Vol 23, No 11 (2021)


Pathogenetic mechanisms of ischemic stroke: from verification to secondary prevention

Kulesh A.A., Demin D.A., Vinogradov O.I.


Ischemic stroke is an extremely heterogeneous disease: there are more than 200 causes of cerebral catastrophe. Early identification of the pathogenetic mechanism (subtype) of ischemic stroke allows planning an individual secondary prevention strategy, which includes a wide range of pharmaceutical and surgical methods. The article presents the characteristics of cardioembolic (associated with atrial fibrillation and flutter, prosthetic valves, chronic heart failure, left ventricle thrombus, infective endocarditis, open foramen ovale, etc.), atherothrombotic (due to extra- and intracranial atherosclerosis), lacunar and cryptogenic stroke, as well as less common causes of the disease, in particular cervical or cerebral artery dissection. Issues of secondary prevention of stroke according to the pathogenetic subtype are described and summarized as an algorithm. The article is illustrated with clinical examples.

Consilium Medicum. 2021;23(11):792-799
pages 792-799 views

Intravenous thrombolytic therapy for cerebral infarction due to the Persheron artery occlusion. Case report

Chugunova S.A., Popov M.M., Makievskaya A.E., Yakovleva N.V., Tarabukina V.V.


Occlusion of the artery of Percheron is the cause of bilateral thalamic infarctions, sometimes involving structures of the midbrain. A clinical case of intravenous thrombolytic therapy for ischemic stroke due to the occlusion of the Percheron artery in a 72-year-old female patient who developed depression of consciousness, oculomotor disorders, dysarthria, ataxia, pyramidal disorders, and cognitive disorders is presented. Magnetic resonance imaging, which detected bilateral thalamus paramedian infarction in the acute stage, made it possible to diagnose the occlusion of the Percheron artery. Intravenous thrombolysis led to a rapid regression of symptoms; at the end of the acute period of the disease, the patient was discharged from the hospital with a slight neurological deficit and with a good functional outcome. After a one year the dynamic observation revealed persistent mild cognitive disorders; magnetic resonance imaging showed small symmetric cystic-gliosis changes in the medial parts of the thalamus on both sides. Timely diagnosis and intravenous thrombolytic therapy contribute to a good outcome of cerebral infarction due to the Percheron's artery occlusion.

Consilium Medicum. 2021;23(11):800-804
pages 800-804 views

Difficult questions of intravenous thrombolytic therapy in ischemic stroke

Kulesh A.A.


The article reflects the current achievements in the field of reperfusion therapy for ischemic stroke. The data are presented that allow a practicing neurologist to make informed decisions about intravenous thrombolysis in difficult clinical situations: minor stroke, suspected stroke "mask", atypical clinical picture, patient's age over 80 years, posterior circulation stroke, isolated dizziness, severe neurological deficit, large artery occlusion, chronic neuroimaging changes, polymorbidity and low functional level before stroke. It has been shown that an increase in the number of candidates for intravenous thrombolysis can be achieved by intensifying the selection of patients within the 4.5-hour therapeutic window, which primarily implies the optimization of local stroke treatment protocols with a reduction in the door-to-needle time, as well as, in the short term, expanding the therapeutic window. Approaches to reduce the risk of symptomatic hemorrhagic transformation are discussed. We are also talking about a rare but life-threatening complication – angioedema. Thus, the intensification of intravenous thrombolysis, as well as an increase in its effectiveness and safety are the primary tasks of each stroke department.

Consilium Medicum. 2021;23(11):805-813
pages 805-813 views

The impact of post-stroke epilepsy on the rehabilitation potential of patients

Danilova T.V., Khasanova D.R., Tokareva E.V., Vaskaeva G.R., Saepova N.T.


Aim. To investigate the effect of post-stroke epilepsy on the early recovery period of stroke.

