[Long-term results of surgical treatment of patients with cerebral arterial aneurysms]

OBJECTIVE

To study the long-term results of surgical treatment of patients operated on for cerebral aneurysms and their impact on functional recovery, independence and cognitive functions in the long-term period.

MATERIAL AND METHODS

A multivariate regression analysis of long-term results of surgical treatment of 324 patients for cerebral aneurysms was performed (on average after 3.5 years). Upon admission of the patient to the hospital for surgical intervention, a clinical diagnostic examination was performed to confirm the diagnosis and determine the volume, timing and type of intervention. In the late period, a clinical neurological study was performed, which included an assessment of the degree of disability with the Barthel index and a modified Rankin scale, cognitive functions with MMSE, and the mental sphere with HADS.

RESULTS

The severity of the condition at admission, corresponding to grade III-IV according to the Hunt-Hess classification, was the risk factor for an unfavorable prognosis for the recovery of patients in the long-term period of cerebral aneurysm surgery. The severe condition of patients at the onset of the disease increases the risk of disability by 1.9 times (p<0.05) and the risk of dementia by 6 times (p<0.05). An independent risk factor for the development of cognitive impairment is the patient's age: with an increase in age by 1 year, the MMSE score decreases by 0.27 (p<0.05). The prevalence of hemorrhage according to the Fisher classification, corresponding to grade III, is a predictor of the development of angiospasm in 91% of cases. In patients with established angiospasm, the risk of developing dementia and pre-dementia cognitive impairment was 57.3% (p<0.05). The best predictions for recovery of cognitive functions in the long-term period were observed in patients who underwent simultaneous aneurysm clipping with extra-intracranial anastomosis (mean MMSE score 25) compared with patients who underwent only aneurysm clipping (mean score 20), endovascular intervention (average score 21) or microsurgical intervention followed by intrathecal fibrinolytic injection (mean MMSE score of 20) (p<0.05).

CONCLUSION

The predictors of unfavorable recovery of cognitive functions and the development of disability in the long-term period of surgical treatment of cerebral aneurysms were the severity of the condition at admission, corresponding to III-IV st. according to the Hunt-Hess classification, the age of the patient at the time of the intervention, the prevalence of hemorrhage according to Fisher, and the choice of surgical technique.

Experience of Stanford neuromodulation therapy in patients with treatment-resistant depression

Stanford neuromodulation therapy (SNT) is the state-of-the-art magnetic stimulation protocol that has been developed for management of treatment-resistant depression (TRD). The study was aimed to assess the possibility of SNT implementation in clinical practice and to define the protocol safety and efficacy in patients with TRD being an episode of the recurrent depressive disorder or bipolar disorder at the independent center. The study involved six patients (among them three women aged 21–66) with TRD associated with recurrent depression and type 1 or 2 bipolar disorder. The patients received intermittent theta-burst stimulation in accordance with the SNT protocol for five days: applying 10 triple blocks of stimulation daily at intervals of 1 hr between the blocks to the selected stimulation site showing maximum negative functional connectivity with subgenual cingulate cortex within the left dorsolateral prefrontal cortex. The Montgomery–Asberg Depression Rating Scale (MADRS) was used for clinical assessment of the effects, the follow-up period was three months. The improvement of depressive symptoms to the levels characteristic of remission immediately after the SNT completion was observed in five patients (MADRS score ≤10). After three months, two patients still had remission, the condition of three patients met the criteria of mild depressive episode, and one female patient withdrew from the study due to logistical difficulties. No serious adverse events were reported. The findings confirm safety and potentially high efficacy of SNT, including in patients with type 1 and 2 bipolar disorders.

Unsolved Issues of Atherosclerosis Prevention and of Adequate Lipid-lowering Therapy in Patients with Acute Ischemic Cerebrovascular Accident

The existing system of medical care for patients with acute cerebrovascular accident of atherothrombotic genesis, namely lipid metabolism disorders, the modern evidence base for lipid-lowering therapy in this category of patients and the feasibility of interdisciplinary interaction of cardiologists and neurologists were discussed at a meeting of the expert council of cardiologists and neurologists in Moscow on 2021 July 7.

Plasma low molecular weight aminothiols in ischemic stroke patients with type 2 diabetes mellitus

It was found that ischemic stroke (IS) results in decreased levels of a number of reduced forms of low molecular weight aminothiols (LMWTs). The study was aimed to assess the impact of type 2 diabetes mellitus (Т2D) on the total content, reduced forms and redox status of LMWTs in patients with IS. A total of 175 patients with IS in the internal carotid artery basin (the average age was 62 (55–69)) years) were assessed, who were admitted to the Center within the first 10–24 h since the onset of neurological disorder. The index group included 68 patients with IS and T2D (males made up 41.2%). The comparison group consisted of 107 patients with IS and stress hyperglycemia (males made up 57%), and the control group included 31 non-diabetic patients with chronic cerebrovascular disease (CCVD) (males made up 54.8%). The admission plasma levels of LMWTs were assessed by liquid chromatography in all patients. It was found, that IS in patients with T2D was associated with the rapid decrease in total cysteine (tCys), total glutathione (tGSH), total homocysteine (tHcy), reduced glutathione (rGSH), and glutathione redox status (GSH RS), along with the increase in cysteine redox status (Cys RS) and homocysteine redox status (Hcy RS). In contrast to patients with stress hyperglycemia developing during the acute period of IS, patients with T2D had lower tCys, tGSH, and tHcy levels. Thus, GSH RS of 4.06% or lower in the first 24 hours after the IS in patients with T2D was a predictor of poor functional outcome (mRS score was 3 or more 3 weeks after IS).

[Validation of the Russian version of the Fugl-Meyer Assessment of Physical Performance for assessment of patients with post-stroke paresis]

OBJECTIVE

To perform linguistic and cultural adaptation of the Fugl-Meyer Assessment of Physical Performance.

