No 39 (2015)



Kotov V.S., Isakova E.V.


Almanac of Clinical Medicine. 2015;(39):6-10
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Gurov A.N., Katuntseva N.A.


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.

Almanac of Clinical Medicine. 2015;(39):11-14
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Kotov S.V., Turbina L.G., Bobrov P.D., Frolov A.A., Pavlova O.G., Kurganskaya M.E., Biryukova E.V.


Background: Efficacy of physical exercise and movement imagination for restoration of motor dysfunction after a stroke is seen as proven. However, the use of movement imagination is complicated by impossibility of objective and subjective control over  the exercise, as well as by the absence of their motor support. The brain-computer interface based on electroencephalography is a technique that enables a feedback during movement imagination.

Materials and methods: We assessed 10 patients (6 men and 4 women) aged from 30 to 66 years (mean age, 47 ± 7.7 years) with an ischemic (n = 9) and hemorrhagic (n = 1) stroke during the last 2 months to 4 years. Online recognition of movement imagination was done by a classifier with a brain computer interface. An exo-skeleton supported passive movements in a paretic hand managed by the brain-computer interface. During 2 weeks the patients had 10 sessions of 45–90 minute duration each. For control, we used data from 5 stroke patients who, in addition to their standard treatment, underwent an imitation of rehabilitation procedures without movement imagination and feedback. To assess efficacy of treatment, we used a modified Ashworth scale, Fugl-Meyer scale, test for evaluation of hand functions ARAT, British scale for assessment of muscle force MRC-SS. Level of everyday activity and working ability was measured with a modified Rankin scale and Bartel index. Cognitive functions were assessed with Schulte tables.

Results: Online recognition of movement imagination according to desynchronization of μ rhythm was registered in 50–75% of patients. All patients reported a subjective improvement of motor functions and working ability. Positive results for at least one parameter were observed in all patients; however, there were no significant difference between the parameters before and after rehabilitation procedures, excluding cognitive functions (degree of warming-up, p < 0.02).

Conclusion: In post stroke patients, the use of movement imagination, brain-computer interface and exo-skeleton does not seem to affect the rehabilitation process negatively. In all cases, some positive results were achieved in motor recovery, as well as in working ability and daily activity. The results of the rehabilitation procedure are promising; however, the study should be continued.

Almanac of Clinical Medicine. 2015;(39):15-21
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Alakova M.A., Kotov A.S., Kiselev A.M., Romanova M.V.


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.

Almanac of Clinical Medicine. 2015;(39):22-28
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Lar'kov R.N., Kolesnikov Y.Y., Sotnikov P.G., Lazarev R.A., Zagarov S.S., Kotov A.S., Litvinenko M.A., Kazakova E.K.


Background: At present, efficacy of carotid endarterectomy for prevention of cerebrovascular accidents has been convincingly proven. Its results in patients with a history of an ischemic stroke depend on multiple factors.

Aim: To study results of reconstructive interventions on internal carotid arteries in patients with post-stroke cerebral cysts.

Materials and methods: We analyzed data from 210 patients who had undergone an intervention (159 men and 51 women, aged 61 ± 2.7 years) with occluding lesions of the internal carotid artery and a history of an ischemic stroke. Depending on the size of a post-stroke lesion, patients were divided into 5 groups: patients from group 1 had a lesion of more than 5 cm in diameter, from group 2, from 2 to 5 cm, from group 3, ≤ 2 cm, patients from group 4 had a lacunar cysts and patients from group 5 had no focal lesions.

Results: A clear positive correlation between the size of a post-stroke cyst and the degree of hemodynamic abnormalities in internal carotid arteries was found. The most prominent asymmetry of blood flow in the middle cerebral artery (on average, 34.1%) was seen in patients from the group 1. Patients from the group 1 more often had low and critical brain tolerance to ischemia (42.9%). In patients with large post-stroke cysts (group 1) mean Barthell index was 69 ± 8.1, and NIHSS score 8.2 ± 1.6. In patients from other groups neurological deficiency was less pronounced: 80 ± 6.8 and 7.6 ± 1.9 in the group 2, 82 ± 5.7 and 4.1 ± 1.3 in the group 3, 94 ± 4.6 and 3.2 ± 1 in the groups 4 and 5. The differences between groups in the rates of postoperative complications were not statistically significant (p > 0.5). However, signs of hyperperfusion without any clinical manifestations were more often observed in patients from the group 1 (19%). Assessment of changes in neurological status at 1 year after the intervention, depending on the size of post-stroke lesions, showed that in patients with large cysts the regression of neurological deficiency was less obvious, than in other groups (NIHSS 7.5 ± 1.7, Barthell index 76 ± 7.7). The best restoration of impaired neurological functions was seen in patients with small cysts (NIHSS 2.2 ± 0.7, Barthell index 91 ± 3.4).