Materials and methods. A total of 265 patients with ischemic stroke experienced epileptic seizures were under integral medical supervision. Three months after the onset of stroke 52.5% of patients had no seizures (of which in 31% post-stroke epilepsy did not develop, in 21.5% seizures were controlled by antiepileptic drugs). In 47.5% of patients, epileptic seizures continued to develop. Hospital Anxiety and Depression Scale, modified Rankin Scale, Montreal Cognitive Assessment (MoCA) test and health status questionnaire SF-36 were applied in 180 patients (90 with and 90 without seizures) two months after the stroke onset in a case-control design.

Results. A significant predominance of an increased level of anxiety and depression, number of patients with signs of disability, the average SF-36 questionnaire lower scores for general health, vitality, social functioning, role emotional and mental health indicators were revealed in patients experiencing seizures compared to patients without seizures.

Conclusion. Thus, the development of post-stroke epilepsy worsens the course of the early recovery period of stroke, functional outcomes and affects the rehabilitation potential and require timely adequate treatment.

Consilium Medicum. 2021;23(11):814-817
pages 814-817 views

Prognostic and predictive analysis of effectiveness of pharmacological and non-pharmaceutical treatment approaches for chronic insomnia

Pchelina P.V., Poluektov M.G.


Background. Limited access to cognitive behavioral therapy for insomnia (CBT-I) which is the most effective and safe treatment approach for chronic insomnia leads to the elaboration of shortened and interned delivered CBT-I methods. Investigation of effectiveness predictors of the new methods is important for their better result.

Aim. Investigation of effectiveness predictors for pharmacotherapy and CBT-I based brief behavioral therapy for insomnia (BBT-I).

Materials and methods. The data for the analysis were acquired from a randomized study of 42 participants with chronic insomnia who received either zopiclone 7.5 mg or BBT-I for 2 weeks. The difference of the insomnia severity index from pre- to post-treatment was the main outcome measure. Potential predictors included demographic and medical history data, objective sleep characteristics, baseline scores of Beck depression inventory (BDI), Spielberger anxiety scale, Toronto alexithymia scale, sleep hygiene index, dysfunctional beliefs and attitudes about sleep scale, Epworth sleepiness scale. Univariate linear regression analysis was used for prognostic analysis. To identify predictors of treatment outcome after the treatment course and after the 2 weeks follow-up we used multiple linear regression models with interaction.

Results. In the prognostic analysis higher amount of awakenings during the night and a higher proportion of the 1 stage NREM sleep measured objectively correlated with better outcome E=0.2202 (p=0.05) and E=0.55 (p=0.039) respectively. Older age and higher baseline BDI score significantly worsened the outcome: E=0.233 (p=0.047) and E=0.2 (р=1.55e-06) respectively. Clinical predictors of the BBT-I effectiveness were an absence of the sleep onset problems and absence of GABA hypnotics use in medical history and the higher baseline daytime sleepiness.

Conclusion. Neurophysiological (frequency of awakenings, percentage of the sleep stage N1) and clinical (severity of depression, age, daytime sleepiness) predictors of the effectiveness of BBT-I were revealed. This findings will help to select the patients who should undergo a shortened course of CBT-I.

Consilium Medicum. 2021;23(11):818-824
pages 818-824 views

Sleep disorders in patients with COVID-19

Samushiya M.A., Mironova N.V., Poluektov M.G.


Sleep disorders often accompany COVID-19 and are a part of post-COVID syndrome. Some of the sleep disorders that occur in patients hospitalized for COVID-19 can be attributed to acute forms of insomnia. This type of sleep disorders is due to special conditions associated with hospitalization, and is short-term. Other sleep disorders appear as a part of anxiety-depressive symptoms diagnosed in patients with COVID-19. These symptoms can be classified as nosogenies – psychogenic disorders that are associated with diagnosis of coronavirus infection; somatogenies – psychopathological conditions resulting from pathological effects on the central nervous system of somatic and neurological complications of COVID-19; iatrogenies – mental disorders that occur due to the intake of medication. Currently, information on the impact of sleep quality on the severity of COVID-19 and the effectiveness of treatment for post-COVID syndrome is accumulating. This review provides up-to-date information on sleep disorders in patients with COVID-19 and the principles of their therapy.

