The paper considers the relevance of the problem of cerebral small vessel disease (CSVD) that is an important cause of ischemic and hemorrhagic stroke, associated with the development of cognitive impairment and complications of antithrombotic therapy. It presents briefly the current issues of etiology and pathogenesis of the disease. Sporadic non-amyloid microangiopathy, cerebral amyloid angiopathy, and cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) are discussed in detail from the point of view of their clinical presentation, neuroimaging, and features of therapeutic tactics. An algorithm for diagnosing CSVD in patients admitted to hospital for stroke and a differentiated approach to their treatment are proposed. Consideration of the neuroimaging manifestations of CSVD is noted to be necessary for the safe and more effective treatment of patients with cerebrovascular diseases.

The paper provides data on current neuroimaging techniques for diagnosing Alzheimer’s disease and vascular cognitive impairment (CN). Structural neuroimaging methods can identify potentially treatable diseases leading to dementia and assess the magnitude and localization of atrophic and cerebrovascular changes in brain tissue. Particular attention is paid to the specific signs of Alzheimer’s disease: to the visual assessment of sections and the use of various rating scales (GCA, MTA, Koedam). Vascular changes that are most significant for the development of CI are considered. A new approach to diagnosing CI is presented, by taking into account the biomarkers of amyloidosis, tauopathy, neurodegeneration, and cerebrovascular damage. The results of the authors’ own investigations using positron emission tomography, single photon emission computed tomography, magnetic resonance spectroscopy, and functional magnetic resonance imaging at rest allow these techniques to be recommended for the early diagnosis of CI of different genesis.

Vascular depression is a very frequent and serious complication of cerebrovascular diseases. Vascular factors play an important role in the development of affective disorders. Depression, in turn, also has a negative impact on the course of cardiovascular disease, contributing to its progression, worsens quality of life in patients, reduces functional activity, increases mortality, and increases the risk of stroke. The diagnosis of vascular depression is confirmed by MRI detection of leukoaraiosis; in this case, deep white matter hyperintensities are of importance. The very important features of vascular depression are the presence of CI and an increased risk of dementia.

The paper reviews the data available in the literature on and the results of the authors' own investigations of the signs of brain damage in hypertension in its early stages. The signs of early brain damage in hypertension can be considered as deteriorated control functions, white matter hyperintensities (WMH), as evidenced by the standard modes of magnetic resonance imaging (MRI), decreased fractional anisotropy in the frontal lobes, as shown by diffusion tensor MRI, and reduced cerebral perfusion. The latter two signs are detected even in hypertensive patients without WMH. Cognitive function testing and brain MRI using special regimens make it possible to identify a group of hypertensive patients at higher risk for cerebrovascular complications just in the early stages of the disease.

Headache is a common symptom in acute cerebrovascular diseases; however, no studies have evaluated the prevalence of specific headache types in patients with transient ischemic attacks (ТIАs).

Objective: to analyze all headaches within the last year and the last week before and during ТIАs.

Patients and methods. TIA patients included in the study (female 55% (n=120); mean age, 56.1 years) according to the existing definition of TIAs had a transient neurological dysfunction episode caused by focal brain damage or retinal ischemia for up to 24 hours without forming a new acute heart attack on diffusion-weighted MRI (n=112) or CT (n=8). All the patients were examined by one neurologist within one day after their admission. Patients (female 64% (n=192); mean age, 58.7 years) who had been admitted with a diagnosis of lumbago, lumbar spine osteochondrosis, or gastrointestinal ulcer were examined as a control group. A clinical semistructured face-to-face interview with the patients of both groups was carried out to analyze headache.

Results and discussion. The prevalence of migraine without aura during one year before TIA was substantially higher in patients with TIA than in control ones: 20.8 and 7.8%, respectively (p=0.002). Twenty-two (18.3%) patients had sentinel or warning headache within the last week before a TIA that manifested as an increase in and greater frequency of previous headache, as lack of effect of painkillers, and as the emergence of a new type of headaches, which were previously absent. During TIAs, 16 (13.3%) patients developed a new type of headache. Twelve of these 16 patients had migraine-like headache; three patients had headache resembling tension headache; one patient had a thunderclap headache. None of the control patients was found to have a new type of headache. TIAs were significantly more common in the vertebrobasilar basin than in the carotid artery one in patients with headache during the last week before and during TIA.

Conclusion. The one year prevalence of migraine was significantly higher in ТIА patients than in control patients, and so was the prevalence of headache within the last week before and during TIA. Migraine-like headache prevailed among the new types of headaches in the development of TIA. A previous headache with a change in characteristics and a new type of headache can be predictors for TIA. 

Locked-in syndrome in basilar artery thrombosis is a classic example of dissociation between preserved consciousness and complete deefferentation as total myoplegia with preserved vertical eye movement. Something similar is observed in post-comatose patients, described under the name “functional locked-in syndrome”, and is also a clinical reflection of the phenomenon of cognitive-motor dissociation (CMD). Diagnosis of this condition in a patient with chronic consciousness disorders indicates that there may be a cognitive imprint, which gives a chance for the maximum realization of the rehabilitation potential of latent consciousness as an exit to the clinical level of small consciousness or creation of a brain-interface. In any case, this patient should be given an extended rehabilitation program.

Objective: to search for the optimal set of clinical and instrumental diagnostic methods, allowing the identification of CMD in patients with chronic consciousness disorder.

