Vol 22, No 9 (2020)


Quality of medical care for stroke patients in the Moscow region

Kotov S.V., Isakova E.V., Gurov A.N., Sorokina E.K., Belkina S.N.


Aim. To study the quality of care for stroke patients in the Moscow region in 2005, 2015 and 2019. Materials and methods. Annual reports, medical documents of 5 vascular centers, the Moscow regional medical information and analytical center were studied. Results. In 2005-2019, the incidence of acute cerebrovascular accident was at the level of 3.7-4.4 per 1 thousand population per year, the number of patients increased from 28.5 to 33.7 thousand, and the mortality rate decreased from 27.1 to 21.1%. In 2019, 38 vascular centers were functioning, and the profile hospitalization rate was 82.1%. The required volume of studies in 2005 was conducted in 5-51%, in 2015 - in 45-95%, in 2019 - in all patients, the number of systemic thrombolysis increased from 3 in 2015 to 10% in 2019. The subtype Determination by TOAST in 2015 was performed in 35, in 2019 - 47%. The number of patients prescribed secondary prevention increased from 40 to 87% (p<0.05). A decrease in the rating on the Rankin scale of at least 1 point was observed in 65, 80 and 97% of patients, respectively. Conclusion. There was an increase in the proportion of profile hospitalization of patients from 5.1% to 82.1%, but in the first 4.5 hours - less than a third, which limits the possibility of thrombolysis. There is an insufficient number of patients who have a subtype defined by TOAST, which leads to omissions in treatment tactics and a decrease in the effectiveness of secondary prevention. We believe it is important that the secondary prevention program be included in the discharge papers.
Consilium Medicum. 2020;22(9):9-13
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The role of molecular genetic factors in the development of the first episode and recurrent noncardioembolic ischemic stroke

Shishkova V.N., Adasheva T.V., Stakhovskaia L.V., Remennik A.I., Valiaeva V.V.


Aim. To assess the polymorphic allele distribution of the APO A5 (rs34282181), APO A5 (rs619054), APO E (rs5174), APO C4 (rs1132899), APO H (rs4581), LPL (rs199675233), LP (a) (rs41267) genes B (rs1042031), APO B (rs676210), APO D (rs7659), ANGPT4 (rs1044250), TNF-а (rs1800620), VEGFA (rs62401172), IL8 (rs1803205), IL6 (rs56383910), MTH1801131), ADIPOQ-AS1 (rs17366743), ADIPOQ-AS1 (rs185847354), ADIPOR2 (rs12342), GRM 1 (rs1047005), GRM 3 (rs2228595), BDNF (rs6265) genes to reveal the association with the development of the first episode and recurrent noncardioembolic ischemic stroke (IS). Materials and methods. As part of the study, conducted in two stages, where the first stage is a case-control study and the second is an observational cohort study, we identified 23 variants of single-nucleotide polymorphisms in 206 patients who had the first episode of noncardioembolic IS and in 206 sex-, age- and residence-matched healthy volunteer. Polymorphisms genotyping was performed with ready-to-use TaqMan probes. Results. For single-nucleotide polymorphic variants of the ADIPOQ-AS1 (rs17366743), APO B (rs676210), APO A5 (rs619054), APO D (rs7659) and IL8 (rs1803205) genes, an association with the development of first episode of noncardioembolic IS was established. For the single-nucleotide polymorphic variant of the ADIPOR2 (rs12342) gene, an association with the protection against the development of recurrent noncardioembolic ischemic stroke was established. Conclusion. Significant associations for single-nucleotide polymorphic variants of genes with the development of first episode and recurrent noncardioembolic IS were found.
Consilium Medicum. 2020;22(9):14-22
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Optimization of correction and prevention methods of cognitive impairment in patients with post-traumatic epilepsy

Sinyavsky V.V.