Consilium Medicum. 2021;23(11):825-828
pages 825-828 views

Issues of optimization of management of patients with discogenic lumbosacral radiculopathy

Prokopovich V.S., Parfenov V.A.


Background. Discogenic lumbosacral radiculopathy (DLSR) is less common than lumbar musculoskeletal pain, but more often accompanied by a long disabilities. To improve patient management with DLSR, the study of conservative and surgical management of patients in real clinical practice is required.

Aim. Optimization of patient management aimed at surgical treatment.

Materials and methods. Surgical treatment (microdiskectomy) due to the ineffectiveness of conservative DLSR was suffered by 90 patients (33 men, 57 women, average age – 59.78±12 years). The duration of the disease to operation ranged from 2 to 14 weeks and was an average of 6±3 weeks. The intensity of pain was evaluated on a visual analog scale (VAS), disability on Oswestry Disability Index (ODI) and Roland–Morris Disability Questionnaire (RMDQ) before the operation, after 10 days, 1, 3 and 6 months after surgery.

Results. Patients were not informed about the favorable course of the DLSR, the possibilities of natural (without surgical intervention) of the regression of the disk hernia, as well as expediency to maintain all types of activity, avoid a long bed mode. After microdiskectomy after 10 days, significant reliable (p≤0.01) decrease in pain with 7 (95% confidence interval – CI 7–8) to 4 (95% CI 3–4) points for VAS and reduction of disability with 13 (95% CI 12–16) to 9 (95% CI 7–11) RMDQ points, from 63 (95% CI 61–65) to 32 (95% CI 30–34) % by ODI. After 1, 3 and 6 months, a further decrease in pain was observed [6 months to 3 (95% CI 2–3) points for VAS] and a decrease in disability [6 months to 5 (95% CI 4–7) points for RMDQ and up to 18 (95% CI 17–19) % on ODI]. To reduce the intensity of pain 6 months after the operation, it was significantly (p≤0.05) influenced the initial intensity of pain according to VAS and conducting kinesitherapy after the operation. To reduce the disability in RMDQ after 6 months, the initial disability in RMDQ and the conduct of kinesitherapy after surgery was significantly (p≤0.05) influenced.

Conclusion. Patients with DLSR should be informed about the favorable course of the disease, the possibilities of natural (without surgical intervention) of the regression of the disc hernia; after performing surgical treatment, it is advisable to the kinesitherapy, capable of improving the functional recovery of patients.

Consilium Medicum. 2021;23(11):829-833
pages 829-833 views

The possibilities of using topical nonsteroidal anti-inflammatory drugs in the complex pain syndrome therapy of musculoskeletal system diseases

Shavlovskaya O.A., Bokova I.A., Shavlovskiy N.I.


Diseases of the peripheral joints (osteoarthritis – OA) and the spine are the most common pathology among other chronic conditions. One of the most common diseases characterized by degenerative periarticular changes with various clinical manifestations is periarthritis. Unlike OA, periarthritis is characterized by a discrepancy between active and passive movements, increased pain during strictly defined movements, the absence of joint swelling or local swelling in the projection of the affected tendon. As the basic therapy of OA (step 1), it is recommended to prescribe locally nonsteroidal anti-inflammatory drugs (NSAIDs), as drugs with less systemic adverse effects. Local NSAIDs have a sufficient analgesic effect in knee joints OA. Among topical NSAIDs for reducing pain in knee joints OA and periarticular tissues, diclofenac gel (Voltaren Emulgel 2%) is approved for use, the effectiveness of which has been demonstrated in many studies. To achieve maximum effect, the gel is applied according to the instructions for use of the drug: 2 ml on the anterior, posterior and lateral surfaces of the knee 2 times a day (every 12 hours) for 4 weeks.