Patients and methods. The 2016–2018 prospective single-center study enrolled patients with unresponsive wakefulness syndrome (UWS) who had received a treatment cycle at the Clinical Brain Institute (Yekaterinburg). The study included 39 patients (22 men, 17 women) aged 19 to 71 years who had sustained various cerebral injuries (traumatic, hypoxic, and acute vascular disease-associated) in different periods (from 32 to 2431 days) before being included in the study. All the patients underwent 5-fold clinical assessments according to the Coma Recovery ScaleRevised (CRS-R) and navigated transcranial magnetic stimulation (nTMS) in order to determine the time course of changes in the activity of the cortical motor centers at the time of presentation of verbal paradigms. Registration of the changes was assessed as the presence of a cognitive imprint and served as a criterion for diagnosing CMD as a positive predictor for the outcome of UWS. The outcome of the state was analyzed using the Glasgow Outcome Scale (GOS) at 180 days.

Results and discussion. Positive changes (GOS >3) were noted in 10 (66%) patients with established CMD; the patients who had not diagnosed as having the cognitive potential showed a further increase in the level of cognition in 3 (12.5%) cases. Whether the identified sign could be used in the comprehensive prediction of chronic consciousness disorder was discussed.

Conclusion. The use of TMS in diagnosing the phenomenon of CMD optimizes the routing of patients, for whom intensive rehabilitation can contribute to more favorable long-term outcomes. 

Despite progress made in laboratory methods, genetic studies, and modern neuroimaging, the diagnosis of diseases that cause dementia makes difficulties. The review presents an update on the epidemiology, risk factors, pathogenesis, clinical presentation, diagnosis, and treatment of Alzheimer's disease (AD). It discusses the issues of symptomatic and pathogenetic treatments and combination therapy for AD. The efficacy of memantine (akatinol memantine) and the expediency of its use at different stages of the disease in patients with AD are noted. Non-pharmacological treatments for this disease, including physical activity and cognitive training, are considered.

The paper reviews the literature on vascular cognitive impairment (VCI), the diagnosis widely used in foreign neurological practice, as well as chronic cerebral ischemia (CCI) and dyscirculatory encephalopathy (DEP), the common diagnoses in Russian neurological practice. According to the etiology, risk factors, and manifestations, Stages I and II DEP largely corresponds to moderate VCI; Stage III DEP does to severe VCI. The results of the author’s studies show that a considerable proportion of patients followed up with a diagnosis of CCI, DEP, have no signs of chronic cerebrovascular disease (CVD), but suffer from primary or secondary headache, vertigo of various origins, emotional disorders, and other diseases. The diagnosis of CCI, DEP should be based on the presence of CCI, the reliable neuroimaging signs of chronic CVD, and the ruling out of other diseases. When treating and preventing VCI, CCI, and DEP, a premium is placed upon both non-drug (regular physical activity, smoking cessation, rational nutrition) and drug therapy aimed at normalizing blood pressure and blood lipid spectrum, preventing blood clots, and improving cognitive functions.

The review considers basic methods for non-drug correction of cognitive disorders, as well as a combined approach, including the use of drugs and cognitive-motor training in the rehabilitation of patients with impaired cognitive functions. The authors present their own data on the efficiency of non-drug therapies in patients with Alzheimer’s disease.

The review analyzes data on the detection rate of and the abilities to predict and prevent non-cardioembolic strokes in non-valvular atrial fibrillation. According to accumulated facts, vitamin K antagonists in non-valvular atrial fibrillation are noted to be inferior to antiplatelet drugs in efficiency in preventing non-cardioembolic (atherothrombotic in particular) strokes, and the widespread use of oral anticoagulants in combination with antiplatelet drugs does not generally reduce the incidence of poor outcomes, markedly increasing the risk of serious bleeding. Nevertheless, it is conceivable that this combination antithrombotic therapy may be useful for certain categories of patients at the highest risk for atherothrombotic stroke and at relatively low risk for hemorrhagic complications. Cohorts of patients, to whom such an approach should be reasonable considered to be applied, have not yet been identified.

The paper reviews an update on the possibilities of providing care for patients with spontaneous non-traumatic intracranial hemorrhage (ICH) developing in patients with atrial fibrillation who use oral anticoagulants. The incidence of ICH is shown to be considerably lower when nonvitamin K-dependent anticoagulants (NOACs) are used, but the hematoma evolution scenarios do not differ between the groups of patients receiving vitamin K antagonists or NOACs. The results of studies assessing hypertension therapy in patients with ICH are compared. The possibilities of using various reversal agents for various oral anticoagulants are also discussed. Since one of the main problems associated with increased mortality and severe disabilities is the progression rate of ICH, the possibility of using a specific antagonist can determine the choice of an anticoagulant for the primary prevention of ischemic stroke in a patient with atrial fibrillation.

Secondary prevention of recurrent stroke and other cardiovascular diseases is of key importance for the management of a patient after ischemic stroke. Medications (antihypertensive, antiplatelet, or anticoagulant drugs and statins) are recommended for use; and a small proportion of patients should undergo surgical treatment (carotid endarterectomy); non-drug treatments (smoking cessation and alcohol abstinence, adherence to the Mediterranean diet, and increased physical activity) are of great importance. Movement disorders are seen in 80% of patients after a stroke and are the leading cause of disability. Therapeutic exercises aimed at training movements in the paretic limbs and at preventing the development of contractures are of utmost importance in post-stroke movement disorders. The use of citicoline to improve motor function recovery is discussed.