Conclusion: In patients with large and intermediate post-stroke cerebral cysts surgery is associated with a higher complication rate, and, first of all, of hyperperfusion syndrome. However, the risk of these complications is significantly smaller than the probability of repeated acute cerebrovascular accidents.

Almanac of Clinical Medicine. 2015;(39):29-38
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Telenkov A.A., Kadykov A.S., Vuytsik N.B., Kozlova A.V., Krotenkova I.A.


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.

Almanac of Clinical Medicine. 2015;(39):39-44
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Belova Y.A., Chuksina Y.Y., Shevelev S.V., Yazdovskiy V.V., Kotov S.V.


Background: Early diagnosis of stroke, its treatment and rehabilitation are considered priorities in the state health care policy. Pharmacological intervention is used as a strategy to protect the neurons from the ischemic penumbra. Aim: To evaluate changes of functional state and levels of endothelial progenitor cells (EPC) in the circulation in ischemic stroke patients under administration of citicoline.

Materials and methods: We assessed 11 patients in their early rehabilitation period of ischemic stroke (9 men and 2 women, mean age 58.4 ± 9.2 years). Patients from group 1 (n = 7) were given citicoline at dose 2000 mg/daily for 14 days, whereas patients from group 2 (n = 4) received regular treatment. Two healthy volunteers served as a control group. Circulatory EPC phenotype was assessed by multicolor laser flow cytometry and monoclonal antibody assay. Stroke severity and functional abilities were measured with NIHSS, Rankin scale and Rivermead mobility index.

Results: Patients with ischemic stroke had decreased levels of early EPC, compared to healthy subjects. After 7 days of treatment in the group 1, there was a significant increase of circulatory EPC expressing VEGFR2+ up to 25.5 ± 20.9%, as well as an increase of early EPC numbers (CD117+ / CD133+) up to 18.8 ± 14.6%, compared to their respective baseline levels (21.9 ± 19.2 and 9.4 ± 5.4%) and compared to respective parameters in the group 2 (8.1 ± 2.7 and 5.5 ± 3.4%). In the group 1, severity of stroke and functional ability at baseline and at day 7 were as follows: NIHSS scores, 5.8 ± 4.9 and 3.5 ± 0.7, Rankin scale scores, 2.7 ± 1.3 and 2.3 ± 0.5, Rivermead mobility index, 8.8 ± 4.9 and 9.4 ± 4.8, respectively. In the group 2 corresponding parameters scored as 4.5 ± 2.3 and 3.3 ± 0.5, 2.5 ± 0.6 and 2.5 ± 0.4, 12.5 ± 1.3 and 12.7 ± 0.7, respectively.

Conclusion: Treatment with citicoline in acute ischemic stroke promoted almost a 2-fold increase in early EPC levels. A decrease in neurologic deficiency and an improvement of functional status of patients with ischemic stroke were observed.

Almanac of Clinical Medicine. 2015;(39):45-50
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Litvinenko M.A., Kotov A.S., Romanov S.V., Terpigorev S.A., Kabanova T.G., Borisova M.N.


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.

Almanac of Clinical Medicine. 2015;(39):51-55
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Kozyaykin V.V., Isakova E.V., Eliseev Y.V.


Background: Evaluation of prevalence and degree of control of leading risk factors for stroke among population of various regions of the Russian Federation enables rational planning of preventive activities.

Aim: To analyze prevalence of the leading stroke risk factors, to assess efficacy of their control and to determine their impact on outcomes.

Materials and methods: We examined and treated 129 patients with primary and repeated cerebral accidents living in a small town of the Moscow region.