Consilium Medicum. 2021;23(11):834-840
pages 834-840 views

Treatment of painful diabetic neuropathy

Parfenov V.A., Konyashova M.V.


Painful diabetic neuropathy is observed in almost half of patients with diabetes mellitus (DM) and is associated with a decrease in the quality of life, emotional disorders, sleep disorders. The achievement and maintenance of the normal level of glucose in the blood is the basis for the prevention and treatment of DM, but this often does not allow the patient from pain and other clinical manifestations of neuropathy. Drug diabetic neuropathy therapy methods are discussed, the results of randomized placebo controlled studies on the efficiency and side effects of various drugs are analyzed. It is noted that pregabalin and gabapenitin, as antidepressants – duloxetin, venlafaxin and amitriptyline, are most effective as anti-epileptic agents. In our country, with painful diabetic neuropathy, the preparations of a-lipoic acid are widely used. Analyzed data on efficacy and complications of the use of transcutaneus electrical nerves stimulation and spinal cord stimulation with pain diabetic neuropathy refractory to drug therapy. It is noted that many patients with pain diabetic neuropathy have combined diseases, detection and effective treatment of which can lead to an improvement in the state of patients and reduce the manifestations of neuropathy.

Consilium Medicum. 2021;23(11):841-846
pages 841-846 views

Abuse of medications for the treatment of migraines: results of an online survey

Koval'chuk N.A., Shagbazian A.E., Tabeeva G.R.


Background. The abuse of headache medications is an important factor in the formation of drug-induced headache.

Aim. To determine the prevalence and nature of drug use among patients with migraine and chronic cephalgic syndrome.

Materials and methods. An Internet survey was conducted among 1598 Internet users, as well as through social networks (Instagram, Facebook, VK) using Google Forms.

Results. 60% of respondents with chronic headache and migraine symptoms did not have a reliable diagnosis. More than 70% of patients choose a drug for pain relief on their own and 62.7% take the drug in every headache attack.

Conclusion. Among patients with chronic headaches and migraines, there is a high percentage of people abusing symptomatic drugs, which indicates a high risk of drug-induced headache formation.

Consilium Medicum. 2021;23(11):847-851
pages 847-851 views

Treatment of chronic migraine and neck pain with cognitive-behavioral therapy. Case report

Golovacheva V.A., Golovacheva A.A.


The article presents a case of a patient with chronic migraine, neck pain, drug-induced headache and generalized anxiety disorder. We analyzed the relationship between migraines and neck pain. The article discusses the interdisciplinary treatment of chronic migraine, which included educational conversation, detoxification therapy, rational relief of migraine attacks, preventive pharmacotherapy and cognitive-behavioral therapy. The latter allowed to change the patient's perception of the disease, reduce anxiety and catastrophization of pain, cope with fears, stop taking benzodiazepines, reduce the intake of pain relievers, and increase daily activity and productivity at work. Clinical efficacy (reduction in the frequency of headaches per month by 50% or more) was achieved after 3 months of treatment. Long-term (12 months) follow-up of the patient showed long-term clinical effect of the interdisciplinary treatment.

Consilium Medicum. 2021;23(11):852-857
pages 852-857 views

Vitamin D deficiency in benign paroxysmal positional vertigo

Bedenko A.S., Antonenko L.M.


Aim. To assess the level of vitamin D (D3) in patients with benign paroxysmal positional vertigo (BPPV).

Materials and methods. The study included 25 patients. The control group consisted of 30 people, comparable in age with the main group, without BPPV. All patients included in the study underwent a standard examination of the vestibular sphere, which compised the Head impulse test, the Fukuda test, the Shaking test, the Dix–Holpike and Maclura–Pagnini test. Hydroxyvitamin D levels were analyzed by enzyme immunoassay. In the study of the psychological sphere, the following questionnaires were used: Dizziness Handicap Inventory, Beck Depression Scale, Spielberger–Khanin Anxiety Scale, TAS-26 alexithymia scale.

