Current neuroprotective agents in stroke

What is expected from neuroprotection is to inhibit neuronal death and halt or decelerate the neuronal loss to lower the mortality rates, decrease disability, and improve the quality of life following an acute ischemic stroke. Several agents were described as neuroprotective up to date; however, there is still debate which to use in the neurorehabilitation of stroke patients, in terms of both efficacy and also safety. In this review, we discuss the agents, citicoline, cerebrolysin and MLC901 (NeuroAiD II), the three agents which have started to be used frequently in neurorehabilitation clinics recently in the light of the current literature.

Efficacy, safety, and cost-effectiveness analysis of Cerebrolysin in acute ischemic stroke: A rapid health technology assessment

This study conducts a rapid health technology assessment to systematically evaluate the effectiveness, safety, and cost-effectiveness of Cerebrolysin as an adjunctive therapy for acute ischemic stroke to provide evidence-based medicine for clinical decisions of Cerebrolysin. All systematic reviews/meta-analyses, pharmacoeconomic studies, and health technology assessment reports of Cerebrolysin for the treatment of acute ischemic stroke before August 17, 2023, were retrieved from PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, Wanfang, Weipu, Sinomed database and the official website of health technology assessment. According to the inclusion and exclusion criteria, 2 researchers independently carried out screening, data extraction, and quality evaluation and descriptively analyzed the results of the included studies. A total of 14 pieces of literature were incorporated, comprising 8 systematic reviews/meta-analyses and 6 pharmacoeconomic studies. In terms of effectiveness, compared to control groups, the use of Cerebrolysin as a treatment for acute ischemic stroke demonstrates certain advantages, including enhancement in total efficacy rate, neurological function, upper limb motor dysfunction, and facilitation of the recovery of activities of daily living. Especially in patients with moderate to severe acute ischemic stroke, Cerebrolysin has demonstrated the ability to enhance neurological function recovery and ameliorate disabilities. Regarding safety, adverse reactions were mild or comparable to those in the control group. The primary findings of economic studies reveal that advocating for the use of Cerebrolysin offers certain cost-effectiveness advantages. Cerebrolysin contributes to improved clinical efficacy and evaluation indexes while demonstrating favorable safety and economic benefits.

[Algorithms for the diagnosis and treatment of cognitive impairment and dysphagia in stroke patients]

Stroke is a socially significant neurological disease, the second most common cause of disability and mortality. A wide range of neurological problems that occur after stroke: cognitive, motor, speech, and language disfunction, neuropsychiatric, swallowing disorders and others, complicate rehabilitation, impair social and everyday adaptation, and reduce the quality of life of patients and their caregivers. Cognitive impairment (CI) is one of the most significant and common complications of stroke. Stroke increases the risk of their development by 5-8 times. Dysphagia is also a common symptom of stroke, the cause of aspiration complications (pneumonia), and nutritional imbalance. It increases the possibility of developing CI and dementia, and contributes to an increase in mortality. Older adults with CI are at a higher risk of developing dysphagia, therefore the early symptoms of dysphagia (presbyphagia) should be diagnosed. In recent years, the connection between CI and dysphagia has been actively studied. It is extremely important to identify CI and swallowing disorders as early as possible in patients both before and at all stages after stroke; as well as to develop combined multidisciplinary protocols for the rehabilitation of patients with these disorders with pharmacological support for the process.

[Cerebrolysin in the treatment of cognitive impairment]

Cognitive impairment is one of the most important problems of modern health care. Currently, according to WHO, more than 55 million people worldwide are living with dementia. Dementia is one of the leading causes of disability and addiction among older people worldwide. Even more significant is the number of patients with mild cognitive impairment who have an increased risk of progression to dementia compared to people of the same age without cognitive impairment. The number of patients with cognitive impairment has also increased due to the consequences of COVID-19. It is necessary to use drugs that not only improve cognitive functions, but also slow down their progression. One of these drugs is cerebrolysin, the effectiveness of which has been confirmed in various types of cognitive impairment. Cerebrolysin, being a preparation from the brain of a pig, belongs to the group of biological drugs. In the production of Cerebrolysin very strict measures are taken to comply with the technology, which ensures the quality and identity of the product from batch to batch. The experience of many years of clinical use of Cerebrolysin testifies not only to its high efficiency, but also to its safety. It should be taken into account that similar substances can be developed in relation to biological products - biosimilars or biosimilars, which can be considered comparable only in case of equivalent pharmacokinetic parameters, efficacy and safety.

[The effect of the start date of cognitive rehabilitation after ischemic stroke on the level of recovery]

OBJECTIVE

The dependence of result of cognitive training in patients who have suffered an ischemic stroke (IS) on the timing of their onset continues to be discussed. The aim was to study the results of cognitive rehabilitation of patients after IS during various periods after it.

MATERIAL AND METHODS

140 patients were examined during complex rehabilitation in terms up to 1, 2-3, 4-6 and 7-12 months after IS, 78 of them received drug support (DS) of rehabilitation with intravenous injections of ampasse. The Montreal Cognitive Assessment (MoCA) and Hospital Anxiety and Depression Scale (HADS) were used to monitor the effectiveness of rehabilitation.

RESULTS

In all subgroups, there was a statistically significant increase in the MoCA score after the course, but number of people with an increase in the score by 1 or more points was highest among those who started the course 3 or more months after the development of IS (p=0.015). Among those who received DS, an increase in the MoCA was noted in 87.2%, in those who did not receive it - 38.7% (p<0.001). There was no statistically significant increase in the severity of anxiety and depression after the course of treatment in any of the subgroups.

