[Optimization of secondary prevention in patients with high-risk atherothrombotic ischemic stroke or transient ischemic attacks]. / Optimizatsiya vtorichnoi profilaktiki serdechno-sosudistykh sobytii u patsientov s aterotromboticheskim ishemicheskim insul'tom ili tranzitornymi ishemicheskimi atakami vysokogo riska.

High and very high risk atherothrombotic ischemic stroke (ATIS) includes patients with severe extracranial atherosclerosis, any intracranial atherosclerosis, and aortic arch atheromatosis. The article discusses the most effective approaches to medical short- and long-term secondary prevention of ATIS, major vascular events and death, based on the results of modern research and current clinical guidelines. Clinical studies of recent years have proven the possibility of individualization and intensification of secondary prevention of ATIS. In the treatment of high-risk patients, it is advisable to use more widely short-term dual antiplatelet therapy (combination of ASA with clopidogrel or ticagrelor), long-term dual antithrombotic therapy (combination of ASA and rivaroxaban at a dose of 2.5 mg twice a day not earlier than 30 days from the development of stroke or TIA) to reduce the risk of recurrent stroke and death, as well as intensive lipid-lowering therapy (including the use of a combination of statins and ezetimibe or PCSK9 inhibitors).

[Ischemic stroke associated with patent foramen ovale: hospital database analysis]. / Ishemicheskii insul't, assotsiirovannyi s otkrytym oval'nym oknom: analiz dannykh gospital'nykh registrov.

OBJECTIVE: To analyze clinical and instrumental characteristics of patients with ischemic stroke (IS) due to paradoxical embolism according to the data of hospital registers of Moscow and Perm. MATERIAL AND METHODS: A comprehensive study of 114 patients, aged 18 to 55 years, with IS by the mechanism of paradoxical embolism was carried out. All patients underwent clarification of the cause of IS (electrocardiography, ultrasound scanning of the brachiocephalic arteries, CT or MRI of the brain, CT or MR angiography, transthoracic and/or transesophageal echocardiography). The presence of right-left shunt blood flow (RLS) was confirmed by transcranial dopplerography with a bubble test. The clinical significance of patent foramen ovale (PFO) was assessed according to The PFO-Associated Stroke Causal Likelihood Classification System (PASCAL). RESULTS: Clinical and instrumental characteristics of patients with IS due to paradoxical embolism were obtained from two hospital registries. In both groups, the leading trigger for the development of IS was the Valsalva phenomen (>20%), the share of other provoking factors did not exceed 10%. Significant differences between the analyzed groups related to the ultrasonic characteristics of RLS/PFO: patients with a grade 4 shunt predominated in the Research Center of Neurology (RCN) population, while patients with a grade 3 shunt predominated in the City Clinical Hospital (CCH) №4 group. At the same time, there were twice as many patients with aneurysm of the interatrial septum in the CCH №4 group. In accordance with the PASCAL classification, in 93% of RCN patients, PFO can be considered as a probable cause of IS, while in the CCH No. 4 group, a probable causal relationship was traced only in 51% of cases, in 18% of patients, the role of an anomaly in the development of stroke was unlikely. CONCLUSION: The analysis showed that the primary screening of RLS in a regional vascular center allows classifying PFO as a probable cause of IS in only half of the patients. For a more accurate selection of patients for whom endovascular occlusion of the PFO will be most effective, an in-depth examination in a specialized hospital is recommended.

[COMPASS study results as a foundation for new treatment approach for neurological patients. Opinion of the expert council of december 18, 2021]. / Znachenie rezul'tatov issledovaniya COMPASS v izmenenii podkhodov k lecheniyu patsientov nevrologicheskogo profilya. Zaklyuchenie soveta ekspertov ot 18 dekabrya 2021 g.