Results. The average level of hydroxyvitamin D among patients was 19.65±8.6 ng/ml, which corresponds to a deficiency of vitamin D, in the control group, vitamin D3 was within the reference values (30–100 ng/ml) and amounted to 33.78±10.7 ng/ml (p<0.001). There is a negative correlation between the level of hydroxyvitamin D and the age of the patients. There is a correlation (Spearman's criterion -0.463254, p<0.001) between the frequency of recurrence of BPPV and a decrease in the level of hydroxyvitamin D.

Conclusion. Vitamin D deficiency prevails among patients with BPPV.

Consilium Medicum. 2021;23(11):858-861
pages 858-861 views

Tardive dyskinesia

Tolmacheva V.A.


Tardive dyskinesia is a group of hyperkinetic and hypokinetic movement disorders, following the administration of dopamine receptor-blocking drugs. The severity of these syndromes varies from soft forms to the development of life-degrading situations. Phenomenologically tardive dyskinesia can be represented both in isolation and in various combinations. Recognition of these syndromes early in the development of tardive dyskinesia can optimize therapeutic treatment and reduce the risk of severe complications. As a means of treatment, deutetrabenazine or valbenazine are used as first-line drugs, with resistance to therapy and in severe cases, drugs of other groups are used (amantadine, baclofen, botulinum toxin type A, clonazepam, donepezil, gabapentin, ginkgo biloba, levetiracetam, melatonin, pregabalin, thiamine, verapamil, vitamin B6, vitamin E). Our own experience of 12 patients with tardive dystonia showed the effeciency of local injections of botulinum toxin.

Consilium Medicum. 2021;23(11):862-866
pages 862-866 views

The experience of comprehensive rehabilitation of a patient after a stroke with moya-moya disease. Case report

Slyunkova E.V., Kondur A.A.


The article describes a clinical case of neurorehabilitation with a multimodal approach of a young patient with repeated ischemic strokes against the background of a rare chronic progressive cerebrovascular disease – moya-moya disease. The multimodal approach consisted in the use of high-tech complexes with biofeedback, such as a stabilometric platform for visual and support reactions, cognitive training using computer technologies, as well as mirror therapy, physiotherapy procedures and physical therapy, including physiotherapy exercises and individual targeted training with paretic limbs. In accordance with the clinical scales used, convincing data were obtained on the effectiveness of the selected complex of rehabilitation measures.

Consilium Medicum. 2021;23(11):867-872
pages 867-872 views

Questions of effective treatment of fibromyalgia. Case report

Nasonova T.I., Romanov D.V., Isaykin A.I.


A clinical case of effective treatment of fibromyalgia in a 58-year-old patient by an interdisciplinary team of neurologists and a psychiatrist-psychotherapist is presented. For 5 years before being hospitalized at the Sechenov First Moscow State Medical University (Sechenov University) Clinic of Nervous System Diseases, a patient suffering from widespread chronic pain in the back and extremities was not diagnosed with fibromyalgia, she underwent numerous expensive examinations and various methods of therapy that were not effective, worsened her condition and increased the intensity of the pain syndrome. The establishment of fibromyalgia, the identification of concomitant mental disorders, allowed the use of pharmacotherapy and non-pharmacological methods of treatment (cognitive behavioral therapy, kinesiotherapy), which led to a persistent improvement in the condition, a decrease in pain syndrome during 6 months of follow-up.

Consilium Medicum. 2021;23(11):874-878
pages 874-878 views

Parsonage–Turner recurrent acute idiopatic neuralgic amyotrophy case. Case report

Kovrazhkina E.A., Abramova T.A., Serdyuk A.V., Lelyuk V.G.