MATERIALS AND METHODS

The study for assessment of psychometric properties included 53 post-stroke patients with neurological deficit presented by hemiparesis of different severity. The patients were assessed twice: at admission and after 14 days of treatment and rehabilitation procedures. The Russian version of the Fugl-Meyer Assessment of Physical Performance was developed with consideration of language and cultural characteristics.

RESULTS AND CONCLUSION

Results of assessment of psychometric properties of the Russian-language version show its high validity, reliability and sensitivity. The developed Russian-language version of Fugl-Meyer Assessment of Physical Performance is recommended for using by neurologists and rehabilitation specialists both in everyday clinical practice and in clinical studies of patients with post-stroke paresis. The results obtained in the study show necessity for pre-training of specialists who perform assessment of patients with post-stroke paresis using the Fugl-Meyer Assessment of Physical Performance.

Effects of virtual reality exergame on psychophysiological and postural disorders in elderly patients

Balance impairment at advanced age is a serious medical problem that often has significant implications and affects the quality of the patient’s life. Among the underlying causes are overall slowness of motor response and vestibular syndrome. Virtual reality exergames, including reaction and balance training, hold promise for managing balance dysfunction. The aim of this study was to investigate the effects of a combination rehabilitation program containing elements of virtual reality exergame on the postural and psychophysiological parameters of elderly patients with small vascular disease The study was conducted in 24 patients with small vascular disease (median age: 66 years). All patients underwent a virtual reality rehabilitation program. Psychophysiological, postural and clinical evaluations were performed at baseline and after the program was completed. Balance function measured on the Berg scale improved significantly and was 53 [52; 55] after the training program vs 50 [45; 54] at baseline (p < 0.05). The strategy of balance control also changed: the Romberg ratio was 266 [199.5; 478.5] before rehabilitation and 221 [149.25; 404] after the program was completed (p < 0.05). The most pronounced changes in the measured psychophysiological parameters occurred in the simple audiomotor reaction, which improved from 210 [174.25; 245.5] at baseline to 180.5 [170.5; 208] after rehabilitation (p < 0.05). Thus, the combination balance and reaction virtual reality training is an effective rehabilitation method for advanced-age patients with balance impairment.

Structural and functional biomarkers of efficacy of navigated repetitive transcranial magnetic stimulation in therapy for trigeminal neuralgia

Repetitive transcranial magnetic stimulation (rTMS) is an alternative treatment option for patients with drug-resistant trigeminal neuralgia (TN). However, the effect of rTMS is variable. The aim of this study was to find neuroimaging biomarkers of clinical efficacy of navigated rTMS. Seventeen patients with TN (14 women and 3 men, median age 56 years) received 10 sessions of high-frequency rTMS of the motor cortex contralateral to pain side. The data were analyzed for correlations between functional connectivity (FC), the grey matter (GM) volume and the reduction in pain intensity. Positive correlations were established between the reduction in average pain intensity and GM volume in caudate nuclei in both hemispheres (p(unc) = 0.03), both cerebellar hemispheres (p(unc) = 0.002) and the postcentral gyrus contralateral to pain side (p(unc) = 0.005); between the reduction in peak pain intensity and GM volume in the caudate nucleus contralateral to pain side (p(unc) = 0.04) and the cerebellar hemisphere ipsilateral to pain (p(unc) = 0.03). Significant positive correlations were discovered between the reduction in average pain intensity and FC between the thalamus contralateral to pain side, the postcentral gyrus and the insular operculum (both ipsilateral to pain side; (p(FWE) = 0.018), as well as between the cingulate cortex and the anterior cingulate cortex ipsilateral to pain (p(FWE) = 0.017), between the contralateral subcallosal gyrus and the cerebellar hemisphere ipsilateral to pain (p(FWE) = 0.018). A negative correlation was established for FC between the contralateral putamen and the occipital lobes in both hemispheres (p(FWE) = 0.001). Our findings may spur the development of individual predictors of rTMS efficacy in patients with chronic pain.

[Issues of diagnostic and therapeutic use of transcranial magnetic stimulation in patients with writing cramp]

OBJECTIVE

To study diagnostic and therapeutic values of transcranial magnetic stimulation (TMS) in writing cramp (WC).

MATERIAL AND METHODS

Twelve right-handed patients with WC were enrolled in the study. All patients underwent low-frequency repetitive TMS (rTMS) of the premotor cortex of contralateral to affected hand hemisphere. The clinical efficacy was assessed using the Writer's Cramp Rating Scale (WCRS) and the Medical Outcomes Study-Short Form (MOS-SF-36). Before and after last rTMS session, motor mapping of Abductor pollicis brevis muscle (APB) was performed using navigated TMS (nTMS). Localization, area, and amplitude-weighted area of the APB muscle cortical representations were compared with the healthy controls. After the rTMS course, the dynamics of the studied parameters was assessed.

RESULTS

Ten sessions of low-frequency rTMS of premotor cortex reduced the severity of WS clinical symptoms with a duration of effect of at least 1 month (p<0.05). There was no statistically significant difference between the area and the weighted area of cortical muscle representations between patients and healthy controls or in patients before and after rTMS. When assessing the localization of cortical muscle representations, two trends were noted: in 4 patients, the localization remained stable, with a shift in the center of gravity of less than 4 mm; in the other 8 patients, a shift in the center of mass of more than 5 mm was noted. No significant correlation between the stability of the cortical muscle representations (the magnitude of the shift in the center of gravity) and the improvement on the WCRS were found.

CONCLUSION

The low-frequency rTMS of the premotor cortex of the contralateral to affected hand hemisphere can be used as an adjuvant therapy for WC. The TMS-motor mapping study did not show its diagnostic value.

[Aminothiols in blood plasma at different subtypes of ischemic stroke]

OBJECTIVE

To evaluate the hemostasis of plasma aminothiols in different subtypes of ischemic stroke (IS).

MATERIAL AND METHODS

The study included 177 patients, aged 62 (55-68) years, admitted in the first 8-24 hours since IS onset. The pathogenetic subtype of IS was clarified according to the results of clinical and instrumental examination by the Trial of ORG 10172 in Acute Stroke Treatment criteria. Determination of the total plasma aminothiols levels, their reduced forms and redox status was performed using the ultra-efficient Acquity H-Class UPLC liquid chromatograph (Waters, CSHA).