Results: The most prevalent stroke risk factor was arterial hypertension (94.6%). During 6 months before the stroke, target levels of systolic blood pressure had been achieved in 36/122 patients with arterial hypertension and those of diastolic blood pressure, in 4/122 patients. During the last 2 years preceding the index stroke, 48.8% of patients had hypertensive crises. More than half of the patients (71/122) either had not been taking their antihypertensive medications, or had not taken them regularly. There was a positive correlation between duration of arterial hypertension and degree of stroke-related disability, assessed by NIHSS (r = 0.263, p = 0.003), as well as between duration of arterial hypertension and functional activity index on Rankin scale at manifestation of stroke (r = 0.268, p = 0.003). Other prevalent risk factors were smoking (51.9% of patients), alcohol use (67.44%), diabetes mellitus (23.26%). Hypercholesterolemia that was diagnosed in 102/129 of the stroke patients, did not significantly affect any parameter of stroke severity (p > 0.05). There were weak positive correlations between body mass index and difference in NIHSS scores at admission and at discharge (r = 0.204, p = 0.049), between body mass and difference in NIHSS scores at admission and at discharge (r = 0.227, p = 0.028), as well as between body mass and difference in Rankin scale scores at admission and at discharge (r = 0.247, p = 0.016). Chronic stress situation (depression) during time period preceding the stroke was found in 37.21% of patients, but this factor had no statistically significant influence on stroke severity and outcome (p > 0.05).

Conclusion: Among patients with stroke living in a small town of the Moscow region, the most significant factors affecting severity of stroke were arterial hypertension, diabetes mellitus and obesity. An insufficient control of arterial hypertension and low compliance to treatment were found.

Almanac of Clinical Medicine. 2015;(39):56-61
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Poplavskaya N.M., Sidorova O.P., Kotov S.V.


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.


Almanac of Clinical Medicine. 2015;(39):62-68
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Scherbakova M.M., Kotov S.V.


Background: Research data on the compensatory mechanisms in patients with stroke sequelae that have been accumulated within the last years, allows for reconsideration of conventional techniques to restore aphasia.

Aim: To increase efficacy of the logopedic rehabilitation of patients with sequelae of the local posterior cortical lesions of the brain.

Materials and methods: Two hundred and eighty six patients with aphatic speech disorders during the early and late restorative periods of stroke participated in the study. The presence of aphasia caused by suppressed functioning of the posterior cortical areas was confirmed by the results of neurologic and logopedic assessments using the method of speech assessment in aphasia (L.S. Tsvetkova et al., 1981). Depending on the type of aphasia, the patients were divided in the groups as follows: 1) those with acoustic + gnostic aphasia (middle temporal gyrus); 2) those with acoustic + amnestic aphasia (upper temporal gyrus); 3) those with semantic aphasia (parietal – temporal – occipital areas). All patients underwent a course of logopedic rehabilitation aimed at restoration of the speech thinking.

Results: Until now, there was no technique for restoration of acoustic + amnestic and semantic types of aphasia with severe speech impairment. We have developed and implemented modified restoration methods for patients with posterior types of aphasia that increased the efficacy of rehabilitation. An improvement was seen in 61% of patients with severe aphasia, in 68% of those with moderate degree of aphasia and in 90% of patients with mild aphasia.

Conclusion: The clue for achievement of very good results of speech thinking restoration was the consideration of the mechanisms of speech impairment and compensatory processes in patients with the stroke sequelae
Almanac of Clinical Medicine. 2015;(39):69-74
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Kotov S.V., Isakova E.V., Volchenkova T.V., Smetana L.V., Belkina S.N.


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.

Almanac of Clinical Medicine. 2015;(39):75-81
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Yakushina T.I., Kotov S.V., Yakushin M.A.


Background: Due to high prevalence of multiple sclerosis among women of childbearing age, special attention is paid to the problems of pregnancy management in such patients.

Aim: To study clinical particulars of the course of pregnancy, delivery and postpartum period in patients with multiple sclerosis.

