Vol 44, No 3 (2016)

Background: High prevalence of stroke and constant mortality which is related to thromboembolic complications in one fourth of patients make it necessary to continue evaluation of clinically precise and technologically feasible methods of adequate control of coagulation and anticoagulation systems and predicting of venous thromboses and embolism. Aim: To improve diagnostics and treatment of patients with acute stroke of various types through assessment of haemostasis system and pathophysiological mechanisms of venous thromboembolism (VTE). Materials and methods: One hundred and forty five (145) patients with acute cerebral stroke (mean age, 69±13.2 years; 75 male and 70  female) were included into the study. All patients were admitted to the neuroresuscitation unit within 6 to 24 hours from manifestation; the diagnosis was verified by multiaxial computerized tomography. One hundred and four (104) (71.7%) of patients had ischemic stroke, 41 (28.3%) of patients had hemorrhagic stroke. At admittance, all patients had a  certain level of consciousness derangement. All patients were monitored by means of computerized tomography, general and neurological assessment, functional assessment, chest X-ray, ultrasound examination of extremities and assessment of haemostasis (screening and direct thrombodynamics test). Results: In 95%  of cases, VTE risk factors were found; VTE developed in 40  (27.6%) of patients. The most frequent complication was pulmonary embolism (90%  of all VTE and 24.8%  of 145  patients). In-hospital mortality was 44.1%  (n=64) and correlated with VTE (r=0.384; р<0.01). Outcomes of ischemic stroke depended mainly on VTE (at autopsy, they were found in 58.5%  of patients with ischemic stroke and in 26.1%  of those with hemorrhagic stroke) and other complications. Outcomes of hemorrhagic insult depended on the size of the lesion that correlated with severity of clinical symptoms. Screening coagulation parameters were not informative enough for the assessment of haemostasis. Development of VTE correlated with some hypercoagulation in the first days after stroke that were quickly transformed into hypocoagulation. This process could be reliably assessed by the thrombodynamics test. Conclusion: Taking into account high incidence of VTE in patients with severe stroke and low informative value of coagulation screening, it is reasonable to use direct methods of haemostasis assessment and individualized approached to preventive and therapeutic anticoagulation.

Background: Evaluation of risk factor prevalence is of great practical importance. There have been few studies on modifiable and non-modifiable risk factors for stroke in Russian Federation. Impacts of individual factors and their interplay have not been assessed. Aim: To assess prevalence of modifiable

risk factors (atrial fibrillation, obesity) in stroke patients living in a small town. Materials and methods: We assessed 129 living in a  small town and admitted to a hospital due to acute stroke. Results: Fifty two (40.31%) stroke patients had heart disorders, including 27 patients (20.93%) with atrial fibrillation. The majority of patients with atrial fibrillation (n=23, 85.19%) had not taken any antithrombotic treatments before stroke or had not taken them regularly. High body mass index was found in 98 (75.97%) of patients. Mean body mass index in female patients was significantly higher than that in male patients (р=0.0002). Abdominal obesity was diagnosed in 80 (62.02%) of patients and was also more prevalent among females (p<0.0001). Conclusion: Stroke patients in a small town have a significant prevalence of such risk factors as atrial fibrillation and obesity. The control of atrial fibrillation was insufficient, if not lacking.