The resolution of the Council of Experts devoted to the discussion of the effectiveness of the use of a combination of rivaroxaban 2.5 mg 2 times a day and acetylsalicylic acid 100 mg per day to prevent recurrent non-coronary ischemic stroke results of the COMPASS study is presented. The advantages of this combination and the safety of its use are considered. Recommendations for the implementation of the results of the study in clinical practice are given.

[Cerebrovascular disease with neurocognitive impairment]. / Tserebrovaskulyarnoe zabolevanie s kognitivnymi narusheniyami.

In the International Classification of Diseases 11th revision in the section «Diseases of the nervous system¼, it is proposed to distinguish «Cerebrovascular disorder with neurocognitive impairment¼, which corresponds to both discirculatory encephalopathy (DEP) or chronic cerebral ischemia (CCI) accepted in our country, and also vascular cognitive impairments. The terminology, prevalence, risk factors and pathological basis of the disease are discussed, in particular multiple infarctions, strategic infarctions, cerebral small vessel disease, specific microangiopathies, intracerebral hemorrhage and global hypoperfusion. Post-stroke cognitive impairments are discussed in detail. The article presents relevant data on the pathogenesis of the disease, highlights the issues of clinical and neuroimaging diagnostics. Based on the data presented in the article, we can conclude that the diagnosis of DEP, CCI should be based on the presence of cerebrovascular disease with neurocognitive impairment, which implies the verification of vascular cognitive impairments and reliable neuroimaging signs of cerebrovascular pathology while excluding other causes. Early diagnosis and effective treatment of cerebrovascular disease with neurocognitive impairment (DEP, CCI) is becoming increasingly important, since treatment can slow the progression of the disease and lead to a decrease in the incidence of stroke and dementia.

[Familial hemiplegic migraine]. / Semeinaya gemiplegicheskaya migren'.

Hemiplegic migraine (HM) is a rare subtype of migraine with aura which prevalence is about 0.01%. The characteristic features include motor symptoms (hemiparesis) along with the signs of migraine with typical aura (visual, sensory and/or speech disturbances). The diagnosis of familial hemiplegic migraine (FHM) is established when at least 1 or more relatives of the 1st or 2nd degree in the family have the attacks of HM. This report describes a family in which two members (father and daughter) develop attacks of severe headache with nausea and, sometimes, vomiting, accompanied by visual disturbances, speech impairment, followed by unilateral numbness and weakness of extremities. The diagnosis of FHM was established. The report includes the review of literature and the discussion of some aspects of differential diagnosis.

[Vestibular vertigo in stroke and vestibular neuronitis]. / Vestibulyarnoe golovokruzhenie pri insul'te i vestibulyarnom neironite.

The article discusses two main causes of acute vestibular dizziness - vertebrobasilar ischemic stroke and vestibular neuritis. The features of acute vestibular syndrome depending on the localization of cerebral infarction - in the territory of the posterior inferior, anterior inferior and superior cerebellar arteries, as well as in the brain stem are presented. Detailed clinical characteristics of vestibular neuritis is given. The issues of differential diagnosis of diseases, including the features of nystagmus and head impulse test, are discussed. The approaches to the treatment of acute vestibular syndrome depending on its etiology are considered. The authors present a treatment and diagnostic algorithm and consider features of clinical practice in acute dizziness. Fundamental differences in the treatment of vestibular neuritis and vertebrobasilar stroke dictate the need for neurologists of vascular departments to master the skills of otoneurological examination, which is the key to differential diagnosis. When choosing a treatment method, the most individualized approach is required.

[CADASIL syndrome: differential diagnosis with multiple sclerosis]. / Sindrom CADASIL: differentsial'naia diagnostika s rasseiannym sklerozom.

Two cases of clinical and MRI manifestations of genetically verified CADASIL syndrome in female patients under 40 years of age are presented. The primary misinterpretation of clinical data and the neuroimaging results within multiple sclerosis indicates a lack of awareness of radiologists and neurologists about this disease. The article reviewed the current literature on the problems of diagnosis and treatment of CADASIL. The clinical and neuroimaging pattern of the syndrome, the approaches to genetic testing and the basic principles of patient management are considered in detail.

