No 39 (2015)

Background: Cerebrovascular disorders are major contributors into mortality of the population. Annually, more than 14 000 subjects die of cardiovascular disorders in the Moscow Region, 50% of them when being in a hospital.

Aim: Informational support of the programs aimed at decreasing of populational morbidity, lethality and mortality from cerebrovascular disorders, including stroke, improvement of healthcare quality and finally maintenance of patients’ health and quality of life.

Materials and methods: We calculated rates of mortality, in-hospital lethality, total (according to referrals) and hospital incidence of cerebrovascular disorders in the Moscow Region in 2014. The sources of information were report forms of the Federal statistical surveillance #12 and #14, as well as materials of the State Statistical Service of the Moscow Region, related to mortality of the population. Changes of the parameters during the last years were monitored.

Results: The leading cause of total morbidity (registered according to referrals) among the adult population of the Moscow Region is “other cerebrovascular disorders” category (ICD-10) that include cerebrovascular atherosclerosis and other chronicdiseases (35.3 per 1000 of population). The same group of disorders was the main cause of hospitalization among adults (5.2‰). The highest in-hospital lethality was registered for intracerebral and other intracranial hemorrhage (53.3% of cases), for subarachnoid hemorrhage (29.8%), and for cerebral infarction (23%). During the last years, there was a decrease in population cerebrovascular mortality rates, especially mortality from strokes.

Conclusion: The medical and statistical analysis allowed quantification of amount and changes in populational cerebrovascular morbidity, lethality and mortality in the Moscow Region as a whole in 2014. Regional monitoring would allow for determination of the efficacy of implementation of the planned measures aimed at lowering of these parameters. Such analysis performed at the level of a medical district or at municipal level would make it possible to assess a “contribution” of a territory into the general problem and to determine its rank.

Background: Investigation of patients with intracranial non-traumatic hemorrhage (INH) with the use of prolonged electroencephalographic (EEG) monitoring allows for more effective identification of acute symptomatic seizures, subclinic epileptiform activity, local and diffuse abnormalities that are markers of brain functional activity.

Aim: To increase treatment efficacy of patients with INH.

Materials and methods: Thirty three patients were assessed in acute period of INH. Assessments included clinical and neurological examination, NIHSS (National Institute of Health Stroke Severity scale), GCS (Glasgow coma scale), HHS (Hunt-Hess scale); prolonged EEG monitoring with computerized tomography and/or magnetic resonance imaging of the brain. Patients received medical and surgical treatment (minimally invasive endovascular interventions or open operations, such as aneurysm clipping or wrapping/coating).

Results: Twenty seven patients had open-type surgeries (among them, 23 patients had aneurysm clipping and 4, aneurysm wrapping). Two patients underwent the procedure of aneurysm embolization. Four patients were treated conservatively. According to results of prolonged pre-, peri- and postoperative EEG monitoring, most of patients had signs of disorganized electrical activity, with no regional differences, fragmented or absent alfa rhythm and diffuse polymorphic theta-activity. Marked EEG abnormalities correlated with severity registered with the assessment scales and with outcomes. During the study, epileptiform activity was registered in 1 patient, EEG comate in 3, diffuse abnormalities in 15 and local abnormalities in 14.

Conclusion: The use of prolonged pre-, peri- and postoperative EEG monitoring allows for timely identification of status epilepticus, including the one without seizures. Minimally invasive interventions performed on time are associated with better prognosis in INH patients, whereas marked EEG abnormalities are associated with low scores of the assessment scales and adverse outcomes. In conscious patients with local brain lesions EEG does not have any significant value for topical diagnostics.

Background: In the post-stroke period, arthropathies of paretic limbs are frequently seen. They may lead to formation of contractures, with significant limitation of active and passive movements due to severe pain in affected joints. This can hinder restoration of motor functions and consequently lead to a dramatic deterioration of quality of life.

