[Vestibular rehabilitation for peripheral vestibular hypofunction: an interdisciplinary consensus]

The literature review presents approaches to the management of patients with vestibular disorders. The principles of organization of vestibular rehabilitation in peripheral vestibular hypofunction, indications for appointment, factors influencing its implementation, technique, methods of evaluating effectiveness are considered in detail. Attention is drawn to the fact that the selection of exercises and the duration of vestibular rehabilitation is carried out individually and depends on many factors, including the nature of vestibular deficiency and the specific characteristics of the patient. The possibilities of using additional pharmacological therapy with histamine preparations, which can accelerate the onset of vestibular compensation, are shown. It is noted that vestibular rehabilitation is a safe and effective method of treating peripheral vestibular hypofunction and should be recommended to patients of all ages with vestibular disorders leading to limited social and physical activity.

[Experience of using a Russian alteplase product as thrombolytic therapy in patients with ischemic stroke in routine practice]

OBJECTIVE

To assess the efficacy and safety of thrombolytic therapy (TLT) with Revelisa in patients with ischemic stroke (IS).

MATERIAL AND METHODS

The retrospective study included the data of 72 patients (mean age 64.0±17.1) with IS who were admitted to the Regional Vascular Center of the V.V. Veresaev City Clinical Hospital within the first 4.5 hours after the disease onset in the period August 2022 through February 2023. All patients underwent clinical, instrumental and laboratory examinations under the reperfusion therapy protocol. The severity of neurological deficit measured with the NIH Stroke Scale (NIHSS); the degree of self-care was assessed using the Modified Rankin Score (mRS); hemorrhagic transformation (HT) was classified according to the ECASS 3 criteria. The safety of TLT was evaluated by the incidence of HT, any extracranial hemorrhage, and mortality.

RESULTS

At admission, the mean NIHSS score was 6.0 (IQR 4.0-10.0). In 34.7% of patients, there was an improvement in the form of neurological deficit regression in the NIHSS score by ≥4 points within 24 hours after TLT. One day after TLT, the median NIHSS score was 2 points (IQR 0.00-5.00) in all patients. The changes in neurological deficit according to the NIHSS score were statistically significant (p<0.001). At day 30 after the stroke, 68.1% of patients achieved a favorable outcome (Rankin score: 0-2). Asymptomatic HT (type 1 HT according to the ECASS classification) was reported in 5.6% of patients (4 patients). None of the patients in the sample reported symptomatic HT or extracranial bleeding. The mortality rate was 1.3%.

CONCLUSION

Revelisa has demonstrated high efficacy and safety when used for TLT in patients with IS in real-world clinical practice.

[Treatment of patients with chronic nonspecific lumbalgia with various pain triggers]

OBJECTIVE

To evaluate the effectiveness of complex therapy in patients with chronic nonspecific lumbalgia associated with various pain triggers.

MATERIAL AND METHODS

There were 121 patients with chronic nonspecific lumbalgia (average duration of pain 8.0±5.0 months) aged 22 to 59 years (average age 42.1±10.5). The lesion of the facet joints (24.8%), sacroiliac joint (23.2%), muscles (16.5%) or their combined lesion (35.5%) was established as pain triggers of lumbalgia. The patients underwent complex therapy, including medications, kinesiotherapy and cognitive therapy. Before and after the course of therapy (on average 3 weeks), a digital rating scale for pain assessment, the Oswestry Disability Index and the Hospital Anxiety and Depression Scale (HADS) were used.

RESULTS

After treatment, there was a significant (p<0.01) decrease in pain (6.1±1.1 to 1.13±0.37 points, p<0.01), disability (40.09±3.56 to 22.15±13.20%), anxiety (8.98±0.50 to 6.46±0.34 points) and depression (8.72±0.17 to 6.02±0.26 points). A significant improvement in the condition was found in all pain triggers of chronic lumbalgia. The duration of chronic lumbalgia, the severity of life limitations on the Oswestry Disability Index and anxiety on HADS were the reliable predictors of the low effectiveness of complex therapy.

CONCLUSION

Complex therapy, including medications, kinesiotherapy and cognitive therapy, is effective for various pain triggers of chronic lumbalgia.

[Mental disorders in blepharospasm]

OBJECTIVE

To analyze mental disorders in blepharospasm (BS) before and after botulinum therapy (BT).

MATERIAL AND METHODS

We examined 25 patients with BS (9 men and 16 women), aged 50 to 85 years (mean 64.1±18.5), with BS (main study group). The control group consisted of 20 healthy individuals (7 men and 13 women, mean age 63.5±8.5). Patients were examined before and after BT (after 3 weeks) using a diagnostic structured interview Mini International Neuropsychiatric Interview, GAD-7, PHQ-9, fear of negative assessment (short version) and The Liebowitz Social Anxiety Scale (LSAS).

