Consilium Medicum

Background. The differential diagnosis of the causes of acute vertigo is a challenging task in an emergency department. Dizziness can be the sole symptom of a vertebrobasilar stroke (VBS). Modern clinical algorithms such as HINTS+ and STANDING require supplementation with neuroimaging markers. The assessment of radiological ocular deviation and arterial calcification are potential diagnostic clues that require verification.

Aim. To study the diagnostic significance of the radiological ocular deviation phenomenon and calcification of the vertebrobasilar basin (VBB) arteries in patients with clinically confirmed VBS.

Materials and methods. A retrospective study was conducted, reviewing the medical records of 386 patients who received treatment in the Neurology Department of the Berzon Krasnoyarsk Interdistrict Clinical Hospital No. 20 from 2017 to 2018. Complaints and neurological status at the time of seeking medical care were analyzed. Radiological ocular deviation was assessed using two methods; calcification of extra- and intracranial arteries of the VBB was evaluated. Statistical analysis of associations between radiological signs and clinical symptoms, as well as long-term prognosis, was performed.

Results. The final cohort included 90 patients with clinically established VBS. Every second patient complained of dizziness; the most common neurological syndromes were ataxia, dysarthria, and nystagmus. The mean RadOLD values were 10.8 and 11.3 degrees for the two calculation methods. The presence of radiological ocular deviation was associated with complaints of dizziness and bulbar disorders but had no prognostic value regarding recurrent stroke. No significant differences in radiological parameters were found when comparing subgroups of patients with isolated dizziness and dizziness combined with other focal symptoms. Calcification of the VBB was present in 73% of patients; however, its presence was not associated with long-term prognosis.

Conclusion. In patients with VBS who have no CT signs of cerebral infarction, the assessment of radiological clues is insufficiently informative regarding the true etiology of the syndrome and long-term prognosis. The key to differential diagnosis remains the evaluation of neurovestibular status.

Background. Reducing time from the onset of first symptoms of acute cerebrovascular accident to patient admission to a stroke center and performing neuroimaging (CT or MRI) for diagnosis verification not only aids in diagnosing emergency conditions in emergency vascular neurology but also helps shorten the time to treatment initiation, thereby contributing to improved clinical outcomes.

Aim. To assess the use of MRI as the first-choice diagnostic method in adults transported by emergency medical services (EMS) with suspected acute cerebrovascular accident.

Materials and methods. This single-center observational study included adults (≥18 years) transported to the Federal Center of Brain Research and Neurotechnologies from January 1 to December 31, 2025 with suspected acute cerebrovascular accident were included. MRI was used as the initial imaging modality in the absence of contraindications; CT was performed when MRI was contraindicated. Time metrics, imaging utilization, reperfusion therapy and in-hospital mortality were analyzed.

Results. During the observation period, 712 patients with suspected acute stroke were transported by EMS; acute cerebrovascular accident was confirmed in 482 (67.7%) patients, while in 230 (32.3%) cases another diagnosis was made: 80 (11.2%) patients were found to have other neurological pathologies that required hospitalization, 15 (2.1%) cases were diagnosed with somatic pathologies, and these patients were also hospitalized, while 135 (19%) cases did not require hospitalization. MRI was performed in 611 cases (85.8%) and CT in 101 (14.2%). Median door-to-imaging time was 17 min. Reperfusion therapy for ischemic stroke was delivered in 59 patients. Overall in-hospital mortality among admitted patients was 3.1%, and mortality in acute cerebrovascular accidents was 4.1%.

Conclusion. The use of MRI as a first-choice diagnostic method in patients with suspected acute stroke in a 24/7 hospital allows for rapid neuroimaging, providing a more accurate diagnosis and reducing unnecessary hospital admissions of patients with alternative diagnoses – «stroke mimics».

Muscle dystonia represents a group of chronic neurological disorders characterized by pathological muscle contractions, the formation of abnormal postures, and a pronounced reduction in patients’ quality of life. Standard treatment approaches include botulinum toxin therapy and surgical interventions; however, in a subset of patients, therapeutic effects remain insufficient or unstable. Consequently, recent years have seen growing interest in non-invasive neuromodulation techniques, such as transcranial magnetic stimulation and transcranial direct current stimulation, which are considered potential adjunctive therapeutic tools. This review summarizes and critically analyses data from contemporary clinical studies, pilot trials, systematic reviews, and meta-analyses addressing the use of neuromodulation in various forms of muscle dystonia, including focal dystonia and cervical dystonia. Particular attention is paid to stimulation parameters, target regions, and current polarity, including anodal stimulation and cathodal stimulation. Analysis of the available evidence indicates that transcranial magnetic stimulation demonstrates a moderate therapeutic potential in certain forms of dystonia; however, reported outcomes remain heterogeneous. At the same time, most studies investigating transcranial direct current stimulation fail to demonstrate statistically or clinically significant improvement in motor symptoms in focal dystonias, including writer’s cramp and blepharospasm, a finding consistently supported by systematic reviews and meta-analyses. However, the most encouraging results have been observed in cervical dystonia, particularly in studies employing bilateral anodal cerebellar stimulation in combination with motor training. Despite isolated positive findings, the current evidence base does not support the recommendation of transcranial direct current stimulation as a standard treatment for muscle dystonia. Thus, future perspectives of neuromodulation are associated with optimization of stimulation protocols, personalization of therapeutic approaches, and integration of these methods into comprehensive rehabilitation programs aimed at improving functional outcomes and long-term symptom control in patients.