Aim: To study phenomenology of a post-stroke arthropathic syndrome and specific types of joint abnormalities.

Materials and methods: The study included 148 patients with post-stroke hemiparesis. In all patients we analyzed demographic characteristics, stroke type, localization and size, absence or presence of concurrent circulatory encephalopathy and diabetes mellitus. A full neurologic examination was done with assessment of a degree of motor dysfunction. Pathogenetic subtypes of ischemic strokes were determined by means of duplex scanning of major head arteries, assessment of blood rheology and lipid profile. Assessment of joints was done by ultrasound examination and computer tomography.

Results: One hundred and eighteen of 148 patients had post-stroke hemiparesis without joint abnormalities, whereas 30 patients had post-stroke hemiparesis with associated arthropathies. Most patients were elderly (≥ 60 years, 75 patients), 16 of them having arthropathies. One hundred and twenty of patients had ischemic strokes, 28 patients had hemorrhagic strokes. A lacunar subtype of stroke was the most prevalent among all patients (29 of patients, or 24%), whereas among those with arthropathies, the most prevalent type of stroke was cardioembolic (8 of patients, 33%). From 30 patients with arthropathies, isolated shoulder arthropathy was seen in 26, in combination with other arthropathies, in 2; isolated wrist arthropathy was seen in 2 patients. Arthropathies manifested within the first two to three weeks after a stroke in 9 patients (including shoulder arthropathies in 7 of them). In all other patients, arthropathies manifested within the first two months (after 3 weeks).

Conclusion: Post-stroke arthropathies are quite common and affect 20% of all patients with poststroke hemiparesis, mainly in the elderly and in the middle-aged patients. Arthropathies were more prevalent in patients with right hemispheric lesions and with a cardioembolic subtype of stroke. In patients with severe and advanced paresis, arthropathies were seen significantly more often.

Background: Coronary artery atherosclerosis is one of the main causes of ischemic heart disease. Formation of chronic vascular brain insufficiency in ischemic heart disease has a complex pathogenesis and can be related to a lower cardiac output. Occurrence and progression of neurodegenerative process in such patients can manifest by significant cognitive impairment deteriorating their quality of life and leading to social disadaptation.

Aim: To assess neuropsychological functions in patients with coronary artery atherosclerosis and to identify potential risk factors predisposing to the development of cognitive and neurological impairment.

Materials and methods: The study included 30 patients with stable angina requiring coronary surgical interventions and 25 patients with acute coronary syndrome. The patient age was 57.3 ± 1.8 and 58.3 ± 10.9 years, respectively. In 15 of cases, acute coronary syndrome was associated with ST elevation on ECG and in 10 of cases no ST elevation was noted. All patients were seen by a neurologist and underwent neuropsychological testing. The patients were divided into two groups: those in need of a stent placement (group 1), those in need of coronary artery bypass grafting (group 2) and those with acute coronary syndrome ( group 3).

Results: Assessment of cognitive functions with a Montreal cognitive assessment scale gave the following results: the total mean score in the group 1 was 24.3 ± 0.5, in the group 2, 26.3 ± 0.5 (normal at least 26), the difference between the groups being statistically significant (p = 0.0172). Cognitive impairment was more frequently found in acute coronary syndrome patients with ST elevation, who had more severe cardiac abnormalities, compared to those with acute coronary syndrome without ST elevation.

Conclusion: Most patients with clinically significant atherosclerosis of coronary arteries have mild and moderate cognitive disorders, that indicate the importance of a neuropsychological screening for early detection of cognitive and neurological impairment in such patients.

Background: Inherited connective tissue pathology is the most frequent genetic abnormality. Weakness of connective tissue in this group of disorders is manifested not only by excessive joint mobility, but also by abnormalities in other organs and systems, including vessels. In inherited connective tissue disorders brain artery aneurysms and abnormal vascular tortuosity is found that can be a risk factor for stroke.

