[Type 2 diabetes and cognitive functions in patients with chronic cerebrovascular diseases].

BACKGROUND: Type 2 diabetes (Т2DM) both directly and indirectly impacts the development of morphological and functional changes of the central nervous system. AIM: The study was to determine clinical and neurophysiological patterns of cognitive impairment (CI) in patients with chronic cerebrovascular diseases (CCD) and Т2DM. MATERIALS AND METHODS: We examined 132 patients with CCD. First group included 58 patients without Т2DM aged 64.5 [58; 72], second group 74 patients with CCD and Т2DM 63 [57; 70]. Clinical, neurological, neuropsychological, neurophysiological (cognitive evoked potentials (EP) and neurovisualisation (brain MRI) examination was carried out to all patients. RESULTS: Somatic and neurological characteristics of the patients were similar in both groups with the exception of more distinct metabolic changes in Т2DM patients. Neurovisualisation study of the brain MRI in Т2DM patients revealed more distinct changes in the form of white matter hyperintensity and subarachnoidal spaces enlargement. Neuropsychological examination in patients revealed the reduction of intellectual flexibility, constructive praxis disruption, optical spatial dysfunction and deteoration of delayed word recall. Significant disorders in the way of overall cognitive impairment, lobar dysfunction and impaired verbal associative productivity, proved by statistically lower amplitude and higher latency of P300 EP peak were noted in Т2DM patients. Correlation links were detected: for P300 amplitude and direct and inverse number listing test (r=0.366 and r=0.520; p=0.006 and p0.001 respectively); P300 latency and HbA1c (r=0.32; р0.05) in group 2 and glucose levels in both groups (r=0.30; p0.05); inverse relationship of latency with control functions evaluation (r=-0.34; p=0.008). CONCLUSION: CCD especially with Т2DM manifests with neurocognitive imbalance, including control functions disruption and are accompanied by neurophysiological and neurovisualistion changes.

[A pathogeneteic approach to the treatment of vestibular disorders in angioneurology]. / Patogeneticheskii podkhod k lecheniiu vestibuliarnykh rasstroistv v angionevrologii.

AIM: To study the efficacy of vinpocetine (cavinton comfort) in the treatment of vestibular disorders in patients with chronic cerebral ischemia. MATERIAL AND METHODS: A prospective study included 82 patients (43 men and 39 women, aged 61-75 years, mean age 63,8±5,4 years, with chronic cerebrovascular disease (1-2 stages) with vestibular disorders. Patients were divided into two groups. Patients of the main group were treated with cavinton comfort (10 mg three times per day during 60 days), while patients of the control group did not receive the drug. Subjective and objective symptoms of chronic cerebral ischemia were assessed on a 5-point scale. The results of objective otoneurological examination and auditory evoked potentials were also taken into account in assessing the effectiveness of therapy. RESULTS: The main clinical symptoms comprised vestibular disorders, cephalgia and asthenic syndrome. The reduction in subjective symptoms was noted in 71% of patients in the main group and 34% in the control group and improvement of objective manifestations in 74% and 37%, respectively. The efficacy of cavinton comfort was confirmed by the results of auditory evoked potentials. There was a decrease in the latency of the main peaks and increase in their amplitude (bilaterally). CONCLUSION: Cavinton comfort is an effective treatment of vestibular disorders, associated with central lesions of the vestibular system.

[Cerebral atherosclerosis: a biomarker profile]. / Tserebral'nyi ateroskleroz: biomarkernyi profil'.

