Vol 12, No 3 (2018)

Original articles

Healthcare system for patients with stroke in Russia. Results of 10-years implementation of the measures aimed at improvement of medical care for patients with acute cerebrovascular events

Skvortsova V.I., Shetova I.M., Kakorina E.P., Kamkin E.G., Boyko E.L., Dashyan V.G., Krylov V.V.

Abstract

The implementation of measures aimed to improve medical care for patients with acute cerebrovascular accidents in the Russian Federation has made it possible to establish a unified healthcare system for patients with stroke, to provide regional vascular centers with modern equipment, to train medical personnel, to introduce modern effective methods of treatment of acute cerebrovascular accidents-thrombolytic therapy and thrombus extraction. The extent of operative treatment of brain aneurysms and hemorrhagic stroke increased more than 7 times. A positive experience has been gained in the arrangement of medical care for a patient with acute cerebrovascular accident at the pre-hospital stage. Measures for reduction of mortality from the main causes are being monitored, and a geo-information map embracing the main statistical parameters of each region is uploaded into the healthcare unified state information system. In the period of 2005–2016, the death rate from cerebrovascular diseases decreased by more than 40%, including 41% reduction of the death rate from stroke.
Annals of Clinical and Experimental Neurology. 2018;12(3):
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Сlinical and instrumental evaluation of vertebral arteries stenting efficiency in the short-term and long-term postoperative periods

Сhechetkin A.O., Skrylev S.I., Koshcheev A.Y., Shchipakin V.L., Krasnikov A.V., Tanashyan M.M., Maksimova M.Y.

Abstract

Objective: to evaluate the effectiveness of transluminal angioplasty with stenting in the treatment of atherosclerotic stenosis of the vertebral arteries (VA) proximal segment.

Materials and methods. One hundred twenty-seven patients (97 men and 30 women, mean age 60 years) with symptomatic (72% of patients) and asymptomatic (28% of patients) stenosis of the VA were examined, the degree of stenosis according to X-ray angiography was 76±11%. One hundred fifteen (91%) patients with 127 (91%) implanted stents were surveyed over time (average follow-up time 13 months).

Results. Technical success was achieved in 94% of cases. In the perioperative period, no acute cerebrovascular events, myocardial infarctions or deaths were registered. Recurrence of symptoms of vertebrobasilar insufficiency was noted in 14% initially symptomatic patients. According to ultrasound study data, restenosis ≥50% or reocclusion of the VA stent was detected in 40% cases. Damage to the integrity of the stent was diagnosed in 8% cases, which in all observations was combined with restenosis. Repeated derangement of stent patency after restenting of 11 VA in the period of 4–6 months was revealed in 60% of cases (2 reocclusions and 4 restenoses).

Conclusion. Angioplasty with stenting is a safe and clinically effective method for treating atherosclerotic stenosis of the proximal segment of VA. In a cohort of 50 patients included in the study, low quality of life was observed prior to stenting of VA. Six months after the VA stenting, the quality of life of patients increasesin both physical and psychological aspects. The main problem remains to be a high incidence of  restenosis or reocclusion of stents after primary and repeated endovascular intervention in the long-term postoperative period.

Annals of Clinical and Experimental Neurology. 2018;12(3):
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The role of personality disorders in the management of patients with pharmacoresistant epilepsy after neurosurgical resections

Narodova E.A., Schneider N.A., Narodov A.A., Dmitrenko D.V., Strotskaya I.G., Moskaleva P.V.

Abstract

The review focuses on the problem of personality disorders that arise in patients with pharmaco-resistant epilepsy after neurosurgical resections. We analyzed 47 research articles, selected by keywords from Russian and international databases for 2010–2017. It was found that, despite the achievements in epilepsy surgery and the high percentage of remission in the postoperative period, the problem of personality disorders remains important. The most frequent postoperative personality disorders are anxiety and depression, which greatly exacerbate the course of the postoperative period and make it difficult for the patient to adapt in society because of his internal stigmatization. In addition, depression can provoke the aggravation of epileptic seizures in the postoperative period. Psychiatric anamnesis and a severe form of depression in the preoperative period are the powerful predictors of the depression onset in the postoperative period. Despite this, there are no psychiatric contraindications to the surgical treatment of pharmaco-resistant epilepsy. The authors discuss the need for perioperative psychiatric testing of patients suffering from epilepsy.