Materials and methods: Eighty seven pregnant women with multiple sclerosis were followed up. Forty eight patients were taking disease modifying therapies (DMT), among them, 27 patients were taking glatiramer acetate, 17, interferon beta, 2, cladribine and 2, mitoxantrone. Thirty nine patients received no DMT. We evaluated the number and time to exacerbations; clinical particulars of the course of pregnancies and deliveries were studied depending on previous treatment with immune modulators.

Results: The rate of exacerbations during pregnancy decreased by 47.7% and increased by 12.4% in the postpartum period, compared to this parameter in the year before pregnancy. Most often, the attacks occurred in the first trimester (54.5%, р < 0.05) and in the first 6 months after delivery (40.1%, p < 0.05). A long remission before the pregnancy (2 years and more, р < 0.01), the use of the 1st line DMT just before conception (p < 0.01) and multiple pregnancies (р < 0.001) were all predictors of the reduced number of postpartum exacerbations of the disease. Pregnancy and delivery did not significantly affect the degree of neurological deficiency (mean EDSS at the postpartum period increased by 0.05 ± 0.01).

Conclusion: Multiple sclerosis and the use of DMT are not contraindications to pregnancy and delivery. Management of pregnancies and deliveries in multiple sclerosis patients does not differ from that in the general population. Previous use of DMT decreased the number of exacerbations during pregnancy and postpartum. Health status of the newborns, the numbers of complications during pregnancy and delivery, as well as changes in EDSS in the patients did not depend on previous DMT and on the time of its cessation.

Almanac of Clinical Medicine. 2015;(39):82-89
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Bogdanov R.R., Borisova S.Y., Kotov S.V.


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.

Almanac of Clinical Medicine. 2015;(39):90-96
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Smirnova A.A., Borisova M.N., Lobov M.A., Lapochkin O.L., Panteleeva M.V.


Background: Publications on the problem of dorsalgia in children are scarce. Inadequate treatment of back pain in children and adolescents promotes the disease progression and contributes to high prevalence of this syndrome in adult population.

Aim: To develop an algorithm of age-dependent treatment of children with dorsalgias based on a multidisciplinary approach and taking into account the stage of the disease.

Materials and methods: One hundred and five (105) patients (54 girls and 51 boys) were assessed after admittance to the in-patient department of neurology with complaints on back pain. Chronic pain syndromes (with duration of more than 12 weeks) were noted in 84 (80%) of children, subacute pain syndromes (with 6 to 12 weeks duration), in 8 (7.6%), and acute pain syndromes (of less than 6 weeks duration), in 13 (12.4%). Pain severity and psycho-emotional status were assessed with a visual analogue scale (VAS) and McGill Pain Questionnaire (MPQ). For their treatment, the methods established in neurology were used with consideration of age specifics. The amount and type of medical care depended on the degree of acuity, symptom severity, results of instrumental assessment methods and patient age.

Results: The use of combined approach to the treatment of vertebral pain syndromes with special emphasis on non-medical techniques significantly expanded treatment opportunities and improved the results of restorative therapy. Before treatment, moderate and severe pain syndrome (from 4 to 10 on VAS) was seen in 74.3% of patients, whereas after the treatment course, in 22.9% (p < 0.05). Minimal pain intensity (VAS 0–3) was noted at admittance to the hospital in 25.7% of patients and after the course of age-adjusted treatment this percentage increased to 77.1% (p < 0.05). In most cases, the effect of the elaborated treatment complex was seen up to 12 months, and if some maintenance treatment courses were performed, up to 2–4 years and more. During the follow- up that lasted from 6 to 48 months, 30.8% of patients was hospitalized again; however, in all of them the pain syndrome was significantly less severe (VAS 1–6) than at primary admittance.

Conclusion: Implementation of treatment algorithms, that are commonly used in adult practice and are adapted to pediatric age, allows for a significant decrease in severity of the pain syndrome or for its complete elimination, for improvement of affective disorders (p < 0.0001) and reduction of relapse risks, as well as for maintenance of social and daily adaptation of patients.

Almanac of Clinical Medicine. 2015;(39):97-103
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Paleev F.N., Ostrovskiy E.I., Karandashov V.I., Shatokhina S.N., Sanina N.P., Ryzhkova O.Y., Gorbunova E.M., Paleev N.R.


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.