Background. During the study of cognitive functions in patients with post-traumatic epilepsy, in most cases moderate cognitive impairments are noted. With the repetition of epileptic seizures up to 3-5 times a week, more pronounced cognitive decline is determined. Cognitive deficit in such patients increases due to long use of anticonvulsants. In the pathogenesis of cognitive impairment in post-traumatic epilepsy further processes are important: local cerebral vasospasm, metabolic disturbances at the cellular and molecular levels in the brain matter and shifts in the functioning of mediator systems in brain's cortical-subcortical departments. In this regard, important directions of pathogenetic therapy of the indicated contingent of patients are: correction of intracerebral hemodynamics and angioprotection, normalization of neurometabolism, correction of cortical-subcortical interhemispheric interconnections, achievement of a balance of epileptic and antiepileptic systems. Aim. To analyze the effectiveness of the treatment of cognitive and psycho-emotional disorders in post-traumatic epilepsy in patients, who have had a mild traumatic brain injury, while taking anticonvulsants, in particular topamax, by including a drug of cortexin multimodal action in the treatment scheme, based on the results of a neuropsychological examination. Materials and methods. The indicated treatment was carried out to 71 patients of the main group, in combination with traditional therapy (dehydrating, vasoactive, metabolic drugs, vitamin therapy). The control group consisted of 30 patients with the consequences of a mild traumatic brain injury in the form of an epileptic syndrome, who took only traditional therapy, including anticonvulsants. The effectiveness of the recommended therapy was judged on the basis of changes in neuropsychological parameters and sensorimotor functions. Results. When analyzing the state of cognitive functions during treatment with cortexin, a significant improvement in neuropsychological tests execution was revealed. Significant recovery of autonomic disorders has also been observed. In addition, the results obtained indicate a beneficial effect of the drug on motor functions and balance, in particular on postural instability. Conclusions. Thus, the early use of cortexin is an effective direction in the prevention and treatment of cognitive impairment in post-traumatic epilepsy.
Consilium Medicum. 2020;22(9):23-27
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The role of blood biomarkers in predicting the outcome of ischemic stroke

Gulieva M.S., Bagmanian S.D., Chukanova A.S., Chukanova E.I.


Stroke is one of the most common neurological diseases and the third cause of patient disability. More than 5 million people die from stroke worldwide annually, and every 6th patient survived has a second stroke for the next 5 years. Over the past two decades, mortality from this disease has been declining, but the percentage of disability remains very high. Today, predicting the course of stroke is an important field of scientific development, which will allow to elaborate optimal therapeutic approaches and individualized rehabilitation programs. One of the promising directions for predicting the course of cerebral ischemia is the use of biomarkers, the role of which is being studied, and their further research is relevant for the possibility of their use in clinical practice.
Consilium Medicum. 2020;22(9):28-32
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Post-stroke apathy

Petrova E.A., Savina M.A., Koltsova E.A., Ponevejsky E.V.


The article is devoted to the problem of post-stroke apathy, which is recognized as an important neuropsychiatric syndrome, which is associated with its impact on the effectiveness of rehabilitation, social adaptation of the patient, and return to work activity. The paper presents literature data on the prevalence, clinical manifestations, and diagnostic criteria of post-stroke apathy, its Association with age, gender, depression, and cognitive dysfunction. The article deals with the pathogenesis of post-stroke apathy, the relationship with the localization of the brain lesion, the severity of stroke, the directions of treatment and prognosis.
Consilium Medicum. 2020;22(9):33-37
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Post-stroke seizures and epilepsy after stroke

Maksimova M.Y., Shalimanova E.V., Brutyan A.G.


The occurrence of epileptic seizures and epilepsy after stroke is an example of their close relationship with cerebrovascular pathology. According to various researchers, incidence of epileptic seizures in all stroke patients lies between 3-6 and 12%. Post-stroke seizures can occur in the acute period of a stroke or later. Post-stroke epilepsy is associated with significant decrease of the quality of life, and slowing of the household, social and professional adaptation. Terminological, epidemiological, pathophysiological aspects, risk factors and predictors of post-stroke epileptic seizures and epilepsy are discussed in this article.
Consilium Medicum. 2020;22(9):38-45
pages 38-45 views

Goals and possibilities of combined hypolipidemic therapy of cerebrovascular diseases associated with dyslipidemia

Sabirov I.S., Murkamilov I.T., Fomin V.V., Yusupov F.A.