Annals of Clinical and Experimental Neurology. 2018;12(3):
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New approaches to correction of cognitive impairment in cerebrovascular diseases

Tanashyan M.М., Konovalov R.N., Lagoda O.V.

Abstract

Introduction. The problem of cognitive impairment of vascular genesis takes an important place in modern angioneurology. Verification of changes occurring in the brain is carried out with the help of neuroimaging methods; and functional magnetic resonance imaging (fMRI) may reveal the main points of pharmacological activity of drugs with the declared neurometabolic effect with a greater probability.

Objective. Objectivization of the effect of basic angioneurological drugs on the cognitive sphere in patients with chronic cerebrovascular diseases.

Materials and methods. A detailed analysis of the neuropsychological sphere (cognitive tests) and neuroimaging results by studying a pharmacological fMRI of the brain with a cognitive paradigm was carried out for 154 patients with discirculatory encephalopathy.

Results. Despite similar clinical indications for the use of vinpocetine (cavinton), cortexin, cerebrolysin, and actovegin, the mechanism of their action at the cellular level, identified with fMRI, was different. The vasoactive and antiplatelet clinical effect of vinpocetine is supplemented with new data on the improvement of cerebral neuroplasticity due to the expansion of the activation zones and intensification of the signal intensity from them, as well as the emergence of new activation zones in the projection of associative fibers. Cerebrolysin and cortexin with a neurotrophic effect lead to a narrowing of the activation zones, both of the main cognitive zones and of the associative regions, which may indicate a decrease in brain energy expenditure during the cognitive loads. Given protective function of drugs appears in a positive cerebroprotective effect. During treatment with actovegin, fMRI revealed a primary increase in activation of the hippocampal brain zones responsible for improving cognitive functions, which reveals the polymodal effect of the drug, with neuroprotective action among the others.

Conclusions. The use of pharmacological fMRI together with a complex clinical and laboratory studies allows us to discover new aspects of the effect of drugs and to justify the need for a personalized approach in the treatment of cognitive impairment.

Annals of Clinical and Experimental Neurology. 2018;12(3):
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Analysis of the factors limiting reperfusion therapy in patients with ischemic strokes

Maslova N.N., Miloserdov M.A.

Abstract

Introduction. Systemic thrombolytic therapy with recombinant tissue plasminogen activator is the only reperfusion method available to most primary vascular units which allows significantly improving the functional prognosis of patients with ischemic stroke.

Objective. To analyze the main determinants limiting reperfusion therapy administration in a subsidized region with demographic aging of the population, and to develop and scientifically justify the ways of their elimination.

Materials and methods. We analyzed the data of the ambulance station in Smolensk electronic archive accounting for 17,143 phone requests for medical aid for patients with strokes, the data from the annual report of the neurological department for patients with acute cerebrovascular accident of the Clinical emergency care hospital, and 200 clinical records of patients diagnosed with acute stroke that were delivered to the in-patient facility by emergency medical service (EMS) teams in the period of the "therapeutic window" and who did not receive reperfusion therapy. The operative work of the dispatcher service, the efficiency of the mobile teams work, the structure of time losses during the call service, and the distribution of patients by the time period before the admission to a hospital depending on the way of admission and the remoteness of the "zone of responsibility" from the primary vascular surgery department were assessed.

Results. It was found that statistically significant differences in time period before admission to a hospital of patients with ischemic strokes depend on the admission way and, in the case of arrival by the EMC, do not depend on the distance of the delivery area. The low efficiency of the mobile teams is due to the imperfection of call processing by dispatchers and the lack of a systematic approach and a single algorithm aimed for diagnosing and providing emergency assistance to the medical personnel of EMS teams. The main non-regulating factors for abandoning systemic administration of the recombinant tissue plasminogen activator in patients with ischemic strokes delivered to the hospital in the period of the "therapeutic window" are mild neurological symptoms, the age over 80 years and poly-morbidity of patients.

Conclusion. It is necessary to adopt a series of measures aimed at advancing the efficiency of the EMS teams and rising awareness within the general public in order to reduce mortality of patients with ischemic strokes through increasing frequency of reperfusion therapy administration.

Annals of Clinical and Experimental Neurology. 2018;12(3):
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Comparison of effects and electrophysiological mechanisms of action of valproic acid and levetyracetam in an experimental model of focal epilepsy

Litvinova S.A., Avakyan G.G., Voronina T.А., Gaidukov I.O., Nerobkova L.N., Kutepova I.S., Avakyan G.N.