Aim: To study frequency of abnormal tortuosities of brachiocephalic vessels in post-ischemic stroke patients, as well as efficacy of secondary stroke prevention in such patients.

Materials and methods: One hundred and seventy two adult patients with ischemic stroke were examined. Neurological deficiency was assessed with the National Institute of Health Stroke Scale (NIHSS) and with the modified Rankin scale. Abnormalities of precerebral arteries were found by ultrasound dopplerography and duplex scanning. To diagnose any abnormalities of connective tissue, clinical and genetic analysis, dermatoglyphic assessment and scoring of excessive joint mobility (Beyton scale) were used.

Results: Abnormal tortuosity of precerebral arteries is found in 47% of patients with ischemic stroke. The screening performed in 25 of such patients showed connective tissue disorders in one third of them (in 2 patients, Ehlers-Danlos syndrome, in 2 patients, connective tissue dysplasia, in 4 patients, mild symptoms of abnormal connective tissue, such as excessive joint mobility scoring to 1–2). In patients without inherited syndromes, some dermatoglyphic traits were found, i.e., distal shift of the axial palmar triradius, higher frequency of patterns on the skin of the thenar, lower pattern frequency on the skin of the hypothenar, higher frequency of simple digital patterns (A and T), lower frequency of complex patterns, such as whorls (W), lower palmar and digital ridgecounts. The results of secondary stroke prevention with antiplatelet agents, antihypertensives and cholesterol-lowering agents depended on patient compliance to medical recommendations. The odds ratio for a repeated stroke in the groups who were regularly taking these agents, compared to the groups who were not, was 0.116 for treatment with antiplatelet agents (p < 0.05) and 0.043 for antihypertensive therapy (p < 0.005).

Conclusion: Dysplasia of connective tissue can lead to formation of tortuous precerebral arteries and become an additional risk factor for strokes. Conventional antiplatelet, antihypertensive and cholesterol-lowering prophylaxis is effective in patients with tortuous precerebral arteries, but its results depend on patient compliance.

Background: As long as systemic thrombolysis is indicated to not more than 10% of patients with ischemic stroke, the search for medical agents for basic treatment of stroke is an important problem of today’s neurology.

Aim: To evaluate efficacy of meldonium in patients with acute ischemic stroke.

Materials and methods: One hundred and fourteen patients were assessed in the acute period of strokes in the internal carotid artery system. The main group included 70 patients who were given meldonium (Mildronate) in addition to their basic treatment regimen. The drug was administered intravenously in daily drop infusions at dose of 10 ml of 10% solution for 10 days, thereafter they were switched to oral treatment at 250 mg daily for 2 to 3 weeks. The control group consisted of 40 patients who received only basic treatment regimen. Both groups were compatible for their age, gender distribution, severity of stroke and degree of neurologic dysfunction.

Results: In the patients who were given meldonium in addition to basic treatment of ischemic stroke, neurological deficiency, assessed by NIHSS, scored significantly better than in those from the control group (3.1 ± 0.1 vs. 2.6 ± 0.17, p < 0.05). Also, they had significantly less disability on modified Rankin scale (1.3 ± 0.03 vs. 1.07 ± 0.07, p < 0.01) and more improvement in mobility as per Rivermead mobility index (3.6 ± 0.17 vs. 2.9 ± 0.25, p < 0.05).

Conclusion: The addition of meldonium to the set of medical treatment in ischemic stroke patients gives positive results reflecting a decreased neurological deficiency, increased levels of mobility and daily activities.

Background: Non-motor signs, including affective and cognitive ones, are important initial manifestations of Parkinsons disease, along with motor dysfunction. Some of them manifest even before motor disorders and affect patients’ quality of life.

 Aim: To evaluate prevalence and severity of affective and cognitive disorders at early stages of Parkinson’s disease, as well as efficacy of their correction with a dopamine receptor agonist treatment.