RESULTS

Large-artery atherosclerosis was diagnosed in 24.3% patients, cardioembolic stroke in 20.3%, lacunar stroke in 55.4%. Significant differences in total levels of cysteine (Cys), glutathione (Gsh) and homocysteine (Hcy) were identified in patients with different IS subtypes. Patients with large-artery atherosclerosis and lacunar stroke showed the highest level of Hcy, patients with cardioembolic stroke had the lowest levels of Cys and Gsh.

CONCLUSION

Total levels of plasma aminothiols are associated with different subtypes of IS.

Effect of robot-assisted gait training on biomechanics of ankle joint in patients with post-stroke hemiparesis

The key factor promoting post-stroke gait disturbances is motor impairment of the ankle joint (AJ) which results in pathological synergies. Robotic devices used for gait training are equipped with hip and knee joint actuators. However, there is no consensus in the literature on their effect on AJ movements. The aim of this study was to investigate the effect of robot-assisted gait training on AJ movements in patients with post-stroke paresis. The study recruited 22 hemispheric stroke survivors. They motor function was assessed using clinical scales and motion capture analysis. All patients received 11 robot-assisted gait training session. After rehabilitation, the total score on the Fugl-Meyer Assessment scale increased from 146.5 to 152 points (p < 0.05); for the lower limb, the score increased from 18 to 20.5 points (p < 0.05). The muscle tone of ankle extensors decreased from 2.5 to 2.0 points on the modified Ashworth scale (p < 0.05). The duration of the stance phase increased from 28.0 to 33.5% relative to the total gait cycle (GC). The main difference in the GC structure before and after rehabilitation is the presence of 3 GC parts instead of 5, suggesting consolidation of patients’ goniograms at 1-61% of GC. Comparison of joint angles before and after rehabilitation revealed that only the interquartile ranges (IR) were different (р < 0.05). The authors conclude that robot-assisted training with knee and hip joint actuators indirectly affects the kinematic parameters of AJ by promoting a shift towards the average gait kinematics.

Effect of neuromodulation on neurotrophic factors in patients with chronic disorders of consciousness

Transcranial magnetic stimulation (TMS) is one of rehabilitation approaches for patients with chronic disorders of consciousness (DOC). The aim of our study was to assess neurotrophic factors and the changes of those after TMS course in patients with chronic DOC. We enrolled 26 patients with chronic DOC of various etiology and 21 heathy volunteers. Blood serum and cerebrospinal fluid (CSF) were collected from all patients before and after the TMS course, the levels of BDNF, NSE, NGF, РDGF, GDNF and NT3 were assessed in the biomaterial. The blood BDNF, NSE, PDGF, GDNF and NT3 in patients with chronic DOC were higher compared to healthy volunteers (p < 0.05). We found no correlations between the type of DOC and neurotrophic factors concentrations in blood and CSF. The CSF level of BDNF in patients after traumatic brain injury (TBI) was higher compared to patients with non-traumatic chronic DOC (p < 0.05). We also found the increase of CSF BDNF after the TMS course in patients after TBI (p < 0.05). No other significant differences between groups and another blood and cerebrospinal fluid biomarker levels were detected. Thus, the serum BDNF, NSE, PDGF, GDNF and NT3 levels in patients with chronic DOC were higher compared to healthy volunteers. The BDNF level in CSF was higher in patients with traumatic DOC, and it also increased after the course of high-frequency TMS in this group. This fact may indicate the long-term neuronal plasticity processes in patients after TBI, as well as more favorable rehabilitation prognosis.

[Clinical and neurophysiological effects of dual-target high-frequency rTMS over the primary motor and prefrontal cortex in Parkinson's disease]

OBJECTIVE

To evaluate therapeutic effects of navigational dual-target high-frequency rTMS over the primary motor (M1, bilateral) and the left dorsolateral prefrontal cortex (DLPFC) on clinical dynamics of Parkinson's disease (PD) symptoms in a parallel placebo-controlled study.

MATERIAL AND METHODS

The study included 46 patients randomized into equal therapeutic and placebo rTMS groups. Navigational therapeutic and placebo10 Hz rTMS was applied over the M1 and DLPFC areas (20 daily sessions, for 3 weeks). Assessment of the dynamics of clinical symptoms was performed using the MDS UPDRS scale (Parts I-IV) before the first session, immediately after 20 sessions, and 4-6 weeks after the rTMS course. Non-motor and mental symptoms were assessed using the Hamilton Depression Rating Scale (HDRS-17), Beck depression inventory (BDI-II), Depression, Anxiety and Stress (DASS-21) scales and the Mini Mental State Examination (MMSE).

RESULTS

Significant therapeutic effects of rTMS compared to placebo were established: a greater decrease in overall score on the MDS-UPDRS scale (parts I-IV), a decrease in the severity of non-motor (part I) and motor symptoms (part III, with a large therapeutic effect for the symptoms of rigidity, bradykinesia and postural instability), as well as the severity of motor complications of dopamine replacement therapy (part IV). The effects of rTMS on motor symptoms persisted 4 weeks after the end of the stimulation course. It is also important to note significant positive dynamics in both rTMS and placebo groups in the form of comparable reduction in the severity of everyday motor symptoms (MDS-UPDRS part II), improvement of the total scores on MMSE, HDRS, BDI-II, DASS-21.

CONCLUSIONS

The dual-target high-frequency rTMS over the primary motor cortex (bilateral) and the left dorsolateral prefrontal cortex has positive therapeutic effects on the motor and affective symptoms of Parkinson's disease, which are significantly stronger than that of the placebo stimulation.

[Influenza-associated acute necrotizing encephalitis in an adult]

A rare case of acute necrotizing encephalitis associated with influenza virus in an adult man is described. This clinical case is one of the few published cases in the world literature and the only one in the Russian literature.