RESULTS

Fifty-six percent of patients with BS, as assessed by the GAD-7, showed a high level of anxiety, while depression, measured by the PHQ-9 and found in 52% of patients, was mainly manifested by mild disorders. In the group of patients with BS, the mean scores were higher on the GAD-7, PHQ-9, fear of negative assessment (p<0.001) and LSAS (p<0.05) than in the control group. After treatment with BT, the levels of anxiety and depression in patients with BS decreased slightly and remained higher compared with the control group. Psychiatric examination in the majority (64%) of patients revealed mental disorders that could not be explained by the occurrence of BS. The remaining 36% of patients had adaptation disorders (nosogenic reactions) caused by BS. Affective mental pathology (recurrent depressive disorder and dysthymia) and anxiety disorders (social phobia and adjustment disorders) were more often observed in the main study group compared with the control group (24% versus 5% and 68% versus 10%, respectively).

CONCLUSION

A significant proportion of patients with BS have anxiety and depressive disorders, the severity of which does not depend only on the severity of motor symptoms and does not significantly decrease after successful BT, but is caused by mental disorders that preceded the manifestation of BS. Identification of mental disorders to varying degrees associated with BS, not only on the basis of psychometric scales, but also consultation with a psychiatrist, will allow, in addition to the correction of motor symptoms of BS, to differentiate the therapeutic approach through psychotherapy and psychopharmacotherapy.

Results of ELBRUS clinical non-interventional study

Objective: non-interventional study ELBRUS (Etoricoxib in the Treatment of Back Pain) was conducted to investigate the efficacy and safety of daily administration of Rixia® (Etoricoxib) 60 mg per day in patients with chronic non-specific low back pain (CNSLBP).

Patients and methods. The study included 50 patients (31 women and 19 men, mean age 54.3±16.8 years) with CNSLBP. Educational conversation, cognitive therapy, regular therapeutic exercises, identification and treatment of comorbidities were conducted. Patients received etoricoxib 60 mg once daily. Pain intensity was assessed on a 10-point numerical rating scale (NRS), pain-related disability was assessed on the Oswestry Scale (ODS), and emotional state was assessed on the Hospital Anxiety and Depression Scale (HADS).

Results and discussion. The causes of CNSLBP were: in 5 (10%) patients – sacroiliac joint involvement, in 14 (28%) – lower lumbar facet joints involvement, in 3 (6%) – myofascial pain, the remaining 28 (56%) patients had a combination of several reasons. As a result of complex treatment, the intensity of pain at rest decreased on average from 4.0±2.5 to 1.4±1.3 points, while moving – from 6.6±1.9 to 2.8±1.8 points, at night – from 2.7±2 to 0.7±0.9 points according to the NRS, disability – from 39±18.9 to 19.9±14.6% according to the ODS, the severity of anxiety – from 6.5±3.9 to 3.3±2.4 points and depression from 5.0±3.7 to 3.1±2.9 points according to HADS (p<0.001). The duration of treatment was 14.14±3.6 days on average. No adverse events were observed during treatment with etoricoxib. Conclusion. The efficacy and safety of etoricoxib in the complex therapy of patients with CNSLBP was noted. Keywords: chronic nonspecific low back pain, non-steroidal anti-inflammatory drugs, etoricoxib, Rixia®>˂0.001). The duration of treatment was 14.14±3.6 days on average. No adverse events were observed during treatment with etoricoxib.

Conclusion. The efficacy and safety of etoricoxib in the complex therapy of patients with CNSLBP was noted. 

[Cerebrovascular disease with neurocognitive impairment]

In the International Classification of Diseases 11th revision in the section «Diseases of the nervous system», it is proposed to distinguish «Cerebrovascular disorder with neurocognitive impairment», 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.

[Results of the round table: modern approaches to drug therapy of cognitive impairment in cerebrovascular pathology]

On June 25-26, 2021, a round table was held in Kazan with the participation of leading neurologists of Russia, where the issues of treatment of patients with cognitive impairment due to cerebrovascular diseases were discussed. Cognitive disorders of vascular genesis (VCD) are widespread in the population, are a common cause of a decrease in the quality of life and restriction of daily activity. The cause of VCD is both acute and chronic cerebrovascular diseases. An effective way to prevent VCD is to control cardiovascular risk factors, ensure a sufficient level of cognitive and physical activity throughout life. The role of drug therapy, aimed, among other things, at normalizing metabolic processes in the brain, is extremely important. The data on the mechanisms of action of the new domestic drug prospecta, the results of its clinical trials in patients with VCD are presented.

[Cognitive and emotional disorders in patients with migraine and signs of leukoencephalopathy]

OBJECTIVE

To identify cognitive and emotional disorders and their correlation with neuroimaging parameters in patients with chronic migraine.

MATERIAL AND METHODS

We examined 50 patients (8 men and 42 women, mean age 41.9±11.9 years) with migraine, including 31 with chronic migraine, and signs of leukoencephalopathy according to magnetic resonance imaging (MRI). A control group comprised 40 healthy individuals (13 men and 27 women) aged 20 to 64 years (mean 42.6±12.0 years). A number of tests for neuropsychological examination and assessment of the emotional state, including a 12-word test, literal and categorical associations, Benton Test, the Montreal cognitive scale (MOCA), the Hospital Depression Scale, the Beck Depression Scale, the Center for Epidemiological Research scale, the Hospital Anxiety Scale and the Spielberger-Khanin scale, were administered at baseline and after 3 and 6 month of preventive therapy.