Background: Essential arterial hypertension is one of the most common causes of chronic kidney disease. Timely identification of asymptomatic chronic kidney disease may help to prevent development of renal failure and maintain kidney functioning. Aim: To assess changes in renal function parameters in patients with arterial hypertension and abdominal obesity with a  history of a stroke, depending on the target levels of systolic blood pressure (SBP) during the recovery period of stroke. Materials and methods: We assessed 88 patients with arterial hypertension with a  history of an acute cerebrovascular accident within the last 1 to 6 months (mean age, 58.8±9.5 years). During 2 to 4 weeks of their hospital stay, their antihypertensive treatments were titrated to reach the chosen target levels of blood pressure. Thereafter, the patients were followed up for 8 to 12 months with baseline and follow-up measurements of their antropometric and clinical chemistry parameters including blood urea nitrogen and serum creatinine and estimated glomerular filtration rate (CKD-EPI). Chronic kidney disease was diagnosed by albumin and creatinine measurements with calculation of albumin/creatinine ratio in the morning urine portion. Results: There was a  positive correlation between office SBP and serum creatinine (r=0.5, р=0.01), serum albumin (r=0.4, р=0.003) and creatinine in the morning urine portion (r=0,5, р=0.0001). Hip circumference negatively correlated with serum creatinine and albumin/creatinine ration at the end of the follow-up (r=-0.3, р=0.04 and r=-0.3, р=0.04, respectively). Bodyweight correlated positively with the glomerular filtration rate (r=0.3, р=0.04), whereas waist to hip ration correlated with urine albumin at the end of the follow-up (r=0.3, р=0.01). Multiple regression analysis showed an association between mean office SBP and serum creatinine (β=0.43, р=0.04), urine albumin (β=0.33, р=0.02) and urine creatinine level (β=0.39, р=0.005). Conclusion: We found an association between SBP and renal function. SBP levels below 135 mm Hg are associated with an improvement of the renal function, whereas SBP levels below 124 mm Hg are associated with a significant decrease in renal function assessed by glomerular filtration rate and albumin/creatinine ratio. The efficacy of antihypertensive treatment in the recovery period after an acute cerebrovascular accident should be assessed with consideration of renal function measured by glomerular filtration rate and microalbuminuria levels. 

Background: Neutralizing antibodies (NAbs) affect the effectiveness of interferon therapy in patients with multiple sclerosis; however, this influence cannot be considered as unequivocal. NAbs formation is determined by several factors, such as frequency and duration of administration, interferon-β (IFN-β) formulation and the patient's genotype. It has been found that NAb titers vary over time. Aim: To assess the levels of NAbs to IFN-β in patients with multiple sclerosis and to investigate their relationship to disease progression. Materials and methods: We analyzed serum samples from 83  multiple sclerosis patients after a  long-term IFN-β-1b treatment; NAbs detection reaction was performed by assessment of their cytopathic effect. Results: NAbs were found in 63.9%  (53  of 83) of patients with dura￾tion of IFN-β-1b treatment of 33.3±17.6 months. All NAb-positive patients were treated with high￾dose IFN-β. Patients with titers>800  LU (n=28) demonstrated a  trend towards more advanced neurologic deficit on the Expanded Disability Status Scale (EDSS), compared to the patients with normal NAbs titers (0  to 20  LU, n=30) and intermediate titers (20 to 800 LU, n=25) (p>0.05). The exacerbation rate in the group with NAbs titers from 20  to 800  LU was insignificantly lower than that in the group with NAbs>800 and in the NAb-negative patients (p>0.05). Conclusion: Testing for NAbs may be a promising method for monitoring of IFN-β therapy in multiple sclerosis. There was a trend towards more pronounced neurological deficit in patients with high NAbs titers, but paradoxical data on a high rate of exacerbations in NAb-negative patients requires further study. 

Background: Mental disorders that sometimes may precede motor dysfunction have an important value in Parkinson's disease, especially at its earlier stages. Personality characteristics of patients with Parkinson's disease have not been studied enough and require a  detailed assessment, because it is a  major factor contributing to treatment efficacy. Aim: To assess personality profiles of patients with early stages of Parkinson's disease and an impact of a dopamine receptor agonist on the personality profile. Materials and methods: We assessed 33 treatment-naïve patients with early symptoms of Parkinson's disease (Hoehn-Yahr stage I and II). The following scales were used before treatment and at 1, 3 and 6 months of treatment with pramipexol: for motor disorders (UPDRS, Unified Parkinson's Disease Rating Scale), depressive disorders (MADRS, Montgomery Asberg Depression Rating Scale) and anxiety disorders (HARS, Hamilton Anxiety Rating Scale), as well as personality profile (MMPI, Minnesota Multiphasic Personality Inventory). Results: The personality profile assessed by MMPI in patients with early stage Parkinson's disease was characterized by highest T scores on scales 2 (pessimism) (74 [64; 86]), 1 (neurotic excess control) (67 [63; 74]), 3  (emotional instability) (64 [56; 70]), 7 (anxiousness) (63 [52; 70]), 8 (autism) (64 [58; 74]), 0  (introversion) (63 [59; 66]). This indicates basic pathopsychological characteristics of patients with early stages of the disease. In particular, their emotional sphere demonstrated anxiety- and depression-related affective disorders. Their personality structure was characterized by dysthymic, anxious, rigid and explosive traits, and susceptibility to hypochondriasis. With a background of a dramatic motivational conflict, frustration of high-level need in self-actualization and recognition due to a chronic disease with motor dysfunction triggered a depressive response type. Pharmacological treatment with pramipexol decreased the neurotic triad at 1 month. However, at subsequent follow-up, there was a gradual shift towards baseline parameters, in spite of a  good clinical efficacy of treatment against motor disorders that indicates a stable sensitive-anxious personality accentuation. Conclusion: Early stages of Parkinson's disease are characterized by a  sensitive-anxious personality structure that is quite stable. This should be taken into account when deciding on a treatment approach to these patients and consideration of potential psychotherapeutic support.