[Influenza - associated acute necrotizing encephalitis in adults]

The authors describe a rare clinical case of non-fatal acute necrotizing encephalitis associated with influenza virus in an adult man. This clinical case is one of the few cases published in the world literature and the only one in the Russian literature.

Target determination for transcranial magnetic stimulation in patients with a pharmacotherapy-resistant depressive episode based on the individual parameters of resting-state functional magnetic resonance imaging (a pilot blind controlled trial)

High-frequency repetitive transcranial magnetic stimulation (rTMS) is approved by the Food and Drug Administration (FDA) for the treatment of pharmacotherapy-resistant depressive disorders (DD). Individual target determination for stimulation can be one of the approaches that can increase the efficiency of the technique. Objective: to compare of the effectiveness and tolerability of standard and personalized rTMS protocols.

Patients and methods. The investigation enrolled 30 patients with pharmacotherapy-resistant DD who were pseudo-randomized into two groups matched for age, gender, and episode severity. In the study group, the target was located at a point within the left dorsolateral prefrontal cortex (DLPFC) with maximum negative functional connectivity of the subgenual cingulate cortex. In the control group, the stimulation point was 5 cm anterior to the primary motor cortex (hand area). All the patients underwent 20 sessions of high-frequency rTMS DLPFC. For clinical evaluation, the investigators used the Beck Depression Inventory (BDI) and the 36-item Short Form Health Survey (SF-36) questionnaire before and after 10 and 20 rTMS sessions, respectively. Tolerability was assessed using the standardized questionnaires during and within 24 hours after each session. Results and discussion. The study group showed a significant reduction in BDI scores and an increase in the SF-36 (“Mental Health” section) scores after both 10 and 20 rTMS sessions; the control group had those only after 20 sessions. The two groups exhibited no significant differences in the reduction of BDI scores before and after 10 and 20 sessions, respectively. The investigation can be considered to be pilot in searching for algorithms to enhance the efficiency of rTMS DLPFC in pharmacotherapy-resistant depression using the algorithm for personification of target selection. It demonstrated the more rapid onset of a clinical effect in the study group patients. No serious adverse events were reported. The patients had dizziness, headache, and contraction of the facial muscles during the session; headache and mood changes within 24 hours after it. Conclusion. In both groups, rTMS was satisfactorily tolerated and effective; however, personalized target selection accelerated the onset of a clinical effect.

[Diagnostic and therapeutic issues of using transcranial magnetic stimulation in patients with writer's cramp]

AIM

To assess diagnostic and therapeutic values of transcranial magnetic stimulation (TMS) in patients with writer's cramp (WC).

MATERIAL AND METHODS

Twelve right-handed patients with WC were enrolled in the study. All patients underwent low-frequency repetitive TMS (rTMS) over the premotor cortex of the hemisphere contralateral to the affected hand. The clinical efficacy was assessed using the Writer's Cramp Rating Scale (WCRS) and the Medical Outcomes Study-Short Form (MOS-SF-36). Before and after the last rTMS session, motor mapping of abductor pollicis brevis muscle (APB) was performed using navigated TMS (nTMS). Localization, area, and amplitude-weighted area of the APB muscle cortical representations were compared with the healthy controls. The dynamics of the mentioned above parameters after the rTMS course was assessed.

RESULTS

Ten sessions of low-frequency rTMS over premotor cortex reduced the severity of WC clinical symptoms, with a duration of effect of at least 1 month (p<0.05). There was no significant difference between the area and the weighted area of cortical muscle representations between patients and healthy controls or in patients before and after rTMS. When assessing the localization of cortical muscle representations, two trends were noted: in 4 patients, the localization remained stable, with a shift in the center of gravity of less than 4 mm; in the other 8 patients, a shift in the center of gravity of more than 5 mm was noted. No significant correlations between the stability of the cortical muscle representations (the magnitude of the shift in the center of gravity) and the improvement on the WCRS scale were found.

CONCLUSION

The low-frequency rTMS over the premotor cortex of the hemisphere contralateral to the affected hand can be used as an adjuvant therapy for WC. The TMS-motor mapping study did not show its diagnostic value.

[The Russian version of Coma Recovery Scale-revised - a standardized method for assessment of patients with disorders of consciousness]

The authors officially present for the first time the Russian version of Coma Recovery Scale-Revised (CRS-R). Today CRS-R is the only validated scale in Russian for assessment of patients with chronic disorders of consciousness (DOC). The study showed high consistency for different researchers, high sensitivity in the evaluation of patients over time as well as high concurrent validity. This article contains the text of the scale and recommendations how to use CRS-R and interpret the data. Presented version of the CRS-R is recommended for use in DOC patients. Russian version of the CRS-R is a standardized, comprehensive and systematic approach to the examination and assessment of patients with chronic DOS. It ensures the standard approach to examination and assessment that warrants the accuracy and homogeneity of the obtained results.

[Pharmacological neuroprotection in stroke in clinical practice: new perspectives]

Despite recent advances in acute stroke care, clinical armamentarium against stroke remains limited. Furthermore, highly effective approaches to stroke treatment, such as systemic reperfusion and mechanical thrombectomy, cannot be performed in the majority of patients. Neuroprotective strategies, i.e. prevention of irreversible cell damage due to the ischemia, may improve stroke outcomes. However, only few pharmacological agents demonstrated clinical efficacy. Citicoline is an endogenous mononucleotide with neuroprotective effect and established clinical safety and tolerability, which effectiveness in acute stroke was studied in several large, well-controlled trials. Recent meta-analysis confirmed benefit of citicoline treatment in terms of increase of chance for better recovery of functional independence compared to placebo. Maximal effect of citicoline is seen when it is administered as soon as possible after stroke onset in patients who are not eligible for reperfusion therapy.

[Post-stroke rehabilitation training with a brain-computer interface: a clinical and neuropsychological study]

AIM

To evaluate the clinical efficacy of BCI-supported mental practice and to reveal specific cognitive impairment which determine mental practice ineffectiveness and inability to perform MI.