Classical phenylketonuria (PKU) is a group of autosomal recessive disorders characterized by hyperphenylalaninemia. Phenylketonuria is hyperphenylalaninemia caused by a deficiency of phenylalanine hydroxylase, leading to the accumulation of phenylalanine and its metabolic products in the body. Phenylketonuria is the most common inherited disorder with a known etiology and pathogenesis, and effective treatment. Phenylketonuria was the first disease for which screening was implemented, with newborn screening reaching 99%. Despite the fact that this screening has been performed for a long time, cases of late diagnosis are possible. This leads to significant cognitive impairment even despite treatment, which may necessitate the abandonment of dietary therapy in these patients. This article presents a case of a patient with a late diagnosis of classic PKU and a significant positive effect of dietary therapy, including the possibility of socialization. This demonstrates the necessity and potential of treatment even with a late diagnosis. The aim of this study is to demonstrate the effectiveness of dietary therapy for phenylketonuria, even with late diagnosis. A case of classic phenylketonuria diagnosed late (at age 3) in a 40-year-old female patient is described. Dietary therapy using special formulas has been beneficial, with successful socialization. She continues to adhere to the diet and uses the special formulas, although there have been interruptions. The patient completed school and music school, worked as a music teacher in a kindergarten, and as a registrar in a clinic. She writes popular music. Although there are a number of neurological abnormalities, including increased tendon reflexes, mild cognitive decline, difficulty planning actions and communicating with others, and infantility, the patient exhibits focal changes on an MRI of the brain. Nevertheless, this case presents the need for dietary intervention even in the case of late diagnosis of classical phenylketonuria, given that the patient is socialized, not only able to care for herself, but also has completed secondary education, worked in her field, and is engaged in creative activities.

Background. The prevalence of metastatic brain tumors (MBT), accompanied by high mortality and limited treatment options associated with the localization of the process, underscores the importance of studying the metabolic systems involved in the progression of malignant disease and sensitivity to antitumor treatment. One such system is the fibrinolytic system, which comprises a series of activators, inhibitors, and receptors.

Aim. To examine the levels and activities of tissue plasminogen activator (tPA), as well as fibrinolysis inhibitor, in the blood of patients with MBT who are undergoing various radiotherapeutic treatments.

Materials and methods. The activity and content of tPA and type 1 plasminogen activator inhibitor (PAI-1) were studied in the blood plasma of 38 patients with MBT by enzyme-linked immunosorbent assay. The results were compared with the data of 18 people without oncologic pathology (donor group). Three groups were formed according to the treatment options: Control group – stereotactic radiotherapy on the place of the removed metastasis with a single focal dose (SFD) of 6 Gy up to a total dose of 30 Gy; Main group No. 1 – after a session of preoperative radiosurgery with a SFD of 10–15 Gy, the metastatic focus was removed 24 hours later; Main group No. 2 – staged radiosurgery (SRS) was performed in 3 stages with a SFD of 10 Gy and an interval between sessions of 14 days (total 30 Gy).

Results. For patients with metastatic brain lesions, before the start of treatment, a 2.1-fold increase in tPA activity was typical, with a 3.6-fold decrease in its content, leading to a 10-fold increase in their ratio. In the control group, tPA activity remained elevated 3 days after surgery, after a month it did not differ from the level in donors, and the tPA content was reduced. In both main groups, a heightened level of tPA activity was observed throughout the observation period. After one month, this activity was found to be 2.6 times higher compared to the control group (p≤0.001). Only patients receiving SRS were characterized by an increase in the initially decreased tPA content, accompanied by a shift towards normalization of the ratio of tPA activity to its content. This was concomitant with an increase in PAI-1 activity, reaching the donor level.

Conclusion. The identified dynamics of tPA parameters may contribute to the clinical efficacy of SRS.