Almanac of Clinical Medicine. 2015;(39):104-110
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Ostapchuk K.A., Kotov S.V., Sidorova O.P., Polyakov A.V., Galeeva N.M., Misikov V.K.


Background: The most frequent mutation of the gene TOR1A (DYT1) (9q34), that causes type 1 dystonia (DOPA-unresponsive torsion dystonia) is the deletion c.907-909delGAG in the 5th exon of the gene (303delGlu). This mutation has not been found in the Russian population of patients with cervical dystonia.

Aim: To elucidate the existence and clinical characteristics of interfamilial polymorphisms in type 1 dystonia patients in the Moscow Region.

Materials and methods: Twenty one patients with dystonia underwent molecular genetic tests with DNA sequencing aimed at identification of the DYT1 gene mutation.

Results: Sixteen of 21 patients had only cervical dystonia without the DYT1 gene mutation. Among 5 patients with torsion dystonia, 2 cases demonstrated the most frequent mutation of the DYT1 gene, i.e., the deletion of three nucleotides (del1302/303, orс.907_909delGAG). There were specific characteristics in clinical manifestation and onset of the disease in the patients with the mutation. In a 30-year old patient the disease manifested at the age of 14 with torsion dystonia. In a 50-year old patient the disease manifested at the age of 46 from trunk dystonia, which at the age of 48 was followed by cervical dystonia (left-side torticollis), where two courses of botulin treatment (type A botulinic toxin complexed with hemagglutinin, 300 U) were minimally effective.

Conclusion: No mutation in the DYT1 gene was found in the population of patients with cervical dystonia in the Moscow Region, which agrees with the literature data. In those with torsion dystonia, the DYT1 gene mutation was found in 2 of 5 (40%) cases. Interfamilial polymorphism of the disease was identified.

Almanac of Clinical Medicine. 2015;(39):111-114
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Sushkova M.O., Kotov S.V., Yakushina T.I., Lapitan D.G.


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.

Almanac of Clinical Medicine. 2015;(39):115-120
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Kil'dyushevskiy A.V., Borodin A.V., Molochkov A.V., Sidorova O.P., Kotov S.V.


Aim: To study efficacy of the trans-immunization method in remitting-relapsing multiple sclerosis.

Materials and methods: The study included 15 adult patients with remitting multiple sclerosis, in 14 of whom transimmunization was used; 1 female patient during the relapse was administered photopheresis without transimmunization (without mononuclear incubation). Clinical assessment of treatment efficacy was performed with Kurtzke Expended Disability Scale (EDSS). Also, subpopulations of peripheral blood lymphocytes and levels of IgA, IgM, IgG, TNF-α were measured.

Results: After 6 courses of transimmunization, the disease process was improved or stabilized in 70% of patients, whereas 30% of patients progressed further. After transimmunization, CD5+ counts significantly increased from 76.6 ± 4.1 to 86.0 ± 2.3% (p < 0.05), HLA-DR+ decreased from 15.3 ± 6.5 to 8.5 ± 1.69% (р < 0.05), the levels of IgG, IgМ and TNF-α in peripheral blood also decreased (p > 0.05). No treatment-related adverse effects were registered.

Conclusion: The data obtained shows efficacy and safety of the transimmunization method in the treatment of multiple sclerosis. It is necessary to continue studies in larger patient numbers, as well as with longer follow-up.

Key words: 

Almanac of Clinical Medicine. 2015;(39):121-127
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Misikov V.K., Stepanova E.A., Ostapchuk K.A., Sidorovich V.I.


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.

Almanac of Clinical Medicine. 2015;(39):128-131
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Kazakova E.K., Kotov A.S., Martakov M.A., Lar'kov R.N., V. P.M.


The article presents a clinical case of 2 patients with heart arrhythmias of the sick sinus syndrome type, who were implanted electriccardiac pacemakers in the acute period of cerebrovascular accidents. There were no cardiac complaints in the clinical manifestation, however, a comprehensive assessment confirmed the diagnosis of sick sinus syndrome.

Almanac of Clinical Medicine. 2015;(39):132-135
pages 132-135 views


Eliseev Y.V.


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.

Almanac of Clinical Medicine. 2015;(39):136-139
pages 136-139 views

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