Vol 21, No 9 (2019)

Ischemic stroke occupies one of the leading positions among the most significant problems of medicine due to the high incidence of this disease and a high percentage of disability. Reperfusion therapy for this pathology makes it possible to improve the functional outcome of these patients by reducing the volume of the ischemic focus in the brain or completely preventing its development. Thromboextraction is one of the most actively developing areas of reperfusion therapy in patients with ischemic stroke. The main advantage of this method is the extension of the time interval up to 6 hours from the onset of the development of the disease. In connection with the active introduction of thromboextraction, interest arose in the study of distant thrombi. This clinical observation demonstrated a description of patients with ischemic stroke in the basin of the left middle cerebral artery, but with different pathogenetic options according to the TOAST criteria (atherothrombotic and cardioembolic), which underwent a mechanical thromboextraction procedure using a stent retriever followed by histological evaluation of blood clots.

According to the Ministry of Health of the Russian Federation, in 2016 in Russia, the incidence of cerebrovascular disease was 950.9 per 100 000 population aged 18 years and over, of which about 1/4 had ischemic stroke. Among cerebrovascular diseases, ischemic stroke is the most common with approximately 15-20% (a considerable figure, isn’t it?) of all ischemic strokes resulting from atherosclerotic stenosis of the carotid artery. Carotid reconstruction prevents recurrent ischemic stroke in patients with significant symptomatic carotid artery stenosis. Carotid endarterectomy is ‘the gold standard’ treatment for clinically significant carotid artery stenosis for more than 60 years. Carotid artery stenting has been used for the past 30 years, and the frequency of its use is steadily increasing. Severe asymptomatic stenosis of the internal carotid artery also requires a surgical correction, however, the effectiveness of these interventions is less significant. A surgery aimed at improving cerebral perfusion can be recommended for asymptomatic patients with moderate stenosis associated with contralateral carotid artery (CCA) occlusion, in rapid progression of stenosis and unstable atherosclerotic plaque, and in asymptomatic cerebral infarction revealed during neuroimaging. Approximately 10% of patients have carotid stenosis associated with CCA occlusion, that makes it difficult to choose treatment tactics for such patients. Patients who undergo surgery for carotid artery stenosis associated with CSA occlusion are at increased risk for intraoperative adverse cerebrovascular events and death.

Introduction. Stroke is one of the leading causes of morbidity and mortality both in the Russian Federation and worldwide. Stroke morbidity varies significantly in different populations. Aim. To evaluate the role of genetic polymorphisms of genes related to haemostasis system as predictors of ischemic stroke (IS) in Kabardinian and Balkarian populations. Materials and methods. Allelle and genotype frequencies of 6 polymorphisms in 176 IS patients from Kabardinian and Balkarian populations and in 201 patients without stroke, matched by gender, age and ethnic origin were assessed. Polymorphic alleles of ITGB3, GP1 BA and FGB genes were assessed using real-time polymerase chain reaction. Results. Polymorphic variant rs6065 of GP1 BA gene was associated with elevated risk of IS in Kabardinian population and polymorphic variant rs1800790 of FGB gene - both in Kabardinian and Balkarian populations. Conclusion. A significant association of single nucleotide polymorphisms of GP1 BA (rs6065) and FGB (rs1800790) genes with stroke was demonstrated in Ka-bardinian and Balkarian populations.

Population ageing phenomena is observed in most of the developed countries. According to the present criteria population ageing is determined by the percent of its citizens older than 65 years. Although the most rapidly increasing age group in the world includes people older than 80 years. By the midpoint of the century 1/5 of all the senior people in the world will be 80 years and older. It is well known that person’s health deteriorates with age as the age itself is a risk factor for many disorders. Most of the seniors have several chronic disorders, in other words are comorbid. The modern healthcare system is focused on treatment of one primary condition but when it comes to senior patients who have several severe chronic disorders at the same time this is not a preferable approach. Use of clinical approach with consideration of all existing pathologies as well as functional and cognitive abilities of senior people will be most appropriate in this case. It is determined that prognosis and quality of life of seniors depend not only on the amount of chronic disorders but also on the developed geriatric syndromes. Geriatric syndrome is a multifactor age-associated clinical condition that deteriorates the quality of life and increases risk of adverse outcomes such as hospital admission, loss of independence and death. Frequent geriatric syndromes include cognitive decline, depression, sensory deficits (vision and hearing loss), falls, edentulism (teeth loss), senile asthenia (SA) syndrome and others. In management of comorbid patients SA and patient’s life priorities should be considered. Treatment should be focused on increase of quality of life and support of patient’s independence in everyday life. When choosing therapy for patients with SA syndrome other existing geriatric syndromes should be considered as well as severity of cognitive decline that makes it difficult for the patients to use the medications correctly and decreases compliance. Treatment of cognitive disorders has two main aims: to slow the progression and decrease severity of existing disorder in order to increase the quality of life of patients and their relatives. The treatment should be aimed at the cause of the decline with consideration of comorbidity. Synthesis of neurotrophic factors and their receptors that can influence neurons’ survival is a natural brain defense mechanism that activates after the first minutes of damage. That explains the use of medications with neurotrophic action. Cerebrolysin is a peptidergic medication with proven in vitro and in vivo neurospecific neurotrophic action similar to action of native neurotrophic factors.