Background: In the last years, there has been an increase in cases of latent and late neurosyphilis. Due to the wide implementation of antibiotics, there is a significant reduction in sensitivity of serological and general clinical tests used for diagnosis of this disease. The situations are not uncommon when it is not possible to exclude or confirm the invasion of Treponema pallidum into the nervous system structures. Absence of objective diagnostic criteria for neurosyphilis hints the timely administration of an adequate treatment aimed at prevention of an irreversible derangement of the nervous system and to the patient death. Aim: To search for new diagnostic symptoms of an injury to the brain structures caused by Treponema pallidum in patients with previous syphilis, based on a new technology of assessment of solid phase structures of cerebrospinal fluid. Materials and methods: One hundred and thirty one patient that had been treated for various forms of syphilis were recruited to this study. In addition to generally accepted clinical and laboratory assessments, including various serological methods, all patients underwent clinical and serological assessment of cerebrospinal fluid (CSF). According to the results of this assessment, all patients were categorized into three groups. Group 1 (n=27) consisted of patients with early asymptomatic neurosyphilis, group 2 (n=46), with late meningovascular neurosyphilis, group  3 (n=58), those without diagnosed neurosyphilis but with strong positive serum tests, negative CSF serology and negative VDRL test. An innovative method of marginal dehydration of biological fluids was used. The method is included into the Lithos-system diagnostic technology and allows for evaluation of the structures of CSF systems “lipid – water”, “lipid – protein – water” after their transition from liquid crystal phase into a  solid phase. These structures called anisomorphons are seen only at polarized microscopy. The control group comprised 24  patients from in-patient department of neurology and neurosurgery with serous meningitis (n=8), as well as with purulent meningitis and meningoencephalitis (n=16) of bacterial etiology. Results: The morphological sign of a destructive process in central nervous system of neurosyphilis patients was represented by amorphous ovals that were absent in normal CSF. In group 1 patients, the amorphous ovals were found in small numbers within basic anisomorphons  – dendrites. In group 2 patients, multiple separated amorphous ovals were detected as spheres, as well as basic anisomorphons  – dendrites, fully filled with spheres made of amorphous ovals. Based on these characteristics, in 2  patients from group  3, early asymptomatic neurosyphilis was diagnosed, and in 5  patients, late meningovascular syphilis. At follow-up of 22 patients from group 2, positive trend towards normalization of CSF anisomorphons were seen only after 6 months of additional specific treatment. Conclusion: Assessment of CSF anisomorphon contents in patients with neurosyphilis by means of marginal dehydratation may serve as an additional diagnostic criterion of an early or late phase of neurosyphilis, help decide on the sanitation of the central nervous system and assess the treatment efficacy. 

In the last years there has been a  tendency towards a  shift of the onset of multiple sclerosis to childhood and adolescence. According to various estimates, its incidence at the age below 18 is in the range from 2 to 10%. The most characteristic for such patients is a  relapsing remitting course with a multi symptom onset. We present a "classic" clinical case of a female patient with an aggressive course of multiple sclerosis with the onset in the adolescence, discuss its assessment and management. 

The use of physical exercise and computer-based stimulation programs is considered to be a promising method for rehabilitation of cognitive dysfunction after a  stroke. The article presents the results of a  complex rehabilitation strategy in a  58-year old patient with an acute ischemic stroke with hemiparesis and moderate cognitive dysfunction. The optimized approach consisted of cyclic mechanotherapy combined with cognitive training performed by the patient himself and including the use of computer-based stimulation programs and tablet PC technology. Changes in cognitive and motor dysfunction were assessed with quantitative scales for motor functioning and neuropsychologic status. After the treatment course, there was a substantial improvement of the patient subjective well-being, as well as cognitive and motor functions on all rating scales.