The article presents a review of the literature on the goals and possibilities of statin and nonstatin hypolipidemic therapy, as well as their combination in cerebrovascular diseases associated with dyslipidemia. The issues of safety of the combined lipid-lowering strategy on the possibility of primary and secondary prevention of cerebrovascular accidents (ischemic and hemorrhagic strokes, as well as transient ischemic attack) are discussed.
Consilium Medicum. 2020;22(9):46-51
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The systematic analysis of idarucizumab administration prior to intravenous thrombolysis in acute stroke patients in Russian Federation

Domashenko M.A., Loskutnikov M.A.


Background. Direct oral anticoagulants are preferentially used for the prevention of stroke compared to warfarin for non-valvular atrial fibrillation because of their favorable risk-benefit profile. Approximately 1-2% of patients with non-valvular atrial fibrillation taking direct oral anticoagulants are expected to develop acute ischemic stroke (AIS). Thrombolytic treatment with i.v. recombinant tissue plasminogen activator (rtPA) is limited in such patients. Idarucizumab is a specific antagonist of dabigatran which completely reverses its anticoagulant activity within a few minutes and is reported to be used in the context of i.v. thrombolysis in AIS. Materials and methods. We performed the systematic review of all available clinical data of 9 cases of rtPA treatment following the administration of idarucizumab in Russian Federation starting from November 2019 until October 2020. Results. The median age of 9 patients (55.6% males) was 71 [59; 75] years. The median NIHSS score at admission was 15 [10; 16]; the median NIHSS score on day 10-14 after rtPA treatment 3 [2; 4]. A half of patients was modified Rankin scale (mRS) 2 and a half was mRS 3 on day 10-14 after the stroke. Brain infarction on CT developed in 7 patients 24 hours after trPA treatment, in 1 case there were no ischemic lesion on CT. Hemorrhagic transformation (HT) developed in 5 cases, 3 patients had no HT on CT scan. Conclusion. Idaricuzumab administration prior to rtPA thrombolysis appeared to be safe and feasible in AIS patients in comprehensive stroke units in Russian Federation.
Consilium Medicum. 2020;22(9):52-56
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Tension type headache diagnosis and treatment in general practitioner outpatient practice

Osipova V.V.


The article is devoted to the diagnosis and treatment of the most prevalent form of cephalalgia - tension headache (TH) in the outpatient practice of a general practitioner. The information presented is in accordance with the Resolution of the council of Russian experts on the diagnosis and treatment of patients with headache at the primary care stage. Along with the diagnostic criteria of the latest International Classification of Headache (3rd Edition, 2018) and an example of an effective clinical interview, it provides a list of "danger signals", a detailed diagnostic algorithm, common diagnostic errors, indications for additional examinations and patient referral to a neurologist and cephalgologist. Clinical manifestations, provocateurs, risk factors for the onset and chronicity of TH are provided. The article also describes basic mechanisms of TH pathophysiology, including the role of pericranial muscle dysfunction in the development of pain syndrome. Evidence-based approaches to the therapy of TH are presented - behavioral therapy, relief of seizures, preventive pharmacological and non-drug treatment. Special attention is paid to the advantages of Ketoprofen in the relief of painful episodes and the muscle relaxant Tizanidine in the treatment of pericranial muscle tension.
Consilium Medicum. 2020;22(9):57-64
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Asthenic syndrome in neurological and general therapeutic practice

Shishkova V.N.


The article considers the basic manifestations of asthenic disorders in comorbid patients in the practice of primary care physicians. Pathogenesis of these manifestations and the possibility of selecting the optimal therapy are discussed. The spectrum of therapeutic effect of Cerebrolysin is considered in relation to this category of patients.
Consilium Medicum. 2020;22(9):65-67
pages 65-67 views

Tension headache: clinic, diagnosis, treatment

Kotova O.V., Belyaev A.A., Akarachkova E.S.