[Familial temporal lobe epilepsy 5 with vestibular seizures (a case report)]. / Semeinaia visochnaia épilepsiia 5-go tipa s vestibuliarnymi pristupami (klinicheskii sluchai).

A clinical case of familial temporal epilepsy type 5 (OMIM 614417) with onset at the age of 14 years is described for the first time in the domestic literature. The leading manifestations of the disease were focal seizures of systemic vertigo, accompanied by vestibular ataxia and, sometimes, vomiting. Cognitive and emotional disturbances were observed as well. On the EEG of wakefulness and sleep, a non-expressed epileptiform activity was detected in the left parietotemporal and frontotemporal zone. Neuroimaging did not show any significant changes. Only a molecular genetic study that identified CPA6 gene mutation made it possible to establish the accurate diagnosis.

[The experience of using thrombolysis in patients with acute disturbances of cerebral circulation: efficacy, safety, predictors of outcome and hemorrhagic transformation]. / Opyt provedeniia tromboliticheskoi terapii u bol'nykh s ostrymi narusheniiami mozgovogo krovoobrashcheniia: éffektivnost', bezopasnost', prediktory iskhoda i gemorragicheskoi transformatsii.

AIM: To evaluate neurological and functional outcomes of early stage of ischemic stroke, their determining factors and predictors of hemorrhagic transformation in patients who received thrombolysis. MATERIAL AND METHODS: A retrospective analysis of 147 patients, who underwent thrombolysis, and 127 patients, matched for basic parameters, who did not receive thrombolysis, was performed. Anamnesis, results of clinical examination, a spectrum of laboratory-instrumental parameters were evaluated. Functional status was assessed at discharge from the hospital using the Rivermead mobility index and the modified Rankin scale. Along with standard computed tomography (CT) at admission and after 24h, 73 patients receiving thrombolysis underwent CT-perfusion examination. RESULTS: The insufficient number of patients (37%) are admitted to a hospital in the first 2 h after stroke. The high prevalence of cardioembolic stroke and aphasia disorders in patients treated with thrombolysis was identified compared to the control group. CT revealed acute cerebral infarction in 14% of patients admitted within 2h. CT-perfusion examination determined brain ischemia only in half of patients. There was a low prevalence of symptom hemorrhagic transformation (0.7%). Thrombolysis was correlated with the higher rate of good functional outcomes of acute stroke, reduced neurological deficit, better mobility at discharge and shorter duration of the first rehabilitation period. Age, smoking, Rankin scale score at baseline, acute infarction on the primary CT, pathogenetic variant of stroke, myocardial hypertrophy, atherosclerosis of carotid arteries and volume of MRI lesions were the main factors associated with the efficacy of thrombolysis. The main predictors of hemorrhagic transformation were the severity of stroke, glomerular filtration rate, atrial fibrillation, treatment with antiaggregants before admission and hemispheric stroke. CONCLUSION: The analysis has demonstrated the safety and efficacy of thrombolysis in ischemic stroke in real clinical practice of a regional Vascular center.

[Post-stroke cognitive impairment and the possibility of treatment with cellex].

OBJECTIVE: To present neuropsychological characteristics of post-stroke cognitive impairment (PSCI) in acute ischemic stroke (IS) and to assess the efficacy of the drug cellex. MATERIAL AND METHODS: A comprehensive neuropsychological testing battery was administered to 288 patients with acute IS. In addition to basic therapy, 30 patients received cellexin the dosage of 0.1 mg (1 ml) subcutaneously for 10 days, treatment was started in the acute phase. RESULTS AND CONCLUSION: Multifunctional PSCI were revealed in 87% of patients with acute IS. Impairments of attention, regulatory functions, speech and memory were identified in the majority of patients. More than a third of patients had multifunctional nonamnestic PSCI. Monofunctionalnonamnestic PSCI were found in 5.5% of patients. Isolated deficit of memory was observed in 2% of patients. PSCI with the predominance of mixed character were found mostly in elderly patients. In the group of young and middle-aged patients,there was a decrease in isolated speed reduction or regulation of cognitive activity, combined cognitive impairment was detected in every fourth patient. There was a trend towards an increase in the age of patients withPSCI of the mixed character. An analysis of the efficacy of cellex in acute IS has shown that the drug improves cognitive status as well as the state of neurodynamic, regulatory and visuospatial functions. Therefore, cellex is effective in treatment of PSCI in acute IS.