Abstract

Introduction. Despite rapid development of the antiepileptic pharmaceuticals market, about 2/3 of patients suffering from epilepsy do not receive adequate treatment, which is partly due to the variety of mechanisms for the development of epileptic seizures

Objective. А comparative study of the electrophysiological mechanisms of action and effects of valproic acid (Depakin Chrono) and levetiracetam (Levetinol) under experimental focal epilepsy and status epilepticus (SE) in rats.

Materials and methods. Focal chronic epilepsy was caused by the application of cobalt to the sensorimotor cortex. On the 7th–8th day, SE was modeled by the injection of homocysteine, which provoked the development of secondary generalized tonic-clonic seizures.

Results. Levetiracetam had a suppressing effect on the paroxysmal activity of the rat brain only under conditions of a stable SE on the 5th–6th day after the application of cobalt. Its most prominant effect was seen in the hippocampus and was characterized by a significant decrease in epileptic activity (EpiA) in this structure and in the maintenance of a regular rhythm. Valproic acid significantly suppressed EpiA in the ipsilateral cortex, hippocampus and hypothalamus at a stable stage of EpiS development, with the most pronounced effect on the primary cortical focus and hypothalamus. In the model of SE caused by the injection of homocysteine, levetiracetam was ineffective, whereas valproic acid decreased the severity of paroxysmal activity in all the studied structures, especially in the cortex (ipsi- and contralateral, 33 times) and hypothalamus (28 times), which was accompanied by suppression of generalized motor manifestations and reduced number of animal deaths.

Conclusion. In the model of focal cobalt-induced epilepsy, the hippocampus is the leading structure and the target of the levetiracetam action, while the effect of valroic acid is executed through the inhibitory effect on the cortical foci of EpiA and the hypothalamus, which may be main feature in its ability to suppress the SE.
Annals of Clinical and Experimental Neurology. 2018;12(3):
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Theoretical basis for classical methods of motor rehabilitation in neurology

Ustinova K.I., Chernikova L.A., Khizhnikova A.E., Poydasheva A.G., Suponeva N.A., Piradov M.A.

Abstract

Authors review the milestones of the historical formation of various theories of motor control, from the reflex to the system model. These theories form the basis forь the methods and approaches of motor rehabilitation of patients with neurological diseases and injuries. The task-oriented approach, based on systemic theories of motor control, is now generally accepted. One of its main fundamentals is the dependence of movement on parameters and conditions of the motor under performance.

Rehabilitation methods and approaches presented in this paper are not mutually exclusive, but supportive. This is the reason why the study of effectiveness of a particular rehabilitation method does not always yield valuable results. Various rehabilitation methods and approaches should be combined in the treatment of neurological patients. Moreover, relative contribution of individual methods into the rehabilitation of each patient may vary depending on the safety of his or her motor functions and many other factors that are to be taken into account when planning rehabilitative activities.

Annals of Clinical and Experimental Neurology. 2018;12(3):
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Surgical methods of treatment of back pain syndrome recurrence in the degenerative pathology of the lumbar spine

Shnyakin P.G., Botov A.V., Amelchenko A.A.

Abstract

The number of surgical interventions on the lumbar spine is constantly growing due to the emergence of new surgical techniques aimed at treatment of degenerative spine pathology and a large number of patients, suffering from the back pain. Quite often, surgical intervention turns to be not effective enough and the pain syndrome persists, leading to the necessity for the repeated revision surgeries with the use of stabilizing systems. The review represents research data on the causes of recurrent-remitting course of degenerative process, problems of epidural adhesion as one of the back pain syndrome predictors, the survey of various stabilization systems and operative approaches for their implantation. The disadvantages and advantages of ventral approach with the use of interbody fusion are summarized in comparison with dorsal approach used for the installation of the transpedicular system and interbody fusion with a bone graft.

The positive features of interbody fusion from anterior retroperitoneal approach include the ability to quickly and completely remove the entire disc, decompress the dural sac without entering the vertebral canal, optimally select an implant corresponding to the size of the vertebral end plates, creation of the optimal lordosis angle, and provision of the shortest approach to the operated disk and to the place of neural structures compression.

