health of patients with chronic cerebral ischemia.

The authors provide the data of their trial of naftidrofuryl used in patients with dyscirculatory encephalopathy, which have confirmed its efficacy in this category of patients. The data available in the literature suggest that oral naftidrofuryl has a good tolerability and safety profile in patients with cerebrovascular diseases.

INFORMATION

116-120 270
Abstract
A Regional Expert Council meeting was held in Moscow on August 21, 2015 to consider different aspects of the efficiency and safety of using the first direct thrombin inhibitor dabigatran etexilate in real clinical practice. The complex and debatable issues of prevention of systemic thromboembolic events in patients with non-valvular atrial fibrillation (AF) were the focus of attention. Five-year clinical use of dabigatran etexilate was noted to confirm its positive safety and efficacy profiles in real practice in more than 250,000 patients from nearly 100 countries of the world. The risk of ischemic stroke, intracerebral bleeding, and death was shown to be statistically significantly lower in the dabigatran group than in the warfarin group. The rate of major bleeding and myocardial infarction was comparable or even lower. An increased risk for bleeding was generally associated with undesirable drug interactions, polypragmasia, and underestimated kidney dysfunction. Renal function was recorded to decrease statistically less significantly in diabetic patients receiving dabigatran 150 mg twice daily than in those treated with warfarin. It was particularly emphasized that direct oral anticoagulants along with warfarin as fist-line agents might be used in patients with AF and acute coronary syndrome. It has been concluded that rich international experience with clinically used dabigatran provides support for a favorable benefit/risk ratio if all dosage guidelines are followed.


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