[Neuroinflammatory, Neurodegenerative and Structural Brain Biomarkers of the Main Types of Post-Stroke Cognitive Impairment in Acute Period of Ischemic Stroke].

Background: Post-stroke cognitive impairment is a clinically heterogeneous condition, some types of which cannot be fully differentiated neuropsychologically that necessitates the active search for biomarkers. Aims: Analyze parameters of neuroinflammation and neurodegeneration in combination with neuroimaging markers in patients with different types of post-stroke cognitive impairment in acute ischemic stroke. Materials and Methods: In 72 patients we performed the assessment of cognitive status and distinguished 3 types: normal cognition, dysexecutive, and mixed cognitive impairment. In each group we determined the concentration of cytokines (IL-1ß, IL-6, TNFα, IL-10) in liquor and serum, ß-amyloid 1−40 in liquor and a number of MRI morphometric parameters and fractional anisotropy. Results: In all groups of patients we detected higher level of IL-10 in serum compared with the control. Patients with dysexecutive cognitive impairment had higher concentration of IL-1ß, IL-10 in liquor, IL-6 level in serum, lower fractional anisotropy of ipsilateral thalamus compared with patients with normal cognition and largest size of infarct. Patients with dysexecutive and mixed cognitive impairment had the higher area of leukoareosis and ventricular volume, reduced fractional anisotropy of contralateral cingulum compared with patients with normal cognition. Patients with mixed cognitive impairment characterized by lower fractional anisotropy of contralateral fronto-occipital fasciculus compared with patients with dysexecutive cognitive deficit. Conclusions: Serum and cerebrospinal fluid concentrations of cytokines studied in combination with MRI parameters particularly fractional anisotropy seems to be informative biomarkers of pathogenic types of PSCI.

[The role of melatonin in the development of post-stroke cognitive impairment in elderly patients in comparison with middle-aged patients].

In the acute phase of ischemic stroke 73 patients aged from 61 to 86 years and 47 patients aged 36 to 60 years underwent a comprehensive neuropsychological testing, evaluation of the concentration of 6-sulfatoximelatonin 6-sulfatoximelatonin in the night urine and brain MRI morphometry in some patients. The control group consisted of 14 persons without cerebrovascular disease. Younger and middle-aged patients had higher levels of 6-sulfatoximelatonin compared to both controls and elderly patients. The level of the metabolite in patients older than 60 years and the control group did not differ. In the group of patients older than 60 years we revealed a direct correlation with the severity of the stroke and concentration of 6-sulfatoximelatonin. Metabolite concentration was inversely correlated with the results of the Mini Mental State Examination, Frontal Assessment Battery, verbal fluency, clock drawing test and directly - with the Shulte tables result. High concentrations of 6-sulfatoximelatonin was also associated with a large size of acute ischemic lesion and hippocampal volume. The highest concentration of the metabolite was observed in patients with dysexecutive cognitive impairment and the lowest in patients with normal cognitive status and amnestic deficit. Thus, in elderly patients a high concentration of 6-6-sulfatoximelatonin is a marker "pure" post-stroke cognitive impairment, whereas a low concentration of metabolite in the presence of cognitive deficits may be indicative of its mixed, that is, in part, of hippocampal type.