RESULTS

Patients with migraine had lower scores (p=0.004) on MOCA, memorization of 12 words (p=0.0003), test for literal (p=0.001) and categorical associations (p=0.0002) compared with the control group. No significant correlations were found between the volume of white matter lesions according to MRI and the severity of cognitive impairment. An inverse correlation of average strength was noted (correlation coefficient R=-0.41) between the number of days with headache per month and the MOCA score (p<0.05). In patients with migraine, signs of depression were found on the Hospital Depression Scale (p=0.04), Beck Depression Scale (p=0.003), the Center for Epidemiological Research scale (p=0.0001), and increased anxiety on the Hospital Anxiety Scale (p=0.0001) and the Spielberger-Khanin scale (p=0.0001). A significant relationship was found between the degree of depression and the MOCA score (p=0.007). The frequency of headaches decreased from 19.4±2.9 to 12.6±4.4 days per month (p<0.05).

CONCLUSION

There were a significant decrease of emotional disorders and improvement of cognitive functions compared with baseline scores during the 6 month therapy. Preventive treatment of migraine and concomitant emotional disorders seems to be the most effective way to improve cognitive functions.

Clinical manifestations and issues of diagnosis of chronic cerebrovascular disease (chronic cerebral ischemia) at an early (pre-dementia) stage

The paper presents experts' opinion on the clinical manifestations and diagnosis of chronic cerebrovascular disease (CVD) (chronic cerebral ischemia (CCI) and dyscirculatory encephalopathy (DEP)) at the pre-dementia stage. It is noted that DEP/CCI is a common diagnosis in Russian neurological practice, the criteria for which have not been updated for a long time. DEP/CCI most often develops in the presence of cerebral small artery (CSA) disease (cerebral microangiopathy (CMA)), the severity of which can be quantified by magnetic resonance imaging. The main clinical manifestation of DEP/CCI is cognitive impairment that may be subjective or moderate at the pre-dementia stage. Emotional disorders (apathy, depression, anxiety) and instability are considered as possible manifestations of CSA disease. It is noted that headache and vestibular vertigo are not caused by chronic CVD; while in patients with CMA, they are usually associated with other diseases (primary headache, peripheral vestibular vertigo, and vestibular migraine). The diagnosis of DEP/CCI should be based on the presence of cognitive impairment, reliable neuroimaging signs of CVD, and the exclusion of another cause of cognitive impairment.

Diagnosis and treatment of migraine: Russian experts' recommendations

Migraine is one of the most common types of headache, which can lead to a significant decrease in quality of life. Researchers identify migraine with aura, migraine without aura, and chronic migraine that substantially reduces the ability of patients to work and is frequently concurrent with mental disorders and drug-induced headache. The complications of migraine include status migrainosus, persistent aura without infarction, migrainous infarction (stroke), and a migraine aura-induced seizure. The diagnosis of migraine is based on complaints, past medical history, objective examination data, and the diagnostic criteria as laid down in the International Classification of Headache Disorders, 3 rd edition. Add-on trials are recommended only in the presence of red flags, such as the symptoms warning about the secondary nature of headache. Migraine treatment is aimed at reducing the frequency and intensity of attacks and the amount of analgesics taken. It includes three main approaches: behavioral therapy, seizure relief therapy, and preventive therapy. Behavioral therapy focuses on lifestyle modification. Nonsteroidal anti-inflammatory drugs, simple and combined analgesics, triptans, and antiemetic drugs for severe nausea or vomiting are recommended for seizure relief. Preventive therapy which includes antidepressants, anticonvulsants, beta-blockers, angiotensin II receptor antagonists, botulinum toxin type A-hemagglutinin complex and monoclonal antibodies to calcitonin gene-related peptide or its receptors, is indicated for frequent or severe migraine attacks and for chronic migraine. Pharmacotherapy is recommended to be combined with non-drug methods that involves cognitive behavioral therapy; progressive muscle relaxation; mindfulness; biofeedback; post-isometric relaxation; acupuncture; therapeutic exercises; greater occipital nerve block; non-invasive high-frequency repetitive transcranial magnetic stimulation; external stimulation of first trigeminal branch; and electrical stimulation of the occipital nerves (neurostimulation).

[Vestibular vertigo]

Vestibular vertigo is most often caused by benign paroxysmal positional vertigo (BPPV), Meniere's disease, vestibular neuritis, vestibular migraine or stroke. Features, diagnosis and treatment of vestibular vertigo in patients with these diseases are discussed. The authors analyze common diagnostic errors based on the data of 700 outpatients (205 men and 495 women, aged 25-88 years, mean age 55 years). It is noted that the cause of vertigo is often misdiagnosed with vertebral-basilar insufficiency, discirculatory encephalopathy, cervical spine pathology; at the same time, BPPV, Meniere's disease, vestibular neuritis or vestibular migraine is diagnosed less often. This fact reflects the lack of awareness of physicians about these diseases. BPPV, Meniere's disease and migraine are effectively treated and therefore their diagnosis and adequate treatment are of great importance.

