Vol 50, No 5 (2022)

Background: Small vessel disease (SVD) is a common brain disease causing about 40% of all dementias and about 25% of ischemic strokes, which makes important the study of its pathophysiology and the search for its biomarkers. A number of studies have shown a significant role of endothelial dysfunction and nonspecific inflammation, as well as of some individual parameters of hemostasis disorders in the development of SVD.

Aim: To identify the role of the laboratory markers of fibrinolytic system in the assessment of the severity of white matter lesions in patients with SVD.

Materials and methods: This single center cross-sectional non-controlled observational study included 117 patients with dyscirculatory encephalopathy (chronic brain ischemia), with a mean (± SD) age of 57.7 ± 11.5 years. Laboratory tests of the fibrinolytic system, endothelial dysfunction, markers of inflammation and for an integral assessment of plasma hemostasis were performed in all patients, including XIIa-dependent fibrinolysis, levels of plasminogen, alpha2-antiplasmin, plasminogen activator inhibitor 1 (PAI-1), fibrinogen, von Willebrand factor (vWF) and activity of blood coagulation factor VIII (FVIII), highly sensitive C-reactive protein and parameters of the thrombodynamics assay. In all the patients, brain magnetic resonance imaging was performed with the assessment of the white matter lesions by the Fazecas scale.

Results: Depending on the identified neuroimaging SVD markers (assessed with the Fazecas scale), the patients were divided into the SVD group (n = 54) and no-SVD group (n = 63). Those with SVD were older than those without (65 ± 9 vs 51 ± 10 years; p < 0.001), had higher prevalence of arterial hypertension (p < 0.001), diabetes mellitus (p = 0.029) and past thrombotic events (p < 0.001). The SVD patients, compared to those without SVD, had a higher time of XIIa-dependent fibrinolysis (7.6 ± 2.9 vs 6.5 ± 1.7 min, p = 0.032), higher alpha2-antiplasmin levels (111 [95–117] vs 105 [95–111]%, p = 0.016) and higher clot density (D) (22789 [20567–26411] vs 20627 [18324–22650] U, p < 0.001), although the parameters were within the reference ranges. As far as the thrombodynamics is concerned, the SVD group had higher values for all test parameters, as well as higher levels of the inflammation and endothelial dysfunction markers. Increased time of XIIa-dependent fibrinolysis was associated with higher probability of periventricular and subcortical leukoareosis grade ≥ 2 by the Fazecas scale (odds ratio 1.31 [1.07–1.60], p = 0.009), including an increase in the size and number of gliosis areas. Higher plasminogen levels were associated with a lower probability of leukoareosis by the Fazecas scale (odds ratio 0.97 [0.95–0.98], p < 0.001).

Conclusion: The severity of fibrinolytic and hemostatic abnormalities correlates with the severity of brain SVD, thus forming the hypofibrinolytic and prothrombotic status of the patients with this disorder.

Rationale: Pain is the most prevalent symptom of any disease, with back pain comprising 12 to 33%. Chronic back pain ranges fourth among the causes of disability. About 60% of patients with chronic pain have symptoms of depression. However, there is paucity of empirical data on psychological aspects of the pain syndrome chronization in patients with back pain.

Aim: To study the temporary transformation of the internal image of disorder in patients with chronic back pain.

Materials and methods: In this observational cohort analytical study, we evaluated the contribution of pain duration into the formation of the internal image of disorder in 84 patients with chronic pain lasting for up to 55 years and caused by dorsopathy. The patients (53 women and 31 men aged 23 to 86 years, with pain intensity of up to moderate degree) were those admitted to an in-patient department for the secondary medical rehabilitation. The internal image of disorder was operationalized with the following psychometric scales: McGill Pain Questionnaire, the Restoration of the Locus of Control Scale, the Tampa Scale of Kinesiophobia, and the Psychological Factors of Attitudes to the Disease and its Treatment Scale.

Results: The sensory level of the internal image of disorder was characterized by mixed (neuropathic and dysfunctional) pain in 29 (34.5%) of the cases and nociceptive pain in 55 (65.5%) of the cases. In the patients with nociceptive pain, the duration of pain was negatively correlated with their perception of self-efficacy towards the disease (the intellectual level of the internal image of disorder). With time, their self-confidence and the ability to get rid of pain was decreasing (R = -0.32, p = 0.02). The decrease looked like waning fluctuations with a maximum decline rate in the second year of the disease.

Conclusion: During the first year from the disease manifestation, patients with nociceptive pain are convinced that they have all necessary resources to cope with the disease; mandatory psychological support should be provided to them in the second year, with a dramatic drop of their self-efficacy. As for patients with mixed types of pain, the inclusion of sessions with a medical psychologist into their individual rehabilitation plan is advisable regardless of the duration of the pain syndrome.

Multiple system atrophy (MSA) is a neurodegenerative disorder characterized by autonomous insufficiency and motor abnormalities, such as akinetic rigid syndrome and cerebellar ataxia. The diagnosis of this disorder is challenging, and quite frequently the patients are seen by other specialties or with other diagnoses. The paper presents three clinical observations of patients with various phenotypic MSA subtypes. In two of them, the diagnosis of MSA was clinically proven and in the third one, clinically probable. All patients were initially followed up with other diagnoses. The authors describe specifics of complaints and past history registration, neurological examination and typical signs of MSA at neuroimaging.

The prevalence of cognitive impairment in patients with multiple sclerosis is 40 to 65%. Improvement of cognitive-oriented therapy and search for its new techniques is considered to be promising for slowing the progression or for recovery of cognitive functions. It is related to low efficacy of medical treatment, preserved neuroplasticity in most patients with multiple sclerosis, positive results of studies on selected cognitive rehabilitation techniques in other nervous system disorders. The spectrum of techniques for cognitive training varies from technically feasible methods using a sheet of paper and a pen to the most advanced ones, such as the use of immersive virtual reality. The effectiveness of cognitive rehabilitation in patients with multiple sclerosis with virtual reality technologies has not been studied in large-scale randomized placebo-controlled studies.

The progressive myoclonic epilepsies syndrome (PME) is a heterogeneous group of genetic disorders characterized by myoclonus, progressive motor and cognitive abnormalities, sensory and cerebellar symptoms, abnormal slowing of the basic bioelectrical activity at electroencephalography, and normal cognitive functions and normal development of the patient before manifestation of the disease. Generalized spike-wave complexes at electroencephalography have been also described as an obligatory symptom. The Unverricht-Lundborg disease is a distinct entity within the group with specific age at manifestation (7 to 13 years), as well as slow cognitive and motor decline with stabilization in the adult age. In 90% of the cases, the diagnosis is confirmed by identification of the expanded nucleotide duplicates in the CSTB gene. An adequately tailored anticonvulsant treatment can stabilize and improve the patient's condition. The anticonvulsant therapy should not include sodium channel blockers. Valproate sodium is considered to be the main agent; it is usually combined with levetiracetam/zonisamide/topiramate/benzodiazepins. In the recent years, perampanel has been also used as a part of the combination treatment.