AIM: To assess the changes in several biomarkers in patients with atherosclerosis of brachiocephalic arteries and shape a biomarker profile of cerebral atherosclerosis as an integrative index. MATERIAL AND METHODS: The study included 124 patients with atherosclerotic lesions of internal carotid arteries (82 men and 42 women) aged from 37 to 73 years. The patients were stratified by history of prior stroke into 'asymptomatic' and 'symptomatic'. Along with general clinical and neurological examinations, ultrasound analysis of brachiocephalic arteries, neuroimaging, identification of biomarkers reflecting different stages of atherogenesis and evaluation of pathomorphological parameters of atherosclerotic plaques removed during carotid endarterectomy surgery were performed. RESULTS: Concentrations of NO2, NO3 and NO in blood plasma significantly differed between groups: 58.4, 43.3 and 15 mcmol/l, respectively, in the symptomatic group and 45, 19.2 and 25.8 mcmol/l in the asymptomatic group. The pro-inflammatory character of changes in atherosclerosis was confirmed by the increase in the concentration of lipoprotein-associated phospholipase A2 in patients with stroke (354.72±44.16 ng/ml versus 298.45±54.12 ng/ml). The level of the atheroprotective marker adiponectin decreased significantly in 'symptomatic' patients. Significant changes towards the prothrombotic state of blood were identified via levels of blood markers of fibrinolytic activity: plasminogen tissue activator and plasminogen activator inhibitor-1. CONCLUSION: Together with other diagnostic methods, identification of biomarkers can increase the accuracy of prognosis and prevention of sudden cardiovascular death. The authors have developed a scale of biomarker 'burdeness' of the patient with cerebral atherosclerosis that may be a first step to individualized prevention of associated ischemic complications.

Multimodal approach to treatment of neurological complications of chronic brain ischemia.

AIM: The study of Actovegin effectin clinical presentations and hemorheological characteristics in patients with chronic cerebrovascular pathology (CCVP) and mild cognitive impairment. MATERIALS AND METHODS: The study group included 47 patients (25 male and 22 female), aged 61-75 years (mean age 63.8±5.4) with CCVP who were treated with Actovegin. The control group comprised 28 patients matched by gender and age, without associated cerebrovascular pathology. All patients along with thorough neurological examination underwent laboratory analyses (platelet and erythrocyte rheology), neurovisualization studies (functional magnetic resonance imaging of the brain). Depending on the dosage all patients were divided in two groups: Actovegin 1000 mg and 160 mg daily. RESULTS: Overall, with Actovegin treatment in 81% of cases positive dynamics both in subjective symptoms, and somatic status was observed. A favorable effect on cognitive function in patients with CCVP was noted. The dose-dependent drug effect was demonstrated. The effect of Actovegin on blood cell functioning included the formation of smaller (Tf and Ts; p=0.0096 and p=0.016) and less solid (γ dis) erythrocyte aggregates (p=0.0034) both in the study and control group. The increase in erythrocyte deformability during therapy was significantly associated with cognitive improvement (via MoCA test, r=0.28). CONCLUSION: Complex (including neuropsychological and neurovisualizational) examination may not only help determine the cognitive status in patients with CCVP, but also assess the efficacy of neurometabolic therapy. New facts of Actovegin's influence on erythrocyte aggregation and deformability have been identified, which may enhance micro- and macrocirculation. The acquired data may prove the wide spectrum of Actovegin's pharmacological effect, which allows to use it in all forms of cerebrovascular pathology.

[Prediction of ischaemic lesions of the brain in reconstructive operations on internal carotid arteries]. / Prognozirovanie ishemicheskikh povrezhdenii golovnogo mozga pri rekonstruktivnykh operatsiiakh na vnutrennikh sonnykh arteriiakh.

The present study was undertaken to examine the relationship between the level of the intensity of the ultrasonic signal reflected from atherosclerotic plaques (ATP) of carotid arteries and the risk for formation of an ischaemic lesion in the brain matter, detected during diffusion-weighted magnetic resonance imaging (DW-MRI) performed 24 hours after carotid endarterectomy (CEA) or carotid angioplasty and stenting (CAS). Our prospective study included a total of 78 patients presenting with stenosis of the sinus of the interior carotid artery. Of these, 42 patients were subjected to CEA and 36 subjects endured CAS. All patients in the preoperative period underwent ultrasonographic examination with determination of the degree of heterogeneity of ATPs and registration of the values of the intensity of acoustic characteristics of the signal. The condition of the brain matter before and 24 hours after the intervention was assesses by the findings of DW-MRI. None of the patients after the reconstructive intervention during the postoperative period demonstrated any evidence of acute cerebral circulation disorders. DW-MRI carried out 24 hours after the operation revealed acute ischaemia foci (AIF) in 9 (21.4%) patients after CEA and in 18 (50%) patients after CAS (p=0.05). It was revealed that the postoperative occurrence of AIF was related to the intensity of the ultrasonographic signal prior to the operation: in the CEA group patients the postoperative ischaemic foci were associated with high-intensity ultrasonographic signals (more than 25 dB), whereas in the CAS group patients, vice versa - with low-intensity signals (less than 25dB). For CEA, sensitivity and specificity of the preoperative ultrasonographic method of predicting postoperative embolic lesions of the brain appeared to be similar, amounting to 100% each (with the cut-off point of high- and low-intensity signals equaling 25 dB), and for CAS, sensitivity of the method turned out to be 75% and specificity - 100% (with the same cut-off point of 25 dB). A conclusion was drawn that quantitative characteristics of the intensity of an ultrasonographic signal from fragments of atherosclerotic plaques of the sinus of the internal carotid artery made it possible with high probability to predict the risk for the development of AIF in the brain matter after both CEA and CAS and may therefore serve as a reliable criterion for appropriate therapeutic decision-making with the lowest risk of inflicting lesions in a particular case. The threshold cut-off points of high- and low-intensity ultrasonographic signals, as well as their clinical significance are yet to be specified and verified with the growing number of cases.