Improving the management of patients with a diagnosis of chronic cerebral ischemia

The diagnosis of сhronic cerebral ischemia is widely used in domestic neurological practice. A significant part of the patients observed with a diagnosis of сhronic cerebral ischemia suffer from primary or secondary headache, dizziness of various origins, emotional disorders and other diseases that are not diagnosed and therefore do not have effective treatment. Improving the management of patients with a diagnosis of сhronic cerebral ischemia requires the diagnosis and treatment of other diseases that are erroneously defined as сhronic cerebral ischemia. The observation data of 90 patients are analyzed, in which the identification of primary headaches (chronic migraine, chronic tension headache) and drug-induced headache allowed an adequate and effective combination treatment, including rational pharmacotherapy, educational conversations, cognitive-behavioral therapy sessions, relaxation classes and therapeutic exercises, with a pronounced positive effect. The results of a survey of 700 patients are discussed, in which the identification of the causes of dizziness (benign paroxysmal positional vertigo, Meniere’s disease, vestibular neuronitis, emotional disorders with instability) made it possible to carry out effective treatment, while most patients were observed for a long time with a diagnosis of chronic cerebral ischemia or vertebrobasilar insufficiency. In the management of patients with vascular cognitive impairment, which is the main clinical manifestation of chronic cerebrovascular disease, the leading role is given to both non-drug methods (regular physical activity, smoking cessation) and drug therapy aimed at normalizing blood pressure and blood lipid spectrum, preventing blood clots and improving cognitive function. The possibilities of naftidrofuril and nimodipine as drugs for improving cognitive function are discussed.

Regression in the Symptoms and Discal Hernia in Case of Lumbar Radiculopathy

BACKGROUND: Discogenic lumbar radiculopathy has a favorable potential for survival; the regression of clinical symptoms may outpace the subsidence of discal hernia. AIM: The objective of the study is comparing the clinical data and the results of magnetic resonance imaging (MRI) in patients with discogenic lumbar radiculopathy over 1 year of observation. MATERIALS AND METHODS: Thirty-two patients (13 males at the average age of 39.1 ± 11.8 years) with discogenic lumbar radiculopathy confirmed by MRI were examined in the study. The intensity of pain condition was assessed using the numerical rating scale; disability was assessed using the Oswestry disability index. Sixteen patients were subjected to repeated MRI. RESULTS: Statistically significant (p < 0.01) reduction of the average pain intensity and intensity of disability more than 2 times was observed as early as in the first 2 weeks. Gradual reduction of pain and disability was observed during the year. Reduction of discal hernia by more than 50% was observed on average after 8.7 ± 4.7 months. CONCLUSION: In the case of discogenic radiculopathy, the reduction of pain and related disability far outstrips the regression of the herniation of intervertebral disk.

[Hypertension and insomnia]

Insomnia is frequently detected in patients with arterial hypertension (AH): from 19% to 47.9% of all cases according to epidemiological studies. On the other hand, the frequency of hypertension in patients with insomnia ranges from 21.4% to 50.2%, whereas in patients without insomnia, from 11.0% to 41.8%. In single studies in which patients with insomnia underwent ambulatory blood pressure monitoring (ABPM), these patients showed higher nocturnal blood pressure levels. Recent data suggests that insomnia is also a risk factor for hypertension. Among the pathogenetic mechanisms explaining the relationship between hypertension and insomnia, an increase in the activity of the main neuroendocrine stress systems, sympatho - adrenal and hypothalamic - pituitary - adrenal, and the frequent presence of concomitant anxiety disorders are discussed. To determine the sleep quality in patients with insomnia, the Pittsburgh Sleep Quality Index (PSQI) is most often used, patients with hypertension in a number of studies had higher total PSQI score compared to individuals with normal blood pressure. PSQI score correlates with systolic and diastolic blood pressure level, as well as with the presence of non - dipper blood pressure profile. Both hypertension and insomnia are associated with impaired cognitive functions. However, the relationship between cognitive impairment and insomnia is rather contradictory, which is most associated with the methodology for assessing cognitive functions and differences in the initial clinical and demographic characteristics of the examined patient population.

Poststroke cognitive impairment

Cognitive impairment (CI) is one of the leading causes of disability after stroke; CI is observed in more than half of patients and reaches a pronounced degree (of dementia) in every three to five patients. CI in poststroke patients is often caused not only by focal vascular lesions of the brain, but also by the presence of concomitant vascular and neurodegenerative diseases. The treatment and prevention of progressive CI are based on stroke prevention, non-drug and drug methods to improve cognitive functions. Blood pressure normalization during antihypertensive therapy is most effective in preventing the progression of CI in stroke patients. The use of Actovegin in patients with CI after stroke is discussed. The results of the author's own 5-year follow-up of 350 patients with stroke are presented.