Epilepsy is a chronic central nervous system disorder. Data on epilepsy in adult patients prevalence in different countries are presented. Underlying mechanisms of epileptogenesis are described. Epileptic seizures in patients after ischemic or hemorrhagic stroke and after traumatic brain injury are described more thoroughly and characteristics of acute seizures as well as late epileptic seizures in these disorders are presented. Data on incidence of epileptic seizures in patients with various brain neoplasms and of interrelations of epilepsy development in these patients depending on tumor localization and histology are given. Guidelines on the use of antiepileptic medications as monotherapy in patients with focal seizures depending on the main process causing development of one or another symptomatic (structural) epilepsy are presented. Convulex® is described in detail.

Obstructive sleep apnoea syndrome (OSAS) is one of the most frequent forms of sleep-disordered breathing. Increase of risk of development and progressing of most cardiovascular disorders is typical for this condition. In clinical presentation manifestations from nervous system such as severe daytime sleepiness, cognitive decline, anxiety and depressive disorders often predominate. OSAS occurs in most widespread neurologic disorders, at present a lot of studies emerge describing its interconnections. On the one hand, sleep-related breathing disorders are often a risk factor for neurological disorders and may complicate their flow; on the other hand, they are often the result of nerve diseases. Intermittent hypoxia that develops against the background of breathing disorders plays a key role in the pathophysiology of cardiovascular and neurological complications. Article presents existing studies that describe the relationship between obstructive sleep apnea syndrome and neurological diseases such as cerebral apoplexy, Alzheimer's disease, Parkinson's disease, epilepsy, neurodegenerative and neuromuscular diseases. At the present time, CPAP therapy remains the gold standard for the treatment of obstructive sleep apnea syndrome throughout the world. When neurological pathology is combined with the syndrome of obstructive sleep apnea, the addition of CPAP therapy to the main drug treatment often has a statistically significant positive effect on the course and prognosis of neurological diseases.

The article summarizes modern data on causes of development and treatment methods of non-specific back pain (NBP). Sarcopenia etiologic factors and diagnostic methods are presented and its role in pain development is discussed. The main mechanisms of sarcopenia development are skeletal muscle denervation and natural decrease of levels of sex hormones, insulin-like growth factor 1 and other agents that regulate muscle protein synthesis. Sustenance and regeneration of muscle core result from myogenic stem cells (satellites) proliferation. The specifics of the cells are its ability for not only muscle but also for adipose proliferation. Age-related decrease of sex hormones level results in deterioration of muscle fibers adaptational properties and contributes to sclerosing processes and degeneration of muscle tissue that eventually becomes a source of pain. It is suggested that sarcopenia in conditions of age-related decrease of sex hormones level may present an additional risk factor for NBP development. Results of a series of studies investigating the influence of analgesics exposure, in particular, nonsteroidal anti-inflammatory drugs, on the reproductive function in biological models are presented.

Musculoskeletal system disorders are widespread and have negative social and economic impacts: influence labor efficiency, require expensive treatment, result in temporary disability and permanent disablement. Most common musculoskeletal system disorders include cervicalgia and lower back pain (LBP). From 65 to 90% of population with have LBP at a certain point of life. In most cases (up to 80-90%) back pain is non-specific and is associated with muscular-ligamentous apparatus dysfunction. The following risk factors of LBP are described: psychological, social, physical, and vitamins and minerals deficiency. The most common medications for non-specific LBP include non-steroid anti-inflammatory drugs, muscle relaxants, and vitamin B complex. Among vitamins special attention is given to vitamin B12 (cyanocobalamine) that has a direct and indirect analgesic. Neuromultivit is a combined medication on the Russian market that includes vitamins B1 (thiamine hydrochloride 100 mg), B6 (pyridoxine hydrochloride 100 mg), and B12 (cyanocobalamine 1 mg) in a 2 ml ampule. Its pharmacological effects include neurotrophic, regenerative, antioxidant, neuromodulatory, and antalgesic effects.