[Chronic cerebrovascular diseases and metabolic syndrome: approaches to pathogenic therapy of cognitive dysfunction]. / Khronicheskie tserebrovaskuliarnye zabolevaniia i metabolicheskii sindrom: podkhody k patogeneticheskoi terapii kognitivnykh narushenii.

Cognitive decline comprises one of the most important symptoms of chronic cerebral hypoperfusion. It leads not only to social disability of the patients with a subsequent decline in life quality but also to a decrease in adequate control of the course of both vascular pathology and comorbid states. Pathogenetic therapy and prevention of cerebrovascular disease progression, along with general medical measures, should include the drugs normalizing different symptoms of metabolic syndrome (arterial hypertension, diabetes mellitus etc) as well as complex drugs with multiple actions (hemangioma correction, antithrombotic, antioxidant and vasoactive) actions.

[Cerebrovascular diseases: perspectives of pathogenetic metabolic haemangiocorrective treatment].

Metabolic syndrome is a serious risk factor for acute and chronic cerebrovascular disease, which are a leading cause of disabling conditions. The association of proatherogenic effects of the main components of metabolic syndrome--hyperinsulinemia, arterial hypertension, dyslipidemia and obesity--leads to prominent haemorheological and hemostasis changes, which in turn play a pivotal role in the initiation, course and outcome of cerebrovascular pathology. Metabolic syndrome also influences the efficacy of the main pathogenetic therapy of cerebrovascular diseases--antithrombotic therapy. Thus, primary and secondary prevention of cerebrovascular disease in patients with metabolic syndrome should include haemangiocorrective, antithrombotic, antioxidant and endothelium-protective treatment, as well as therapy of the main components of metabolic syndrome.

[Ischaemic lesions of cerebral after carotid stenting].

Carotid angioplasty with stenting is a reliable method of primary and secondary prevention of ischaemic stroke in patients with stenosing lesions of the internal carotid artery. However, carrying out such operations is sometimes associated with risk for the development of intraoperative impairments of cerebral circulation due to arterioarterial embolism in cerebral arteries, as well as vasospasm. Presented herein are the results of following up a total of 64 patients with pronounced atherosclerotic lesions of internal carotid arteries (>70%) - "symptomatic" and "asymptomatic", undergoing carotid stenting. Acute foci of ischaemia in the brain after stenting according to the findings of diffusion-weighted magnetic resonance tomography were revealed in 40% of cases, and in only 6% of patients they manifested themselves by symptoms of acute cerebral circulatory impairment. We revealed a direct correlation between the number, size of infarctions in the brain, and the appearance of neurological symptomatology. Intraoperative monitoring of blood flow in the middle cerebral artery during stenting makes it possible to predict the appearance of acute foci of cerebral ischaemia, to specify the genesis of perioperative stroke, as well as to evaluate clinical significance of vasospasm and material microembolism. The obtained findings should concentrate neurologists' attention on active postoperative follow up of patients subjected to carotid angioplasty with stenting in order to perform adequate personified neuroprotective correction, including preventive one.

[Cerebrovascular diseases and metabolic syndrome].