[Diagnosis and treatment of acute low back pain]

Low back pain (LBP) is frequent cause for visit to the doctor and common cause of disability. Modern experts' recommendations for diagnostics and treatment of acute LBP are presented. Common mistakes, difficulties in diagnostics and treatment of acute LBP are discussed. Diagnosis of non - specific acute LBP is based on clinical examination and exclusion of specific causes of back pain. Instrumental studies are not needed in most cases of acute LBP. Key steps in the treatment of patients with acute non - specific LBP are to inform of patients about good prognosis of pain, to recommend daily activity and avoidance of bed rest, to prescribe nonsteroidal anti - inflammatory drug for pain reducing. Effectiveness of vitamins B in acute LBP is discussed.

Hypertension and Headache: the Effect of Antihypertensive Drugs

Headache is considered to be one of the main symptoms of arterial hypertension (HT). Complaints of headache are presented by many patients with HT: from 44% to 87%. It is obvious that the majority of complaints of headache in patients with HT is not due to headaches due to increased blood pressure (BP), but multimorbidity (polymorbidity) – the presence of coexisting primary headaches, most often, as in the population as a whole, chronic tension headache (57-85%) and migraine (15-30%). On the other hand, the frequency of HT in patients with migraine ranges from 32% to 44%. The relationship between migraine and HT may be due to common exogenous (external) and endogenous (genetic) factors, as well as common pathophysiological mechanisms. External risk factors, which can be associated with both migraine and HT, include the nature of the diet (excessive consumption of table salt with food), low physical activity, chronic stress; both diseases are also associated with the presence of a connection with the metabolic syndrome. The role of hyperactivation of the renin-angiotensin-aldosterone and adrenergic system and endothelial dysfunction are actively discussed. Angiotensin-converting enzyme takes an active part in the BP control and vascular tone; it is known that some angiotensin converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB) have demonstrated efficacy in preventing migraine attacks. The presence of HT can contribute to the chronic course of primary headache, and effective treatment of HT with antihypertensive drugs, on the contrary, can have a positive effect on the course of primary headaches. Antihypertensive drugs reduce the frequency of headaches compared to placebo, but heterogeneity between different classes was revealed. There was a statistically significant decrease in the frequency of headaches compared to placebo during treatment with beta-blockers, ACEI, ARB, diuretics, while calcium antagonists did not reduce the frequency of headaches. According to a number of studies, the frequency of headaches during the treatment with ARB (candesartan) is comparable to that in the placebo group. Some antihypertensive drugs are used to prevent migraine attacks.

Vascular cognitive impairment and chronic cerebral ischemia (dyscirculatory encephalopathy)

The paper reviews the literature on vascular cognitive impairment (VCI), the diagnosis widely used in foreign neurological practice, as well as chronic cerebral ischemia (CCI) and dyscirculatory encephalopathy (DEP), the common diagnoses in Russian neurological practice. According to the etiology, risk factors, and manifestations, Stages I and II DEP largely corresponds to moderate VCI; Stage III DEP does to severe VCI. The results of the author’s studies show that a considerable proportion of patients followed up with a diagnosis of CCI, DEP, have no signs of chronic cerebrovascular disease (CVD), but suffer from primary or secondary headache, vertigo of various origins, emotional disorders, and other diseases. The diagnosis of CCI, DEP should be based on the presence of CCI, the reliable neuroimaging signs of chronic CVD, and the ruling out of other diseases. When treating and preventing VCI, CCI, and DEP, a premium is placed upon both non-drug (regular physical activity, smoking cessation, rational nutrition) and drug therapy aimed at normalizing blood pressure and blood lipid spectrum, preventing blood clots, and improving cognitive functions.

Chronic nonspecific (musculoskeletal) low back pain. Guidelines of the Russian Society for the Study of Pain (RSSP)

Examination of a patient with chronic low back pain (LBP) is aimed at eliminating its specific cause and assessing the social and psychological factors of chronic pain. The diagnosis of chronic nonspecific (musculoskeletal) LBP is based on the exclusion of a specific cause of pain, discogenic radiculopathy, and lumbar stenosis. It is advisable to identify possible pain sources: pathology of intervertebral disc pathology, facet joints, and sacroiliac joint and myofascial syndrome.

An integrated multidisciplinary approach (a high level of evidence), including therapeutic exercises, physical activity optimization, psychological treatments (cognitive behavioral therapy), an educational program (back pain school for patients), and manual therapy, is effective in treating chronic musculoskeletal LBP. For pain relief, one may use nonsteroidal anti-inflammatory drugs in minimally effective doses and in a short cycle, muscle relaxants, and a capsaicin patch, and, if there is depressive disorder, antidepressants (a medium level of evidence). Radiofrequency denervation or therapeutic blockages with anesthetics and glucocorticoids (damage to the facet joints, sacroiliac joint), back massage, and acupuncture (a low level of evidence) may be used in some patients.

Therapeutic exercises and an educational program (the prevention of excessive loads and prolonged static and uncomfortable postures and the use of correct methods for lifting weights, etc.) are recommended for preventive purposes. 