[THE RELATIONSHIP BETWEEN SERUM AND LIQUOR IL-1ß, IL-6, TNFα, IL-10 LEVELS AND CLINICAL, COGNITIVE AND FUNCTIONAL CHARACTERISTICS IN ACUTE ISCHEMIC STROKE].

Introduction: Inflammation is probably the main process that links cardiovascular risk factors with damage to blood vessels and neurons. Elucidation of mechanisms of this relationship is an important issue. Materials and methods: 70 acute stroke patients were studied to assess their neuropsychological (MMSE, MoCA, FAB, Clock Drawing Test, Shulte Tables and Verbal Fluency) and functional status (mRS, Rivermead Mobility Index). The serum and liquor IL-1ß, IL-6, TNFa and IL-10 levels were analyzed. Control group included subjects without cerebrovascular diseases. Results: Stroke patients had higher IL-10 serum concentration than controls. No difference was found for other cytokines. There was correlation between serum and liquor cytokines levels. We found positive correlation between IL-1ß, IL-6 and IL-10 levels. High IL-1ß concentration was associated with vascular risk factors, cardio embolic stroke, enhanced severity of cerebral stroke, low processing speed, impaired executive and visual-spatial functions and higher grade of mRS on discharge. The same pattern was revealed for IL-6 and IL-10. IL-6 level was related to mRS without relation to NIHSS on admission. High TNFa concentration was linked with vascular risk factors, low MMSE score and processing speed. Discussion: Despite the antagonistic effects of IL-1ß, IL-6 and IL-10 on inflammation, associations of these cytokines with anamnestic, clinical, neuropsychological and functional characteristics were similar in acute ischemic stroke. Probably, this fact indicates that during the acute ischemic brain damage process the immune response develops at the same time in pro- and anti-inflammatory directions. Its magnitude correlates with the damage severity and is associated with the effects of vascular risk factors before stroke.

[Characteristics of ischemic stroke according to hospital register data: a role of neuroreparative therapy].

AIM: To study characteristics of the acute stage of ischemic stroke (IS) basing on the data of a hospital register of the Perm Regional vascular center and to assess the efficacy and safety of the drug cellex in patients with IS. MATERIAL AND METHODS: Authors have analyzed the group of 128 patients with MRI-confirmed acute ischemic lesion. The subgroup of 40 patients, which beside the basic therapy received cellex in dose of 0.1 mg during 10 days, was randomized. RESULTS: The following data were analyzed: gender and age, prevalence of risk factors, primary prevention, time before admission, clinical presentations, results of instrumental diagnostic methods, pathogenic structure of stroke, use of intravenous thrombolysis, regimens of secondary prevention, functional outcome and its predictors. CONCLUSION: The group of patients was characterized by the high prevalence of risk factors, insufficient primary prevention, prolonged time before the admission, low rate of thrombolysis use and significant prevalence of large artery disease associated with stroke. The main independent predictors of low mobility level at discharge were severe neurological deficit on admission, cognitive impairment and age. Patients treated with cellex were characterized by the lower level of neurologic deficit, higher mobility and better global cognitive status in comparison with controls.

[Frontotemporal degeneration: a clinical case and experience of using of diffusion tensor magnetic-resonance imaging tractography].

Frontotemporal degeneration is a frequent cause of presenile dementia that makes up from 5 to 17% of autopsy-confirmed cases developed at the age of 70 years. Authors report a case of this disease, discuss the possible causes of its development and present the results of diffusion tensor magnetic resonance tractography. Clinical features of this case are practically isolated speech disturbance with the most likely domination of a semantic variant of primary progressive aphasia. Magnetic-resonance imaging has an important practical significance for this pathology due to the possibility of assessing atrophic zones. The use of DTI-tractography allows to extend diagnostic possibilities.

[Poststroke cognitive, emotional impairment and sleep quality: efficience of treatment with melaxen].