MATERIAL AND METHODS

Fifty-five hemiplegic patients after first-time stroke (median age 54. 0 [44.0; 61.0], time from onset 6.0 [3.0; 13.0] month) were randomized into two groups - BCI and sham-controlled. Severity of arm paresis was measured by Fugl-Meyer Assessment of Motor Recovery after Stroke (FMA) and Action Research Arm Test (ARAT). Twelve patients from the BCI group were examined using neuropsychological testing. After assessment, patients were trained to imagine kinesthetically a movement under control of BCI with the feedback presented via an exoskeleton. Patients underwent 12 training sessions lasting up to 30 min. In the end of the study, the scores on movement scales, electroencephalographic results obtained during training sessions were analyzed and compared to the results of neuropsychological testing.

RESULTS

Evaluation of the UL clinical assessments indicated that both groups improved on ARAT and FMA (sections A-D, H, I) but only the BCI group showed an improvement in the ARAT's grasp score (p=0.012), pinch score (p=0.012), gross movement score (p=0,002). The significant correlation was revealed between particular neuropsychological tests (Taylor Figure test, choice reaction test, Head test) and online accuracy rate.

CONCLUSION

These results suggest that adding BCI control to exoskeleton-assisted physical therapy can improve post-stroke rehabilitation outcomes. Neuropsychological testing can be used for screening before mental practice admission and promote personalized rehabilitation.

[Venous thromboembolism in patients with Guillain-Barre syndrome]

OBJECTIVE

To perform an in-depth prospective analysis of the prevalence, risk factors, specific characteristics of venous thromboembolism (VTE) and the dynamics of venous thrombosis during the treatment with low-molecular-weight heparin (LMWH) in patients with different forms and severity of Guillain-Barre syndrome (GBS) admitted to an intensive care unit (ICU).

MATERIAL AND METHODS

Prevalence, risk factors and course of VTE were analyzed for the first time in 65 ICU inpatients with various forms and severity of GBS. Neurological status was evaluated at baseline and in dynamics, duplex scanning of veins of the legsin the system of inferior vena cava was performed.

RESULTS AND CONCLUSION

Despite the preventive using of LMWH, a half of patients with GBS, regardless of the form of the disease during the progression of neurological symptoms, have VTE (deep vein thrombosis--52%, pulmonary embolism--15%). Significant risk factors include: severe disease course requiring artificial ventilation, bed rest for more than 3 days, infectious complications, the presence of the catheter in the central vein, age over 40 years. Venous thrombosis in the system of inferior vena cava in patients with GBS does not differ from that in other critical illnesses suggesting that this pathological process is universal. Preventive measures for this category of patients is insufficient and requires a search for other prevention strategies.

Hypertension and Cerebral Microangiopathy (Cerebral Small Vessel Disease): Genetic and Epigenetic Aspects of Their Relationship

Hypertension (HT) and its cerebral complications are extremely vexing medical and social problems. Despite the obvious association between hypertension and the clinical and neuroimaging features of cerebral microangiopathy (CMA) (also known as cerebral small vessel disease), the causal links between them remain ambiguous. Besides, antihypertensive therapy as the only way to manage these patients does not always prevent brain damage. Knowledge about the key factors and mechanisms involved in HT and CMA development is important for predicting the risk of cerebral complications and developing new approaches to their prevention and treatment. At present, genome-wide association studies and other approaches are used to investigate the common hereditary mechanisms of HT and CMA development, which will explain a large number of CMA cases not associated with hypertension, lack of a correlation between HT severity and the degree of cerebral injury, and failure of antihypertensive therapy to prevent CMA progression. Epigenetic markers likely play a modulating role in the development of these diseases.

[Motor learning of the post-stroke patients presenting with upper limb paresis on the mechanotherapeutic system]

BACKGROUND

the relevance of this study arises from the high prevalence of upper limb motor impairment and pathological synergy in the post-stroke patients; these conditions are very difficult to correct with the use of the traditional rehabilitation methods. A promising but insufficiently studied approaches are the virtual reality (VR) technology as well as its combination with other techniques.

AIM

The objective of the present study was to evaluate the influence of the training making use of the mechanotherapeutic system on the motor function of the paretic hand.

MATERIAL AND METHODS

A total of 30 patients were enrolled in this study. The main group comprised 20 of them who completed the training course on the mechanotherapeutic system allowing for separate adjustment of weight support for the shoulder and the forearm, VR feedback with individual setting of the active working space, and augmented functional exercises. The control group consisted of the patients (n=10) who performed the task-oriented motor training course of an equal duration with arm weight support and visual feedback.

RESULTS AND DISCUSSION

The assessment based on the Fugl-Meyer scale (FMA) showed the statistically significant changes in the passive motion range in the patients of both groups, but only those comprising the main group were found to experience the improvement of the major movements of the arm, wrist, and hand as well as movements outside synergy (p<0.005). Fine motor skills estimated from the results of the Action Research Arm test (ARAT) improved only in the main group due to the cylindrical and pinch grip (p<0.005). Also, only patients of the main group, improved daily living skills evaluated based on the Frenchay Arm test (FAT) (p<0.005).

CONCLUSION

The results of the present study give evidence that the use of combined training with arm weight support and VR feedback contributes to a more complete recovery of motor and daily living skills in the upper limb of post-stroke patients, compared to the classical task-oriented training with visual feedback.

Hypertension and Cerebral Microangiopathy (Cerebral Small Vessel Disease): Genetic and Epigenetic Aspects of Their Relationship

Hypertension (HT) and its cerebral complications are extremely vexing medical and social problems. Despite the obvious association between hypertension and the clinical and neuroimaging features of cerebral microangiopathy (CMA) (also known as cerebral small vessel disease), the causal links between them remain ambiguous. Besides, antihypertensive therapy as the only way to manage these patients does not always prevent brain damage. Knowledge about the key factors and mechanisms involved in HT and CMA development is important for predicting the risk of cerebral complications and developing new approaches to their prevention and treatment. At present, genome-wide association studies and other approaches are used to investigate the common hereditary mechanisms of HT and CMA development, which will explain a large number of CMA cases not associated with hypertension, lack of a correlation between HT severity and the degree of cerebral injury, and failure of antihypertensive therapy to prevent CMA progression. Epigenetic markers likely play a modulating role in the development of these diseases.