Hypertension and Dizziness: is there a Relation?

One of the most frequent complaints of patients with hypertension (HT) is dizziness. Dizziness is understood as a variety of subjective sensations that patients define as “dizziness” – a sense of instability when walking, the illusion of rotation of surrounding objects, the feeling of approaching fainting, the inability to concentrate, and “fog” in the head. Experts share the systemic dizziness (vertigo) and non-systemic. The causes of vertigo in most cases are diseases of the inner ear (Meniere's disease, benign paroxysmal positional vertigo [BPPV], vestibular neuronitis. The most common form of dizziness is psychogenic dizziness. In the vast majority of cases, HT is not the cause of dizziness. The most common cause of vestibular (systemic) dizziness in patients with HT, as in the general population, is BPPV, and the most common cause of non-systemic dizziness is psychogenic dizziness. Among other causes of dizziness in patients with HT should be kept in mind too fast and/or intensive lowering of blood pressure, rhythm and conduction disorders, orthostatic hypotension (especially in elderly and senile patients in the presence of concomitant diabetes).

[Problems of the diagnosis and treatment of compression neuropathy of the median nerve: an analysis of typical medical practice]

AIM

An analysis of typical medical errors in the diagnosis and treatment of compression neuropathy of the median nerve at the level of the wrist (carpal tunnel syndrome - CTS).

MATERIAL AND METHODS

Previous diagnoses and treatment of 85 patients with CTS (14 men and 71 women), aged from 36 to 84 years (middle age 62±10.6 years), who underwent surgery in our clinics were evaluated.

RESULTS

The wrong diagnosis was made in most of patients (60%). The osteochondrosis of cervical spine (45.8%) and diabetic polyneuropathy (5.8%) were the most common mistaken diagnoses. Proper neurophysiological measurements using the Phalen's test and Tinel's sign were not performed in the majority of patients. Magnetic resonance imaging (MRI) of the cervical spine was often unreasonably made, the electroneuromyography was not used. Nonsteroidal anti-inflammatory drugs (NSAIDs), vitamin B group were improperly prescribed to the patients diagnosed with CTS. Local corticosteroids injections were not prescribed to most of patients, immobilization of the wrist was not recommended at the early stage of disease and decompressive surgery at the advanced stage of disease. Clinical observation of the patient with long period of misdiagnosing is presented. Despite the long-standing history of CTS, surgical decompression led to regression of symptoms and complete professional rehabilitation.

CONCLUSION

It is necessary to inform physicians about manifestations, diagnostic criteria and effective methods of treatment of CTS.

Chronic cerebrovascular diseases: use of vinpocetine in neurological practice (Round Table proceedings)

The paper presents the proceedings of the Round Table with the participation of leading neurologists, which is devoted to chronic cerebrovascular diseases. It is noted that chronic cerebral ischemia (CCI), or dyscirculatory encephalopathy (DEP), is one of the most common neurological diagnoses in our country. The pathogenesis, clinical presentations, diagnosis and treatment of CCI (DEP) and its matching with vascular cognitive impairment (CI), which is regarded in foreign literature as the main manifestation of chronic cerebrovascular disease (CVD) were considered. The authors analyze clinical trials evaluating the efficacy of vinpocetine (Cavinton) in chronic CVD, dizziness, CI, as well as the use of new vinpocetine formulations, such as Cavinton Comforte, in various neurological diseases, dysphagia in particular, in poststroke patients.

[Disc hernia regression as a natural course of discogenic lumbosacral radiculopathy]

Disc herniation with radiculopathy is a common cause of severe back pain leading to significant disability and a decrease in patients' quality of life. The authors report a case of 38-year-old female patient with radiculopathy of the first sacral root due to a large (11 mm) sequestered disc herniation between the fifth lumbar and the first sacral vertebrae. Conservative treatment with fluoroscopically-guided epidural steroid injection provided a significant clinical improvement, the patient was able to return to normal daily and professional activity in a short time. MRI in 9 months showed the regression of disc herniation. Possible predictors and timing of disc herniation regression are discussed, as well as the proposed mechanisms, the main one of which is considered to be immune-mediated lysis.