OBJECTIVE: To study melatonin secretion and its correlations with poststroke cognitive, emotional impairment and sleep quality in the acute period of stroke and to assess treatment efficacy of melaxen. MATERIAL AND METHODS: We studied 96 patients with acute stroke. A battery of tests and scales for assessment of neurological deficit, neuropsychological status and emotional impairment was used. The night urinary level of 6-sulfatoxymelatonin was assessed. The relationship between 6-sulfatoxymelatonin and cognitive, emotional status and sleep parameters was analyzed. RESULTS: The level of 6-sulfatoxymelatonin was decreased in the night urine. Patients with dysexecutive poststroke cognitive impairment had higher level of 6-sulfatoxymelatonin and patients with dysmnestic and mixed cognitive impairment had lower level of 6-sulfatoxymelatonin in comparison with patients with normal cognitive functions. Melaxen improved cognitive function and sleep parameters, reduced the level of anxiety in the early recovery period of stroke. CONCLUSION: A role of chronobiological processes in the development of clinical signs of stroke in the aspect of cognitive impairment is discussed.

[Results of the spectral analysis of electroencephalograms of patients with focal epileptic seizures in the interictal period].

A comparative spectral analysis of electroencephalograms in patients with focal and generalized epileptic seizures in the interictal period revealed some specific characteristics of these paroxysms. Slowing of dominating alpha-rhythm was seen in case of the localization of epileptiform activity in frontal-central-temporal and occipital-parietal areas with the further spreading of epileptiform activity to the temporal area. Asymmetry of dominating alpha-rhythm in the right hemisphere was found in patients with focal paroxysms, asymmetry of theta-rhythm in all patients, of beta-2 rhythm in patients over 45 years old and of delta-2 rhythm in female patients.

[Chronobiological characteristics of stroke and poststroke cognitive impairment].

OBJECTIVE: To study chronobiological characteristics of ischemic stroke (II) and post stroke cognitive impairment (CI). MATERIAL AND METHODS: We examined 80 patients with acute ischemic stroke. The cognitive status, sleep quality, chronobiological parameters and night urinary level of 6-sulfatoxymelatonin were assessed. The clinical observation of the efficacy of melaxen treatment in intensive care unit was performed. RESULTS: The results of the study indicate the significance of social and environmental factors which determine the sleep-wake behavior in the development of pineal dysfunction. The pineal dysfunction probably underlies the development of stroke and accompanied neurodegenerative process. CONCLUSION: The use of melaxen in hyperacute stroke was associated with better recovery of circadian rhythms and rehabilitation results.

[Chronobiological parameters, cognitive emotional status and sleep quality in acute stroke].

The night urinary level of 6-sulfatoxymelatonin was assessed in 57 patients in acute ischemic stroke and subarachnoid hemorrhage. The relationship between 6-sulfatoxymelatonin (6-SOMT) and chronobiological parameters, cognitive and emotional status and sleep quality was analyzed. The low levels of 6-SOMT in night urine was revealed and more pronounced in ischemic stroke. The association between low levels of 6-SOMT and domen-specific cognitive impairment, high level of trait anxiety and low sleep quality was found. The deficiency of chronotropic and neuroprotective activity of melatonin may be regarded as a key factor in the development of these pathological phenomena.

[Secretion of melatonin and serum cholinesterase activity as biological markers of cognitive disorders in the acute stage of ischemic stroke].

The content of 6-sulfatoximelatonin in daily urine and butyrylcholinesterase in blood serum was determined in the acute stage of ischemic stroke in 25 and 40 men, respectively. Correlations between these parameters and the cognitive state of patients were analyzed. The decrease in the 6-sulfatoximelatonin excretion and butyrylcholinesterase activity was identified. The level of 6-sulfatoximelatonin in daily urine lower than 4.0 ng/ml may be considered as a biological marker of cognitive impairment with marked memory impairment. The level of butyrylcholinesterase lower than 7.0 nmol/L may be a biochemical marker of multifunctional cognitive impairment.