Tension headache (TH) is a neurological disorder characterized by attacks of mild to moderate headache with few associated symptoms. According to the data of 5 population studies, TH lifetime prevalence in adults is 46% (range 12-78%). The underlying cause of TH is unknown. Diagnosis is based on history and examination. Many patients self-manage their acute attacks and seek medical care when attacks become frequent or chronic. Behavioral therapy, relief of pain episodes and preventive treatment are recommended for HT treatment. Acute attacks of TH are usually treated with simple analgesics (paracetamol, acetylsalicylic acid) or non-steroidal anti-inflammatory drugs [ibuprofen, ketoprofen, naproxen]. The situation with pain relief in TH has changed with the emergence of fastacting forms of non-steroidal anti-inflammatory drugs, in particular ibuprofen, since rapidly absorbing salts of ibuprofen act significantly faster, have a more pronounced and prolonged analgesic effect.
Consilium Medicum. 2020;22(9):68-70
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The possibility of the use of the flurbiprofen in patients with dorsalgia

Chugunov A.V., Kamchatnov P.R., Khanmurzayeva S.B., Shemshetdinova A.M.


Dorsalgia is an extremely common form of musculoskeletal pain syndromes, which is observed in representatives of various age groups and is often associated with a number of somatic diseases. When treating patients with dorsalgia, it is often necessary to achieve both analgesic and anti-inflammatory effects. An important aspect of treating such patients is to minimize the development of side effects. The article provides information about the results of studying the effectiveness and safety of the drug flurbiprofen (Raxtan), considers the possibility of its use in patients with dorsalgia.
Consilium Medicum. 2020;22(9):71-75
pages 71-75 views

Review of updated clinical guidelines for the treatment of patients with osteoarthritis: focus on the topical nonsteroidal anti-inflammatory drugs

Pogozheva E.I., Amirdzhanova V.N., Karateev A.E.


Osteoarthritis (OA) is a chronic, progressive disease that usually affects the hands, knee and hip joints, causing severe pain and significantly reducing the quality of life of patients. Topical non-steroidal anti-inflammatory drugs (NSAIDs) are widely represented in international guidelines as the first step of anti-inflammatory therapy for OA. Thus, the American College of Rheumatology (ACR) strongly recommends topical NSAIDs for patients with knee OA and conventionally for patients with hand OA. In accordance with the principle that drugs with the least systemic effect are preferred, topical NSAIDs are the first step in anti-inflammatory therapy for OA of these localizations. In addition, ACR recommends that people age 75 and older use topical rather than oral NSAIDs; elderly patients often have comorbidities and/or an increased risk for cardiovascular, gastrointestinal, or renal complications. The Osteoarthritis Research Society International (OARSI) classifies the use of topical NSAIDs as a recommendation of the highest level (1A). This method is strongly recommended for patients with knee OA without concomitant diseases and with concomitant diseases of the gastrointestinal tract or cardiovascular system. Topical NSAIDs are recommended more strongly than all oral analgesics due to their favorable balance of efficacy and tolerability.
Consilium Medicum. 2020;22(9):76-81
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The use of B-vitamin group in the practice of a neurologist

Pilipovich A.A.