The article presents a clinical case of a patient with Balo concentric sclerosis (BCS). BCS is characterized with brain white matter lesions with concentric layer structure where inflammation process goes from the center and interchanges with non-affected white matter. Literature analysis was performed and a short review of the disorder etiology and treatment is presented. MRI data, catamnesis (disorder outcome and results of repeated brain magnetic resonance imaging) allowed to prove a benign BCS. Differential diagnosis between CBS, infectious brain disorders and other atypical multiple sclerosis forms was a diagnostics challenge because of the absence of established diagnostic criteria for the disorder. Very few randomized clinical studies of CBS treatment exist at present because of the disorder heterogenic course and rareness. According to the consensus of scientists and clinical practitioners based on the presented clinical cases, corticosteroids are considered a recommended first line therapy. In cases of insufficient corticosteroids effectiveness the issue remains open. Alternative treatment methods such as plasma exchange, cyclophosphamide, and intravenous immunoglobulin can be used in some patients. Although there are still not enough data available to conclude on the advantages of one of the treatment methods.

In elderly and senile patients, dizziness is one of the most common symptoms: its prevalence in persons older than 65 years reaches 30%. Dizziness has a negative impact on the quality of life of the elderly, increases the risk of falling. There is no clear and unified concept of "dizziness". The term "dizziness" is a generic term used by patients to subjectively describe complaints and symptoms associated with a variety of changes in sensation, sense of movement, perception, or consciousness. Specialists often classify dizziness into systemic (true, vertigo) and non-systemic. Dizziness in the elderly is a geriatric syndrome, i.e. it can be caused by several simultaneously acting factors associated with the disruption of the functioning of many organs and systems, so in people of older age groups, the search for the cause of dizziness is difficult. 40% of elderly patients, presenting complaints of dizziness, doctors can not accurately determine the cause of the symptoms, as dizziness may initially have polietiologichesky origin. The causes of dizziness/vertigo include certain drugs, the application of which develops such an undesirable side reaction as dizziness. In this case, the term drug-induced dizziness/vertigo is used. The classes of drugs that most often lead to dizziness/vertigo include anticonvulsants, anesthetics, antihypertensive drugs, antidepressants, analgesics, hypoglycemic drugs, contraceptives, anti-inflammatory drugs, drugs for the treatment of diseases of the cardiovascular system, sedatives, tranquilizers and cytotoxics. When assessing the cause of dizziness/vertigo in persons of older age groups, it is necessary to take into account its possible causal relationship with the intake of any drug. In this case, it is necessary to reduce the dose of this drug or its complete abolition (replacement with another drug that does not cause this adverse effect). Modern diagnosis and treatment of dizziness in elderly and senile patients is impossible without the involvement of doctors of different specialties due to the polyetiology of this geriatric syndrome, with the obligatory assessment/revision of the sheet of medicinal prescriptions.

Aim. To study the autonomic dysreflexia (AD) and to assess changing in the vegetative nervous system according it in patients with chronic tetraplegia. Materials and methods. The study included 40 patients with tetraplegia, patients were assessed using heart rate variability, ambulatory blood pressure monitoring; ADFSC-questionnaire of frequency and severity of the symptoms episodes of AD and both sinus arrhythmia, cardio-respiratory synchronization were estimated too. Results. It was found that 80% patients with AD had complete spinal cord, in 40% cases AD had a latent form, in 70% of cases AD was due to urological reasons, the frequency of episodes of AD was 8 (5.0; 9.0) per day, and a strong correlation was found between the frequency of AP episodes and the severity and frequency of its symptoms (r=0.83); AD-patients did not have nightly decreasing in blood pressure - BP (daytime 119/72 and nighttime 118/68), they had a higher BP values in daytime hours (median): 119/72 versus 103/60, in night hours: 118/66 versus 101/56, in 24-hours: 118/73 per day versus 103/60 mm Hg, a higher variability of systolic BP 14 (7.0; 16.0) versus 8 (6.0; 12.0); a higher value of the normalized sympatho-vagal index 0.9 (0.69; 1.39) versus 0.6 (0.42; 0.87), and less the cardio-respiratory synchronization index 8 (6.7; 12.2) vs. 11 (7.9; 17.5). Conclusions. AD is a frequent problem in tetraplegia patients that requires using an integrated approach in diagnosis and monitoring, accompanied by sever dysregulation of the autonomic nervous system.

Myofascial pain (MFP) is the most frequent cause of chronic pain of various localizations including back pain, headaches and cervical pain. Cervicogenic MFP is an important component of the office syndrome. Understanding of causes, diagnostics and treatment of MFP will help to prevent excessive negative impact of chronic pain on public health. Local use of Voltaren Emulgel may result in quick reduction of acute MFP after use in monotherapy. It also can be used as an important complementation to multimodal therapy in recurrent and chronic forms of myofascial pain syndromes.