[Evaluation of changes in the cortical gait control in post-stroke patients induced by the use of the “Regent” soft exoskeleton complex (SEC) by navigated transcranial magnetic stimulation]

The mechanisms underlying the locomotion recovery in poststroke patients remain unknown. Navigated transcranial magnetic stimulation (nTMS) is a new method to evaluate the functional state of the motor system. Using of the exoskeleton complex (EC) allow to correct walking pattern significantly. The aim of this study was to evaluate the capability of nTMS to assess changes in gait cortical control using EC in poststroke patients. 14 patients suffered subcortical stroke, mean age was 53.0 years [49, 62], mean duration of a stroke of 14.2 [7.0; 23.0] months were included. All patients trained with EC for 10 times and also received standardized physical therapy. All patients underwent nTMS, as well as clinical assessment using a Fugl-Meyer Scale lower extremity section and 10 m walking test before and after trains. A significant decrease of time to walk 10 meter was observed, while Fugl-Meyer Score remained unchanged. Patients showed the significant reduction of the average latency of motor responses from the affected hemisphere and different patterns of size and localization changes in both legs' cortical motor areas. Navigates TMS may demonstrate individual patterns of changes in cortical representation of leg muscles in post-stroke patients with damage of various motor system elements, while using exoskeleton complex. Thus, navigated TMS may be used not only for verification of neuroplasticity process, but it may also provide its detailed description.

[Changes in the Functional Connectivity of Motor Zones in the Use of Multimodal Exoskeleton Complex "Regent" in the Neurorehabilitation of Post-Stroke Patients]

The article discusses the effect of a course of treatment with the use of multimodal complex exoskeleton (MCE) "Regent" on the reorganization of cortical locomotor zones in 14 patients with post-stroke hemiparesis, mainly atthe chronic stage of the disease. Before the course of treatment, we identified specific areas of activation in the primary sensorimotor and supplementary motor areas and the inferior parietal lobules in both affected and healthy hemispheres by means of functional MRI (fMRI) with the use of special passive sensorimotor paradigms. After the course of treatment with MCE, we observed an improvement of temporal characteristics of walking; it was accompanied by a decrease in the activation zones of inferior parietal lobules, especially in the healthy hemisphere, and by a significant increase in the activation zone of primary sensorimotor and supplementary motor areas. The analysis of the functional connectivity of studied zones before and after the course of treatment with MCE showed significant changes in intra- and interhemispheric interactions.

[The application of high-frequency and iTBS transcranial magnetic stimulation for the treatment of spasticity in the patients presenting with secondary progressive multiple sclerosis]

Spasticity is considered to be a common manifestation of multiple sclerosis. Muscle relaxants are not sufficiently effective; more than that, some of them often cause a variety of adverse reactions. Transcranial magnetic stimulation (TMS) can be a promising new tool for the treatment of spasticity. The objective of the present study was to compare the effectiveness of the two TMS protocols: rhythmic (high-frequency) TMS (rTMS) and stimulation with the theta bursts (iTBS) in terms of their ability to reduce spasticity in the patients presenting with multiple sclerosis.

PATIENTS AND METHODS

Twenty two patients with secondary-progressive multiple sclerosis were pseudo-randomized into two groups: those in the first (high-frequency) group received the treatment with the use of rTMS therapy at a frequency of 10 Hz; the patients of the second group, underwent stimulation with the theta bursts (iTBS). All the patients received 10 sessions of either stimulation applied to the primary motor area (M1) of both legs. The effectiveness of TMS protocols was evaluated before therapy and after 10 sessions of stimulation based on the Modified Ashworth scale (MAS), the expanded disability status scale (EDSS), and the Kurtzke functional scale (Kfs). In addition, the patients were interviewed before treatment, after 10 rTMS sessions, immediately after and within 2 and 12 weeks after the completion of the treatment using questionnaires for the evaluation of spasticity (SESS) , fatigue, and dysfunction of the pelvic organs (severity of defecation and urination disorders), fatigue.

RESULTS

The study has demonstrated a significant reduction in spasticity in the patients of both groups at the end of the TMS protocol based on the MAS scale. There was no significant difference between the outcomes of the two protocols. Both had positive effect on the concomitant «non-motor» symptoms (fatigue, dysfunction of the pelvic organs).

CONCLUSION

High-frequency transcranial magnetic stimulation (10 sessions of rTMS therapy at a frequency of 10 Hz) and stimulation with the theta-bursts applied to the M1 area in both legs can be an effective alternative treatment of spasticity in the patients with secondary-progressive multiple sclerosis. Further research is needed to detect more accurately the differences between the outcomes of the two stimulation protocols and the development of indications for their application on an individual basis.

[Brain-Computer Interface: the First Clinical Experience in Russia]

Motor imagery is suggested to stimulate the same plastic mechanisms in the brain as a real movement. The brain-computer interface (BCI) controls motor imagery by converting EEG during this process into the commands for an external device. This article presents the results of two-stage study of the clinical use of non-invasive BCI in the rehabilitation of patients with severe hemiparesis caused by focal brain damage. It was found that the ability to control BCI did not depend on the duration of a disease, brain lesion localization and the degree of neurological deficit. The first step of the study involved 36 patients; it showed that the efficacy of rehabilitation was higher in the group with the use of BCI (the score on the Action Research Arm Test (ARAT) improved from 1 [0; 2] to 5 [0; 16] points, p = 0.012; no significant improvement was observed in control group). The second step of the study involved 19 patients; the complex BCI-exoskeleton (i.e. with the kinesthetic feedback) was used for motor imagery trainings. The improvement of the motor function of hands was proved by ARAT (the score improved from 2 [0; 37] to 4 [1; 45:5] points, p = 0.005) and Fugl-Meyer scale (from 72 [63; 110 ] to 79 [68; 115] points, p = 0.005).