Treatment of patients with acute and subacute dorsalgia

Objective: to investigate the efficiency of treatment for acute and subacute dorsalgia, by providing information to patients and by using nonsteroidal anti-inflammatory drugs (NSAIDs) without conducting physical therapy, reflexotherapy, and manual therapy. Patients and methods. A total of 140 patients (87 women and 53 men; mean age 50.7±17.6 years) with acute and subacute back pain were followed up. Out of them 127 (91%) patients were found to have nonspecific (musculoskeletal) pain; 13 (9%) had discogenic radiculopathy. All the patients were informed of the benign nature of the disease, the high probability of its rapid resolution, the feasibility of abandoning prolonged bedrest, and the lack of need for physical therapy, reflexotherapy, massage, and manual therapy. To reduce pain, the patients received meloxicam 15 mg/day orally or intramuscularly or first 15 mg/day intramuscularly and then orally. The investigators assessed pain intensity with the numerical rating scale and functional activity restrictions with the Roland-Morris disability (RMD) questionnaire. Results. After treatment, the visual analogue scale pain intensity scores decreased from an average of 6.4 to 1.0; the RMD scores dropped from 6.8 to 1.4 (p<0.001). The duration of treatment averaged 11.0±4.4 days. Comparison of different meloxicam dosage regimens showed no significant differences; a positive result was noted in all cases. No adverse events were observed during treatment. Conclusion. The investigation has shown the high efficiency of management in patients with acute and subacute dorsalgia, by providing information to patients (an education conversation), by using meloxicam, and by applying a personalized approach (treatment for concomitant diseases and conditions). Refusing physiotherapy, massage, acupuncture, and manual therapy substantially reduces the cost of treatment in patients with acute dorsalgia.

[Cognitive functions, emotional status, MRI measurements in treatment-naïve middle-aged patients with uncomplicated essential arterial hypertension]

AIM

To study cognitive functions, anxiety and depression levels, 24-hour blood pressure (BP) profile, cerebral blood flow (CBF) perfusion in treatment-naive middle-aged patients with uncomplicated essential arterial hypertension (EAH) depending on the white matter hyperintensities (WMH) burden.

MATERIAL AND METHODS

Forty-one hypertensive patients (mean age 46.2±4.6 years) and 41 healthy volunteers (mean age 50.3±6.7 years) were enrolled to the study. All subjects underwent brain MRI (MAGNETOM Skyra 3.0T, T1, T2 FSE, T2 FLAIR, T1 MPRAGE, ASL), Montreal cognitive assessment (MoCa), 10-word learning task, verbal fluency test, trail making test, Stroop color and word test, anxiety and depression assessment with Hamilton rating scales, 24-hour blood pressure monitoring (ABPM).

RESULTS

WMH were found in 22 (53.7%) hypertensive patients and in 3 (7.3%) healthy volunteers (p=0.0002). Hypertensive patients had the significantly lower CBF compared to controls (p<0.001).

CONCLUSION

WMH were identified in treatment-naive middle-aged patients with uncomplicated mild to moderate EAH. There was an association between WMH and lower CBF in the cortical plate of frontal lobes, SBP variability and worse cognition. Cerebral hypoperfusion can cause cognitive impairment even in the earliest stages of EAH, which increases due to emotional disorders.

Features of the clinical picture in patients of middle age with essential hypertension

AIM

To evaluate the presence and the severity of the complaints (headache, dizziness, memory loss, concentration of attention, sleep disturbances, decreased mood, increased anxiety), the state of cognitive functions, emotional status and quality of night sleep in treatment-naïve middle-aged patients with mild to moderate EAH compared to healthy volunteers of the same age.

MATERIALS AND METHODS

103 treatment-naïve patients with EAH aged 40-59 years at the enrollment, who met the inclusion/exclusion criteria and provided written informed consent (46 men, mean age 53.6±0.8 years) and 50 healthy volunteers (17 men, mean age 51.5±1.0 years) with normal blood pressure (BP) level - control group - were enrolled to the study. Mean EAH duration was 2.9±5.7 years. Cognitive assessment included Montreal cognitive assessment, 10-words learning task, verbal fluency test, TMT, Stroop color and word test. Anxiety and depression were evaluated via Hamilton rating scales (HARS and HDRS). 24-hours ambulatory BP monitoring (ABPM) was performed according to European guidelines.

RESULTS

70% of patients with EAH complained of memory disturbance, 68% - lack of attention, 22% - sleep disturbances, 12% - dizziness, 9% - headache. It took statistically significant more time for patients with EAH to perform on TMT B (p<0.05), they had significantly higher TMT B - TMT A difference score (p<0.01) and lower mean MoCA score (p<0.05). Patients with EAH had significantly higher mean score in Hamilton anxiety (2.1±3.7) and depression (1.1±2.4) rating scales compared to controls (0.3±0.9 points, p<0.01 and 0.1±0.5 points, p<0.001, respectively). Patients with EAH who complained of sleep disturbances had low sleep quality (8.7±2.8 points). Among patients with EAH who complained about headaches 66.6% had episodic migraine and chronic tension type headache (33.4%). Those patients had a substantial impact of headache on life and daily living according to HIT-6 (mean score - 57.5±6.1). Only 2 patients out of 12 with complains about dizziness had benign paroxysmal positional vertigo and Ménière's disease.

CONCLUSION

Complaints about memory dysfunction, lack of attention, sleep disturbances, less common - dizziness and headaches, are most typical in patients with EAH on the early stages of the disease. They differ from healthy volunteers of the same age by having cognitive impairment and higher anxiety and depression scores. Patients with EAH who complained about sleep disturbances had low sleep quality. Headache in patients with EAH was due to episodic migraine and tension type headache which had a negative impact on life and daily living.

[Diagnosis and treatment of cognitive impairment in patients with chronic cerebral ischemia: the results of observational Russian program DIAMANT]

AIM

To investigate the efficacy of divaza in outpatients with cognitive disorders and chronic brain ischemia (CBI).