Recurrent Parsonage–Turner syndrome is a hereditary form of a syndrome from neuralgic amyotrophic group, with a characteristic clinical picture in the form of severe pain syndrome with remission and subsequent development of upper shoulder girdle atrophy, proceeding with the accumulation of neurological deficit. Despite the characteristic clinical picture, the syndrome requires a differential diagnosis with a number of conditions, in which electroneuromyography helps along with other techniques. Wherein neuropathic sings of the upper extremity nerves are usually detected, and the long thoracic and suprascapular nerves are most often affected, at that more often by axonopathic type. Electromyography reveals denervation sings in the upper brachial muscles. This article describes Parsonage–Turner recurrent acute neuralgic amyotrophy case, discusses the issues of the clinical picture, diagnosis and treatment of this disease.

Consilium Medicum. 2021;23(11):879-883
pages 879-883 views

Opticoneuromyelitis associated with melanoma. Case report

Gudkova V.V., Kimelfeld E.I., Paderina V.P., Koshurnikov D.S., Ulianov D.I., Ermakov D.S., Maliutina N.A.


This article presents a clinical review of a patient with an extremely rare assotiation of opticoneuromyelitis and skin melanoma. The paper noted the typical clinical and neuroimaging signs of opticoneuromyelitis and the rare manifestations of myelitic syndrome such as segmental muscle hypertonicity and hand hyperkinesis. The question remains open as to whether these two processes in a patient are linked by a single pathogenesis in the form of a paraneoplastic neurological syndrome or whether two independent diseases are represent there. Two observations of a combination of melanoma and opticoneuromyelitis as a manifestation of the paraneoplastic syndrome have been analysed in the literature. The article highlights the difficulties in the treatment of this patient, as the immunomodulatory therapy used for both diseases has a different vectorial focus. Immunosuppression is recommended for the treatment of opticoneuromyelitis, while immune activation is recommended for melanoma.

Consilium Medicum. 2021;23(11):884-890
pages 884-890 views

Facial nerve lesion as a complication of cryodestruction for facial basal cell carcinoma

Ognerubov N.A.


Background. Skin cancer is the most common malignant neoplasm which represents an important problem for modern health care. Published data show that the incidence is increasing over the past 50 years; by 3–10% annually. The prevalence of skin cancer depends on a number of factors: genetic, environmental influences, age, profession. Treatment options for basal cell skin cancer include surgery, radiation therapy, photodynamic therapy, local chemotherapy and immunotherapy, radio wave therapy, cryosurgery, laser therapy, and targeted therapy. Among them, cryosurgery is an effective, technically simple and inexpensive method of treatment available on an outpatient basis for a number of benign, precancerous and malignant skin tumors. However, the use of cryosurgery is accompanied by various complications.

Aim. To present a case of iatrogenic damage to facial nerve during cryosurgery for facial basal cell carcinoma.

Materials and methods. A 69-year-old patient who, in April 2019, was diagnosed with skin cancer of the left parotid region, stage I cT1N0M0, nodal variant at the regional oncological dispensary. Cytology showed basal cell carcinoma. The tumor, 1.6×2 cm in size, was located at the level of the earlobe. Cryodestruction was carried out by double freezing for 30 s, the thawing time was 60 s. During treatment and 7 days after treatment, the patient noted a sharp pain in the area of intervention, so he took analgesics. On the 8th day, the asymmetry of the face on the left, the drooping mouth and the inability to cover the eyes. The patient consulted a neurologist, he was diagnosed with facial nerve lesion on the left. For this disorder, the patient received conservative inpatient and outpatient treatment for a long time (several months), as a result of which some improvement was observed.

Results. Complete functional recovery did not occur. The wound healed under a scab, with oozing, for 8 weeks. A follow-up examination in April 2021 revealed a local recurrence in the area of the scar, and a cytological examination revealed a basal cell carcinoma.

Conclusion. This case indicates a possible risk of damage to the facial nerve at the site of its exit on the face during cryosurgical treatment for skin cancer in this area. When choosing a method of treatment, attention should be paid to the localization of the tumor, given critical anatomical zones.

Consilium Medicum. 2021;23(11):891-896
pages 891-896 views

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