CONCLUSION

The used approach of a combination of cognitive, physical rehabilitation and DS proved to be justified for achieving results during a two-week course of inpatient rehabilitation of patients both in the early and late recovery period after IS.

[Features of the patient management with traumatic brain injury]

The aim of our study was to consider features of pathogenesis, diagnosis and therapy of traumatic brain injury (TBI) from the viewpoint of neurologist. The mechanisms of emerging injury of the central nervous system, including neuro-inflammation and oxidative stress in patients with TBI, and correlations between clinical manifestations and severity of TBI are discussed. Special attention is paid to the description of certain TBI consequences, e.g. structural drug-resistant epilepsy and post-traumatic stress disorder. We provide evidence for difficulties and lesser availability of rehabilitation programs to patients with TBI during COVID-19 pandemics. One should mention a need for administration of Mexidol as the antioxidant/antihypoxant drug into complex therapy of TBI in such patients. In the period of COVID-19 pandemics, the role of neurologist in management of TBI patients still increases, especially, at the outpatient treatment stage, and when carrying out therapy and medical rehabilitation programs.

Antiamnestic effect of new nicotinic acid derivatives

Introduction: The search for new drugs for the prevention and treatment of vascular cognitive disorders continues to be a relevant task of pharmacology. In this regard, the aim of this work is to study the antiamnestic effect of five new nicotinic acid derivatives in comparison with the well-known drug mexidol (ethylmethylhydroxypyridine succinate) in animals.

Materials and methods: The experiments were carried out on white male mice using conditioned passive avoidance reflex (CPAR). Electroconvulsive shock (ECS), scopolamine administration, and acute hypoxia in a hermetic chamber were used as amnesic effects. Testing for the safety of CPAR was performed 24 h after amnesic exposure. The new substances, reference drug mexidol, and a 0.9% sodium chloride solution (control group) were administered once intraperitoneally 60 min before mice training.

Results and discussion: Three of the five new nicotinic acid derivatives, LKhT 4-19 (100 mg/kg), LKhT 6-19 (25, 50, and 100 mg/kg), and LKhT 7-19 (100 mg/kg), have antiamnestic properties on models of amnesia in mice induced by ESC, scopolamine, and acute hypoxia in a hermetic chamber. At the same time, the most efficient substance – LKhT 6-19 – exceeds the reference drug mexidol on all three models used. In addition, this compound is also more efficient than two other new compounds, LKhT 4-19 and LKhT 7-19, on the model of ESC-induced amnesia and LKhT 7-19 on the scopolamine-induced amnesia model.

Conclusion: Compound LKhT 6-19 is promising for further advanced preclinical studies as a potential drug with antiamnestic activity.

Graphical abstract:

[Efficacy and safety of treatment with ampasse: the results of a randomized, double-blind, placebo-controlled trial in patients with chronic cerebrovascular disorders]

OBJECTIVE

To assess the efficacy and safety of the drug ampasse in the treatment of patients with chronic cerebrovascular disorders (CCVD).

MATERIALS AND METHODS

A multicenter, randomized, double-blind, placebo-controlled, confirmatory study of the efficacy and safety of ampasse (phase III) was conducted in 124 patients aged 50 to 75 years. The main group (MG) - 62 patients, received the test drug ampasse, solution for intravenous administration, 5 mg/ml, at a dose of 5 ml (25 mg), intravenously bolus slowly, the duration of treatment was 15 days. Control group (CG) - 62 patients, received comparison drug: placebo (0.9% sodium chloride-5 ml).

RESULTS

All 124 patients fully completed the procedures and visits, there were no dropouts from the study. The proportion of patients who reached the primary endpoint (an increase in the score by 2 or more points on the MoCA scale) was 83.87% in MG and 22.58% in CG, that is, the efficacy of therapy in MG was 61.29% higher than in CG (p<0.001), and good tolerability of the drug was proved. The secondary endpoint is an increase in quality of life (QOL) on the SF-36 V2 scale on Day 31. In MG, there was a statistically significant improvement in all indicators of QOL compared to the baseline. When assessing the safety spectrum, the proportion of patients who had adverse events was 14.52% in MG and 8.06% in CG (p=0.395).

CONCLUSION

Ampasse has a positive effect on cognitive functions and QOL, does not increase the frequency of adverse events in patients with CCVD compared to placebo, does not cause significant side effects, and is well tolerated by patients.

[Poststroke motor and cognitive impairments: clinical features and current approaches to rehabilitation]

Stroke is one of the most common neurological diseases with high morbidity, disability and mortality, which is an urgent medical and social problem. Clinically, stroke, depending on its nature and location, causes a wide range of neurological disorders, including movement disorders, as well as a variety of cognitive and neuropsychiatric disorders. There is an emerging need for new approaches to manage patients with cerebrovascular diseases during the pandemic of COVID-19. Rehabilitation measures for the correction of motor and cognitive impairments are very diverse. The use of drugs stimulating the production of neurotrophic factors is considered as a promising direction of pharmacotherapy. Cerebrolysin promotes significant regression of motor and cognitive impairments in the acute and recovery period of ischemic stroke. Based on the data of clinical studies, Cerebrolysin is included in the guidelines for the rehabilitation of patients with stroke in Canada and Germany.