[STROKE: INCIDENCE AND RISK FACTORS FOR VENOUS THROMBOEMBOLIC COMPLICATIONS IN INTENSIVE CARE UNIT]

AIM

To study the evidence of venous thromboembolic complications (VTE (acute venous thrombosis (DVT) and pulmonary embolism (PE)) at the background of modern prevention for different characteristics and localization of stroke, as well as defining the role of the main clinical risk factors in the pathogenesis for ITE in stroke patients in intensive care unit.

MATERIAL AND METHODS

The study included 123 patients with different types, localization and severity of stroke. All patients received standard prophylaxis VTE with low molecular weight heparin (LMWH). Neurological status, the severity of the general condition, the main clinical risk factors of stroke were assessed when income and in dynamics. There was planned duplex scanning of the veins of the inferior vena cava performed.

RESULTS AND DISCUSSION

In spite of the application of modern preventive measures VTE, their frequency remains high accounting for 56%. All patients have a place DVT, in 26% of pulmonary embolism occurs. Groups at highest risk of VTE are patients with stroke more than 8 points of NIHSS, who are ventilated and assessed infection-inflammatory disorders, especially pulmonary. This group is considered to be at the highest risk of VTE. Modern preventive strategy for them is not sufficient and needs for the search of other preventive approaches.

[Autoimmune Diseases of the Nervous System: Problem Statement and Prospects]

This review highlights the achievements in the field of autoimmune diseases of the nervous system over the last 15 years. It became possible to deepen the understanding of medical and social significance of these diseases, form the concept of nosologic unit heterogeneity, describe new and atypical forms ofdemyelinating diseases of the central and peripheral nervous system, autoimmune diseases of the neuromuscular synapse. Also, it is important to mention, that the new antigens were identified, the diagnostic panel of autoantibodies was developed and put into practice. Furthermore, the dinical practice guidelinesfor the diagnosis and management of patients were developed, the new drugs were tested and included in these guidelines. The scientists of the biggest Russian neurological centre, Research Centre of Neurology (Moscow), developed a <<vaccine>> for immunotherapy of multiple sclerosis, studied pathomorphosis of Guillain-Barre syndrome, specified the components of its pathogenesis, improved the programs of pathogenetic therapy, which led to the decrease in mortality from 30 to 3%, helped to decrease the A VL period by 2 times, hasten the recovery of independent walking by 2.5 times. Nowadays different biomarkers of diseases of the central and peripheral nervous system are studied and modern technologies in neurorehabilitation are applied.

[Prevention of venous thromboembolism in the acute stroke]

OBJECTIVE

To assess the effectiveness of preventive measures to reduce VTE rates among patients with severe stroke in intensive care unit (ICU).

MATERIAL AND METHODS

The efficacy and safety of previously developed protocol for VTE prevention was assessed in 378 stroke patients in the ICU who received different levels of preventive measures. Subjects were distributed into three groups. We assessed neurological status of all patients on admission and in the course of stroke, and performed ultrasound scanning of lower limb veins for groups II and III.

RESULTS

The rate of VTE events remained high regardless of the level of preventive measures. However, we observed a changing nature of PE from massive to nonmassive without increasing the rate of hemorrhagic complications while the strict protocol of VTE prevention with mandatory use of low molecular weight heparins was applied, including patients with hemorrhagic stroke.

CONCLUSION

The use of the proposed protocol of VTE prevention in routine care for patients with stroke in ICU is safe and may significantly reduce the incidence of fatal pulmonary embolism.

[Stroke: the review of the problem (15 years after)]

The critical review of the key achievements in ischemic and hemorrhagic stroke of the past 15 years is presented in the article including stroke epidemiology and classification, experimental models, treatment of malignant edema after stroke, thrombolytic therapy, surgical treatment of intracranial hematomas, surgery on extracranial arteries, polyorganic insufficiency syndrome, secondary prevention of cardioembolic stroke, neuroprotection and early rehabilitation.

[POEMS-syndrome: a literature review and case reports]

POEMS-syndrome (Polyneuropathy, Organomegaly, Endocrinopathy, M-protein, and Skin Changes) is a rare nosological form occurred in patients with paraproteinemic hemoblastosis. Chronic progressive sensory-motor polyneuropathy is a key syndrome of the disease and it is a common reason for referral to neurologist. The paper presents data about POEMS-syndrome and own case reports with the analysis of disease features and results of examination.

[Lower limb vein thrombosis in dynamics of acute impairments of cerebral circulation]

The present work was aimed at studying the state of the inferior vena cava system according to the findings of duplex scanning in dynamics of acute cerebral circulation impairments (ACCI). Amongst 100 patients with ACCI, lower limb vein deep thrombosis (LLVDT) was revealed in 57% of cases. The incidence of LLVDT in patients with intracerebral haemorrhage was higher than in those with ischaemic stroke, however there were no statistically significant differences between the type of ACCI (p=0.06) and subtypes of ischaemic stroke (atherothrombotic, ceardioembolic) (p = 0.68). The main risk factors for LLVDT are the presence of pronounced motion deficit in the extremities, induced by the underlying disease (p=0.02) and immobilization. In the overwhelming majority of patients (81%) thrombosis localized isolatedly in the crural veins. Ascending thrombosis and the development of a floating thrombus were represented mainly on the side of motility deficit in the extremities. We have confirmed a strong association between positive dynamics in the neurological status of patients and frequency of recanalization of thrombi (p=0.043). Ultrasonographic examination of lower limb veins in dynamics of ACCI is an important component of preventive and therapeutic process.

[Development of neurocritical care]

In this review we provide the definition, goals and objectives of neurocritical care, evaluation of brief history of its development. Mechanical ventilation, intracranial hypertension, neuromonitoring as underlying basics of neurocritical care approaches are discussed. The main types of pathology and specific methods used in neurocritical care units are discussed. The results of our own research on brain death--the development of national criteria; for Guillain-Barre syndrome--a double decrease in the length of mechanical ventilation and in 2.5 times of the recovery time for independent walking ability; on diphteric polyneuropathy--reduced by 11 times mortality compared with nation-wide indicators of nontraumatic persistent vegetative state--the development of diagnostic and predictive neurophysiologic criteria are demonstrated. Research data of multiple organ disfunction syndrome in severe stroke are described. Further development of neurocritical care is being discussed.