AIM: To study various aspects of cerebrovascular diseases (CVD) in the presence of metabolic syndrome (MS). SUBJECTS AND METHODS: A comprehensive clinical, laboratory, ultrasound, and neuroimaging study was conducted in 514 patients with symptomatic and asymptomatic atherosclerotic lesion of the internal carotid artery and MS. RESULTS: MS was found and proven to affect the following factors: a) the course and progression of carotid artery (CA) atherosclerotic lesion with transformation of its asymptomatic to symptomatic state; b) the structure and instability of an atherosclerotic plaque; c) the magnitude of blood theological changes; d) endothelial dysfunction; e) white matter changes; f) the clinical features of both acute and chronic CVD and the development of cognitive impairments. CONCLUSION: The association of the atherogenic activity of major components of MS, such as hyperinsulinemia, hypertension, dyslipidemia, and obesity, in the presence of dysregulated hemostasis and blood rheology substantially increases the risk of a progressive CA atherosclerotic process even in its asymptomatic course and accordingly favors the development and progression of different manifestations of CVD.

[Two patterns of Ct-brain perfusion and Dc-potentials of the brain evoked cognitive task in discirculatory encephalopathy patients].

In patients with discirculatory encephalopathy the influence of verbal fluency test on the characteristics of cerebral perfusion, DC-potentials of the brain, as well as on blood pressure and heart rate was investigated. Two patterns of responses to the verbal fluency test were observed. The first one is the process of generalized activation, manifested by the reduction of the TTP (time to peak) parameters of brain perfusion, the rise of the DC-potentials in all areas of brain and the modulation of blood pressure and heart rate. The second process, directly connected with cognitive processing, was manifested by the shifts of local characteristics of brain perfusion and DC-potentials in the frontal, temporal and central cortex, especially in the left hemisphere. Correlations were found between the characteristics of cerebral perfusion and DC-potentials on the one hand and the number of words during the verbal fluency test performance on the other hand.

[Chronic cerebrovascular diseases associated with metabolic syndrome: new treatment approaches].

Metabolic syndrome is a risk factor for acute and chronic cerebrovascular diseases. The development of oxidative stress promotes the progression of cerebral ischemia and treatment of the biochemical disturbances is needed. Use of antioxidants in patients with cerebrovascular diseases and metabolic syndrome reduce such symptoms as insulin resistance, hyperglyceridemia, hyperglycemia. The authors present results of a clinical study of mexidol in 40 patients, aged from 50 to 70 years, with chronic cerebrovascular pathology. Perspectives of using this group of drugs as universal neuroprotectors are discussed.

[Intraoperative monitoring of cerebral blood-flow and condition of cerebral at open and endovascular interventions in carotid system].

The aim of our research is to study hemodynamic and embolic situation during the carotid endarterectomy (CEA), carotid angioplastic and stenting (CAS), and to reveal the prognostic significance of the data provided by intraoperative monitoring of the brain blood flow in exposing acute ischemic lesions in brain. Intraoperative monitoring of blood flow in artery ophthalmic vas carried out with 60% of patients, in the middle cerebral artery-with 40% during the main stages of CEA, and with 64 patients in the middle cerebral artery during CAS. The comparison of the data of intraoperative monitoring of blood flow in middle cerebral artery with the result of brain diffusion-weighted magnetic resonance imaging (DW-MRI) 24 hours after the operation shows, that solid microembolic signals and vasospasm are prognostic signals (sensibility and specifics make up 95%) in the development of acute ischemic cerebral lesions. The monitoring of blood flow in artery ophthalmic is of the greatest diagnostic value in estimation of the hemodynamic situation, but it is of the lowest practical value in detecting microembolic signals. According to the data of the intraoperative blood flow monitoring in middle cerebral artery in group CEA the development of acute ischemic cerebral lesions were predicted with 11,1% of patients and the cause of postoperative stroke, developed by 2,9% of the patients, was specified. According to the result of DW-MRI, acute ischemic cerebral lesions were diagnosed with 21% of patients, that is, 18% of ischemic cerebral lesions were asymptomatic. In group CAS ischemic cerebral lesions were prognosed with 30% of patients, actually they were later detected with 40,6% of cases by means of DW-MRI. According to the data of intraoperative of blood flow monitoring the cause of the development of postoperative stroke was specified in 6,2% of cause; in 34,4% of cause the acute ischemic cerebral lesions were asymptomatic.