Materials and methods: We assessed 33 treatment-naive patients with Parkinsons disease Hoehn & Yahr stage I and II. Degree of motor dysfunction (UPDRS, Unified Parkinson's Disease Rating Scale), depressive (MADRS, Montgomery Asberg Depression Rating Scale), anxiety (HARS, Hamilton Anxiety Rating Scale) and cognitive (Montreal Cognitive Assessment – MoCA, symbols and figures test, Schulte tables, Gorbovs black and red tables) was assessed at baseline and after 1, 3 and 6 months of treatment with pramipexole.

Results: Patients with early signs of Parkinson’s disease had subdepressive disorders, moderate anxiety disorders, mild cognitive disorders of a neurodynamic type and represented mainly be delayed recall of information and attention disorders. Treatment with pramipexole decreased the degree of depressive symptoms by 82% and of anxiety symptoms by 74%. There was an improvement in cognitive functions, indicated by an increase in a delayed recall (+34%), better efficacy (+31%), a decrease in switching time (-38%) and attention distribution (-33%); however, age-related normal values were not achieved.

Conclusion: Already early stages of Parkinsons disease are characterized not only by motor abnormalities, but also by affective and neurodynamic cognitive dysfunction. Medical treatment with pramipexole was effective in correction of motor and neuropsychiatric disorders in patients with Parkinsons disease Hoehn & Yahr stage I–II.

Background: Photohemotherapy combined with conventional therapy can increase the treatment efficacy in asthma. However, the influence of quantumhemotherapy on pathogenetic mechanisms of the disease has been poorly studied.

Aim: To evaluate the influence of blue and red light hemotherapy on blood immunological parаmeters in asthma patients.

Materials and methods: Four hundred and eighty patients admitted to the in-patient department with mild (44.5%) and severe (55.5%) exacerbations of persistent moderate asthma, were randomized into two groups: the main group (n = 250), which, along with conventional treatment, received photohemotherapy with blue (n = 220) or red (n = 30) light, and the control group (n = 230), which received conventional treatment only. Before and after treatment, immunological assessments were performed that included phenotyping of the lymphocyte subpopulations (CD3, CD4, CD8, CD16, CD19, CD56), assessment of phagocytal activity of leukocytes, measurement of circulating immune complexes (CIC) and immunoglobulin levels (IgE, IgG, IgM and IgA).

Results: After combined treatment, compared to baseline values, patients from the main group had a significant increase in СD3+-lymphocytes (from 32.34 ± 2.28 to 60.73 ± 0.67%) and their immunoregulatory subpopulations – СD4+-helpers (from 17.94 ± 2.01 to 38.55 ± 0.72%) and СD8+- suppressors (from 17.38 ± 1.98 to 27.6 ± 0.48%), as well as a trend towards a decrease in СD16+-killers (from 24.55 ± 0.43 to 16.65 ± 0.37%) and an increase in СD19+ В-cells (from 25.12 ± 1.12 to 27.15 ± 0.45%), a decrease of IgE (from 68.3 ± 0.51 to 60.2 ± 0.61%) and CIC (from 54.5 ± 1.22 to 40.3 ± 0.12%). In the control group, there was a trend towards a decrease of СD3+-lymphocytes (59.83 ± 0.7 and 59.27 ± 0.715%) and СD4+-helpers (38.8 ± 0.5 and 38.41 ± 0.64%), normal counts of СD8+-suppressors (28.12 ± 0.58%), and a trend towards a decrease in СD16+-killers (28.2 ± 0.6 and 26.0 ± 0.57%) and an increase in СD19+ В-cells (29.22 ± 0.6 and 29.47 ± 0.58%), a decrease of IgE (68.8 ± 0.91 and 55.2 ± 0.55%) and CIC levels (49.2 ± 0.9 and 45.3 ± 1.05%, respectively). Analysis of cytokine profiles after conventional treatment showed a non-significant decrease in mean levels of allergic inflammatory interleukins (IL) (from 90.5 to 88.3 pg/mL for IL4 and from 68.25 to 67.4 pg/mL for IL5), as well as a non-significant increase in mean concentrations of infectious inflammatory cytokines (from 1.81 to 1.85 pg/mL for IL10 and from 3.72 to 3.89 pg/mL for IFNγ). The use of photohemotherapy led to a decrease in abnormally high IL4 levels almost to the normal (68.55 pg/mL) and to a trend to a decrease in IL5 levels (42.1 pg/mL). Also, there was a significant increase in IL10 (3.91 pg/mL) and IFNγ (5.23 pg/mL) levels to above their baseline values. In patients with severe asthma, a significantly decreased IgM levels were found, both before and after the course of blue light photohemotherapy (0.97 ± 0.1 and 0.89 ± 0.2 g/L, respectively). After treatment, serum IgG levels increased significantly in patients with moderate asthma, compared to baseline (18.3 ± 2.7 and 11.54 ± 0.8 g/L), whereas initially high levels in patients with severe asthma became normal (15.9 ± 4.8 and 18.3 ± 2.7 g/L, respectively).