[Proteomic technologies for identification of serum potential biomarkers of autoimmune demyelinating polyneuropathies]

Time-of-flight MALDI mass spectrometry (MALDI-TOF-MS) profiling of blood serum of patients with Guillain-Barré syndrome (GBS, 36 samples), chronic inflammatory demyelinating polyneuropathy (CIDP, 24 samples) and practically healthy donors (HD) (35 samples) was carried out in order to identify potential biomarkers of autoimmune demyelinating polyneuropathies (ADP). To simplify the peptide-protein mixture of serum prior to MALDI-TOF-MS analysis samples were pre-fractionated on magnetic microparticles with a weak cation-exchange (MB-WCX) surface. Comparative analysis of mass spectrometric data using the classification algorithms (genetic and neural network-controlled) revealed a characteristic set of peaks, agreed change area with a high specificity and sensitivity of the differentiated mass spectrometry profiles of the blood serum of patients with DPNP and healthy donors (for GBS values of these characteristics reached 100 and 100, and for CIDP 94.1 and 100% respectively). Comparative analysis of mass spectrometric profiles of serum samples obtained from patients with GBS and CIDP, allowed to build a classification model to differentiate these diseases from each other, with a specificity of 88.9 and a sensitivity of 80%.

[Therapeutic efficiency of cytoflavine solution for infusion in emergency conditions]

The author reports results of clinical assessment of cytoflavin for injections in the treatment of different pathological condition including critical ones. It was shown that therapy reduces mortality among patients with acute disturbances of cerebral circulation to 4.8-9.6% compared with 11.7-17.1% in controls. Positive dynamic of neurologic status was documented in 79% of the patients with dyscirculatory encephalopathy versus 25% in control. Duration of comatose state decreased 1,7-fold, length of stay in resuscitation and intensive therapy wards 1.8-fold, and frequency of internal complications secondary to the effect of neurotropic poisons 2-fold. Cytoflavin corrected the level of metalloproteides and stabilized antioxidative potential of sera and cerebrospinal liquid in patient with meningitis including that of zoonotic etiology. In the period of post-narcosis rehabilitation cytoflavin restored conscience in 77% of the patients within 20 min. The drug also inhibited pathological alcohol addiction within 5 days after the onset of therapy as apparent from the improvement of intellectual-mnestic status and activization of attention. The frequency of infectious complications in patients with acute surgical abdominal pathology decreased by 5.1% and lethality by 3.6% compared with placebo group. Cytoflavin exhibited cardioprotective action in patients with myocardial infarction, during cardiosurgical intervention, and chronic brucellosis. It had hepatoprotective effect in iatrogenic hepatic conditions as well as ophthalmo- and oto-protective activity.

[Efficacy of cytoflavin in the treatment of chronic cerebral ischemia]

The author presents results of multicentre randomized studies of therapeutic efficiency of cytoflavin tablets in patients with chronic cerebral ischemia including asthenovegetative syndrome. Cytoflavin was shown to reduce clinical manifestations of asthenia, anxiety, depression, cognitive and emotional disorders and simultaneously improve quality of life. The efficiency of cytoflavin is confirmed by improved physical and psychic state of the patients, their enhanced social activity.

[Prophylaxis of venous thromboembolism after severe stroke]

Venous thromboembolism (VTE), a deep and superficial thrombosis and pulmonary embolism, is a very important problem of severe stroke. Pulmonary embolism (PE) significantly influences the course and outcome of severe stroke. The cause of this effect lies not only in severe patient's condition, high risk of VTE and difficulties in diagnosis of VTE but in still common limits in prophylaxis and treatment of PE in severe stroke, first of all, in brain hemorrhages and large brain infarctions with secondary hemorrhage. The paper presents the main principles and methods of prophylaxis of VTE in severe stroke. The suggested approach allows to decrease the frequency of VTE and fatal outcomes in severe stroke in the modern neuro-intensive care units.

[Diffusion- and perfusion-weighted magnetic resonance imaging: possibilities and perspectives]

The article addresses theoretical and practical issues of using diffusion- (DW-MRI) and perfusion-weighted (PW-MRI) magnetic resonance tomography in acute period of ischemic stroke. The authors consider prognostic value of the results obtained with both methods of MRI-diagnosis and possibilities of their usage in pathophysiological studies of ischemic stroke. Prognostic value of DW-MRI in measuring of final size of stroke used at the first day of stroke is higher compared to standard regimes. A ratio between clinical and MRI data has been analyzed. A conception comparing a ratio between the presence of lesion and its size using DW-MRI and PW-MRI is presented. A longer duration of the penumbra comparing to conventional terms was described. The results of DW-MRI and PW-MRI study are suggested to be used for prognostic purpose as well as for elaboration of an optimal treatment tactics. Some controversial issues of using DW-MRI and PW-MRI, are discussed.

Central synaptic neurotransmission: universal self-regulation theory

A prospective randomized study based on case monitoring and treatment of the patients with chronic tension-type headache was carried out, which revealed the regularities in the effects of basic groups of central neurotropic drugs on clinical manifestations and the EEG data. The patients of control (n=90) and experimental (n=91) groups were followed up for 3 months. The experimental group patients were treated with central neurotropic preparations in addition to the routine medicines having peripheral effects. The control group patients received only the routine preparations. The efficiency was assessed by clinical and EEG criteria. The data obtained were analyzed based on fundamental views of modern experimental neurobiology on the gradual nature of postsynaptic responses and their role in universal process of the central neurotransmission. This analysis led to the views on neurochemical origin of EEG rhythms, which has not been yet defined. A theory is advanced, which is based on clinical experience gained in the process of treatment of various functional CNS disorders in more than 5000 patients. This theory makes it possible to use EEG as an objective criterion of efficiency of neurotropic drugs administered to correct central neurotransmission in the patients with clinical pathological functional disorders of CNS.