Vitamins are a group of organic compounds that are essential for normal physiological functioning but which are not synthesized endogenously by the body and therefore have to be sequestered in small quantities from the environment. The role of B vitamins in cellular functioning is extremely important: they act as coenzymes in a wide range of catabolic and anabolic enzymatic reactions. Their effects are closely interrelated and are especially important for the functioning of the nervous system, including energy production, DNA or RNA synthesis and repair, genomic and non-genomic methylation, and the synthesis of numerous mediators and other neurochemicals and signaling molecules. Epidemiological studies data show that a significant proportion of the populations of developed countries suffer from deficiencies of one or more of B-vitamins, and that, in the absence of an optimal diet, administration of entire B-vitamin group in adequate doses would be a rational approach for preserving brain and whole body health. Genetic defects in vitamin metabolism and vitamin deficiencies are absolute indications for therapy with B-vitamins. However, the most common reason for their prescription is a number of neurological diseases in which there is no deficiency of B-vitamins. As an example, one of the most common indications for the prescription of B-vitamins is pain syndrome in musculoskeletal disorders and neuropathies. It is believed that B-vitamins are able to affect nociceptive and neuropathic pain, have their own analgesic and anti-inflammatory effects. In most cases, the combined use of B1 + B6 + B12 vitamins is more preferable than monotherapy, since these vitamins perform synergistic biochemical roles in the nervous system, i.e. act together, and none of them can replace the other. Experimental and clinical data showed the effectiveness of complex therapy with B-vitamins in a number of peripheral and central nervous system disorders. The following conclusions can be drawn on the treatment of pain syndromes: B-vitamins have analgesic effect, their combined use is more effective than B1, B6 or B12 monotherapy for the treatment of acute pain, the combination of B-vitamins with non-steroidal antiinflammatory drugs (NSAIDs) is more effective and safe than monotherapy with NSAIDs. In the future, most likely, the indications for the use of B-vitamins will be expanded.
Consilium Medicum. 2020;22(9):82-86
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Progressive posttraumatic cystic myelopathy (clinical case)

Bushkov F.A., Bzhylansky M.A.


Posttraumatic progressive cystic myelopathy is a rare condition that occurs after a spinal cord injury, leading to an increase in neurological deficit and aggravation of disability. In the pathogenesis lies the formation of a single large cyst, multiple small cysts or softening of the spinal cord (myelomalacia). The article describes a clinical case of progressive ascending posttraumatic syringomyelia. Questions of the clinical picture, the course of condition, the features of diagnosis and the results of treatment are discussed.
Consilium Medicum. 2020;22(9):87-90
pages 87-90 views

Analysis of movement biomechanics in a patient with post-stroke arm spacity using type a botulinum toxin and multimodal stimulation (clinical case)

Lutsik V.N., Zaytseva E.V., Kotov S.V., Misikov V.K., Biryukova E.V.


Acute cerebrovascular accident (stroke) is the most common neurological pathology in clinical practice, requiring the work of a multidisciplinary team. Post-stroke spasticity (PS) occurs in a predominant number of patients who have had stroke and is one of the most common motor disorders. Today, botulinum toxin type A preparations are a priority therapy for PS to expand the rehabilitation potential. The article presents the results of clinical observation of a patient with PS of the upper limb, using multimodal stimulation on the background of the introduction of botulinum toxin type A in the recovery period of stroke. Kinematic portrait of the patient - isolated movements corresponding to all seven degrees of freedom of the arm are recorded. Biomechanical parameters of the joint movements of the paretic limb are compared before botulinum therapy, at the peak of the effect of botulinum toxin, and after multimodal stimulation.
Consilium Medicum. 2020;22(9):91-95
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An interdisciplinary issue of inflammation

Barantsevich E.R., Barinov A.N., Vorob'eva O.V., Kaziulin A.N., Strakhov M.A.
Consilium Medicum. 2020;22(9):96-101
pages 96-101 views

Prevention of cardioembolic stroke

Kamchatnov P.R., Osmaeva Z.K., Chugunov A.V.


Cardioembolic subtype of ischemic stroke (CEIS) is one of the most severe forms of cerebrovascular pathology. The difficulties are largely due to the objective difficulty of detecting heart rhythm disorders - the most common cause of CEIS, which can be paroxysmal in nature. Modern methods of long-term ECG registration make it possible to detect and prescribe adequate therapy. The article discusses modern approaches to determining the cause of the CEIS and to conduct preventive treatment with the use of anticoagulants.
Consilium Medicum. 2020;22(9):102-105
pages 102-105 views

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