The advantages of the dorsal approach with transpedicular system implantation and interbody fusion with a bone graft are better visualization of neural structures in comparison with discectomy from the ventral approach, the possibility of wide decompression and expansion of the extent of operation, the possibility of ablation of the facet joints by diathermocoagulation after the surgical wound was made, the reliability of posterior fixation, and familial approaches for a neurosurgeon with a lesser duration of training.

Annals of Clinical and Experimental Neurology. 2018;12(3):
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Optical coherent tomography capabilities in the diagnosis of demyelinating diseases of the central nervous system

Polekhina N.V., Surnina Z.V., Zakharova M.N.

Abstract

Optical coherence tomography (OCT) is a non-invasive technique routinely used for obtaining in vivo transverse images of tissues. In the field of neurology, OCT is used to assess retinal changes in various diseases, including multiple sclerosis, opticomyelitis, and opticomyelitis-associated disorders. In these demyelinating diseases, the pathological process involves not only the optic nerve itself, but also the retinal ganglion cells and their axons, the so-called retinal ganglionic complex, as well as the retinal nerve fiber layer. In the last decade, OCT as the method capable of assessing changes in the above-mentioned retinal layers has been applied as a highly sensitive technology for estimation of neurodegenerative process. The article discusses the possible use of OCT for differential diagnosis of demyelinating diseases of the central nervous system, as well as its application as a method for monitoring involvement of the nervous tissue in demyelinating diseases.

Annals of Clinical and Experimental Neurology. 2018;12(3):
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Levamisol-induced leukoencephalopathy: clinical case

Shavlovskaya O.A.

Abstract

This is a description of a clinical case of levamisole-induced leukoencephalopathy. A few hours after the single intake of the immunomodulator levamisole (150 mg), the patient developed following cerebral symptoms: febrile fever, dizziness, frequent urination, impaired color vision, divergent strabismus, unsteady gait, severe weakness, increased drowsiness, retardation, delusions. The symptoms progressed towards a full clinical picture for about 2 months. The course of the disease was of a wavy nature: left-sided hemiparesis and the left facial nerve palsy were present at the beginning, with later inversion of symptoms represented by the right-sided hemiparesis and the right facial nerve palsy combined with dysarthria. Magnetic resonance imaging (MRI) revealed multiple foci of demyelination in both hemispheres of the brain that regressed after corticosteroid therapy administration. No abnormalities of the cerebrospinal fluid were detected. No pathology of the fundus was evident. The evoked potentials of the brainstem (auditory and visual) and somatosensory evoked potentials from the hands and feet were within normal limits. Plasmapheresis (3 procedures, each 2 liter, with intravenous administration of 1 g of solu-medrol after each session) was performed in the acute phase, which benefited the decrease in severity of the neurological symptoms. Vascular and metabolic therapy was performed afterwards, with the regression of the neurologic symptoms. No specific therapy was administered after the woman was discharged from the hospital. For a 10-year survey after the acute demyelinating process outbreak there’s a complete regression of neurologic symptoms and positive dynamics of the patient’s MRI. The woman is fully adapted physically, emotionally and socially.

Annals of Clinical and Experimental Neurology. 2018;12(3):
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Critical neurological conditions: severe toxic polyneuropathy with the development of respiratory failure and rhabdomyolysis

Ryabinkina Y.V., Zakharova M.N., Polishchuk R.V., Luneva I.E., Pavlov E.V., Piradov M.A.

Abstract

This is a description of the clinical case of severe toxic polyneuropathy in a 52-year-old man, caused by a confirmed exogenous intoxication with amphetamine.

The clinical picture was remarkable for muscle weakness in different muscle groups: neck, back, arms and legs, respiratory muscles; as well as for the respiratory failure (requiring mechanical ventilation), rhabdomyolysis, mild nephropathy, liver cytolysis. A differential diagnosis was made between myasthenia gravis, myopathy, amyotrophic lateral sclerosis. After a course of intensive therapy, almost complete regression of symptoms took place, as well as the improvement of electroneuromyographic pattern. Taking into account a rapid partial regression of symptoms in the course of the disease, as well as the results of a neurophysiological study, an immunochromatographic urine drug screen was performed, positive for amphetamine. This clinical case demonstrates "rare" complications of amphetamine use to be kept in mind during a diagnostic search.

Annals of Clinical and Experimental Neurology. 2018;12(3):
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