[Association between changes in characteristics of local cerebral blood flow and slow brain electrical activity in patients with dyscirculatory encephalopathy].

Associated changes in the characteristics of local cerebral blood flow (CBF) and slow brain electrical activity were studied in 40 patients with dyscirculatory encephalopathy. CBF and CBV (cerebral blood volume) values for the frontal and temporal cortex and basal ganglia positively correlated with the constant potential values in the central lead influenced by the blood flow rate in the upper sagittal sinus.

[Results of proximal vertebral arteries endovascular interventions].

OBJECTIVE: To evaluate immediate and long-term clinical and ultrasound efficacy of proximal vertebral arteries stenting. We studied 74 subjects (age 61+/-10 years) who underwent transluminal balloon angioplasty with stenting of vertebral arteries (77 vessels). Technical success (i.e., residual stenosis < 20%) was achieved in 95% patients. No events (acute stroke, myocardial infarction, or death) were recorded during the procedure or in early postoperative period. Clinical improvement was seen in 81% patients presented with symptoms of vetebrobasilar insufficiency at the baseline (n = 52). Sixty six patients (89%) were followed up in the late postoperative period (6 to 54 months after the intervention). No events of acute stroke were recorded in the vertebrobasilar circulation. Relapse of vertebrobasilar symptoms after temporary improvement was seen in 13% patients. Stent restenosis/occlusion was diagnosed in 36% patients although no relationship was revealed between the alteration of stent patency and relapse of clinical symptoms. Restenosis correlated with initial stenosis of > or = 70% (p < 0.05) and type of stent material. Use of cobalt chromium stents was associated with 2-fold decrease of restenosis rate vs non cobalt chromium stents (24% vs 50%, respectively, p < 0.05). Therefore, stenting of proximal vertebral arteries yields good technical and clinical results. High restenosis rate is a major problem of endovascular treatment of atherosclerosis and needs further evaluation.

[A state of hemorheological system in patients subjected to carotid endarterectomy with atherosclerotic lesion of the major cerebral arteries].

To study the influence of changes in the blood rheological indices and blood coagulation on development, progression and clinical course of restenosis and thrombosis, 62 patients (mean age 63.4 +/- 6.0 years), were followed up for 2-15 years after carotid endarterectomy. Above 50% (maximum 70%) restenosis was observed in 7% cases. No critical postoperative restinosis was observed. In 12% patients, restenosis was accompanied with carotid artery occlusion and hematocrit, with fibrinogen (FG) being significantly increased in the absence of fibrinolytic activity (FL) elevation, indicating hemorheological disorders and homeostasis activation in such patients. Long-term follow-up showed that viscosity blood characteristics were elevated but functional activity of platelets and FA in patients did not differ from those in healthy subjects. At the same time, FG was high and fibrinolysis index was lower than mean statistical value that indicated predominance of blood procoagulation activity.

[Asymptomatic stenoses and thromboses of the carotid arteries: hemodynamic and ultrasound aspects]. / Asimptomnye stenozy i trombozy sonnykh arterii: gemodinamicheskie i ul'trazvukovye aspekty.

The problem of asymptomatic stenoses of the internal carotid artery (ICA) has become a matter of great concern especially after ultrasonography of the great arteries of the head and, first of all, duplex scanning were introduced on a wide-scale basis into practice of the physicians of varying specialties. The growing population of patients with asymptomatic stenoses raises the problem of their further management with the purpose of preventing ischemic stroke. In connection with significant advances in vascular surgery carotid endarterectomy (CEE) has assumed an increasing role in the treatment of carotid stenoses. In spite of the fact that the efficacy of CEE for hemodynamically significant stenoses has already been proven, nevertheless at present there is no final decision concerning the problem of the indications for surgical treatment of patients with asymptomatic stenoses. The aim of this study was to assess in detail the vascular system of the brain in patients presenting with stenosis greater than 60% and ICA thrombosis, to distinguish the groups at a high risk for stroke and to delineate the treatment measures for its prevention.