Conclusion: The use of photohemotherapy exerts marked positive effect on blood immunological parameters in asthma patients. The use of blue light is more effective, compared to red light photohemotherapy.

Background: Multiple sclerosis is the most common neurological disease leading to disability in young and productive patients. One of available methods of control over the course of the disease and detection of its progression is neuropsychological testing. However, selection of the most informative tests, as well as the search for interpretation of their results is still ongoing.

Aim: To study cognitive functions in multiple sclerosis patients depending on the disease activity and degree of disability.

Materials and methods: Fifty patients with multiple sclerosis were evaluated during their remissions and 15 of them were additionally assessed during an exacerbation. During neuropsychological testing a computer test “Selection of figures” was used for assessment of attention, productivity, frontal functions and visual neglect. We studied potential dependency of the parameters obtained from degree of disability and disease stage (exacerbation or remission). The control group comprised 12 healthy subjects.

Results: Compared to healthy subjects, the multiple sclerosis patients had a prolonged time of test performance, decreased learning, and statistically significant decrease of the working efficacy (p < 0.05). During an attack, there was a decreased conceptualization (48 answers compared to 51.5 at remission stage); more than 3-fold (from 1,3 to 4,4) increase in the number of figures missed in one visual field, that could indirectly indicate visual neglect. Also, changes in frontal functions were noted as a tendency to almost 2-fold higher numbers of perseverative answers, more frequent categorical escape and learning abnormality. There was a positive correlation between expanded disability scale score (EDSS) and working efficacy (r = 0.453, p = 0.001), and a negative correlation between EDSS and mental stability (r = 0.4055, p = 0.0035).

Conclusion: Patients with multiple sclerosis had abnormal rate and accuracy of test performance, compared to those in healthy subjects. During an exacerbation of the disease, there was a deterioration of the parameters compared to those registered in the remission. Also, a negative association with disease severity assessed by EDSS, was found. The data obtained documents feasibility of the computer test “Selection of figures” for dynamic control in multiple sclerosis patients.

We describe a clinical case of a piriformis syndrome in a patient with lumboischialgia. A technique of botulinum toxin therapy is described which was performed under neuroimaging control, i.e., with pelvic computerized tomography, that allowed for an accurate injection of the botulinum toxin into the deeply located muscle. Insufficient accuracy in determination of the injection site based on external reference points was shown.

Fourteen percent of all ischemic strokes occur in young patients (< 45 years). One of the causes of ischemic stroke in young patients is the isolated cerebral arteritis related to a neuroinfection. The author describes a clinical case of ischemic stroke in a young patient with neurosyphilis. Diagnosis of syphilis was confirmed by laboratory investigations; liquor tests and clinical data allowed to put a diagnosis of meningovascular syphilis. Timely diagnostics and treatment of syphilitic infection are helpful in avoiding progression of neurosyphilis, including its parenchymal forms.