MATERIAL AND METHODS

The non-interventional observational program included the data of 2583 outpatients with CBI from 30 cities (8 federal okrugs of the Russian Federation) who were on outpatient neurological treatment and received divaza in a dose of 2 tablets three times a day from Oct 2016 to Jan 2017. Cognitive functions were evaluated using the MoCA scale before and after 3 months of treatment.

RESULTS AND CONCLUSION

Cognitive disorders were identified in 90.7% of patients (<26 MoCA scores). After treatment, the mean MoCA score increased from 19.58±5.13 to 23.99±4.21 (p<0.0001), the number of patients with normal cognitive functions rate (≥26 scores) increased from 9.3 to 41.3%, the number of patients with marked cognitive impairment decreased. The drug was well-tolerated by old and very old patients, adverse events were observed rarely (0.6% of cases). The majority of doctors (88.4%) noticed the effect of divaza as significant improvement or improvement, and 89.6% of patients valued the effect to be excellent or good. The use of divaza, the drug with endothelioprotective and nootropic effects, is pathogenetically justified and promising in patients with cognitive disorders of vascular etiology.

[Brain Perfusion, Cognitive Functions, and Vascular Age in Middle Aged Patients With Essential Arterial Hypertension]

OBJECTIVE

This study aimed to assess the cognitive functions and cerebral blood flow measured with arterial spin labeling (ASL) and their possible correlations with vascular age in untreated middle-aged patients with grade 1-2 essential arterial hypertension (EAH).

METHODS

We examined 73 subjects aged 40-59 years (33 with EAH and 40 healthy volunteers [controls]). Neuropsychological assessment included Montreal Cognitive Assessment (MoCA), Trail Making test (part A and part B), Stroop Color and Word Test, verbal fluency test (phonemic verbal fluency and semantic verbal fluency), 10‑item word list learning task. All subjects underwent brain MRI. MRI protocol included ASL. Vascular age was calculated by two techniques - using Framingham Heart Study risk tables and SCORE project scales.

RESULTS

Patients with EAH had lower performance on phonemic verbal fluency test and lower mean MoCA score (29.2±1.4 vs. 28.1±1.7 points) compared to controls (13.4±3.2, р=0.002; 29.2±1.4, p=0.001, respectively). White matter hyperintensities (WMH) were present in 7.5 % controls and in 51.5 % EAH patients (р=0.0002). Cerebral blood flow (CBF) in EAH patients was lower in both right (39.1±5.6 vs. 45.8±3.2 ml / 100 g / min) and left frontal lobes of the brain (39.2±6.2 и 45.2±3.6 ml / 100 g / min, respectively) compared to controls (р.

[The peripheral vestibular disorders encountered in the routine out-patient practical work]

The objective of the present study was to elucidate the frequency of causes underlying the development of dizziness and vertigo in the patients seeking advice and care at an outpatient healthcare facility. A total of 590 patients with complaints of dizziness and vertigo were examined. It was found out that the peripheral disorders of the vestibular analyzer were the most frequent causes of dizziness and vertigo in the majority of the examined patients. These conditions were documented to occur in more than 65% of the patients. The most common forms of peripheral vestibular disorders were benign paroxysmal positional vertigo, Meniere's disease, and vestibular neuronitis. The central vestibular disorders occurred considerably less frequently than peripheral ones and were diagnosed only in 10.9% of the patients. The results of the study provided a basis for the development of the algorithm forthe bedside examination of the patients presenting with vertigo and dizziness associated with peripheral vestibular disorders. It is emphasized that such examination should include, besides the standard neurological studies, the neuro-otological tests making it possible to detect the most common forms of peripheral vestibular disorders.

[The acute tetraparesis as a rare presentation of Chiari malformation]

The authors present a case-report of a 25-year-old patient who developed symptoms of transversal injury of the spine. The patient was followed-up for 2 years and had a stable course of Chiari malformation I and syringomyelia. Motor disorders and deep sensory disorders developed without external cause and continued to increase during 2.5 weeks with the further development of pelvic disorders. After the urgent cranial/vertebral decompression with the plastics of the dura mater by a fragment of a wide fascia of the thigh, there was an increase in muscle power (with the complete recovery in hands), regress of deep sensory disorders in hands and pelvic disorders. A literature review on case-reports of acute neurological symptoms in Chiari malformation I and syringomyelia in presented.

Diagnosis and treatment of benign paroxysmal positional vertigo in common clinical practice

Aim. To analyze typical medical practice in managing patients with benign paroxysmal positional vertigo (BPPV). Subjects and methods. 33 patients (5 men and 28 women; mean age, 58 years) with BPPV who had been referred for consultation to the Medical Diagnostic Department, Clinic of Nervous Diseases, I.M. Sechenov First Moscow State Medical University, regarding for vertigo, were examined. Information about the disease before visiting the clinic, such as the duration of vertigo, its pattern, and triggers, previously established diagnoses, prescribed treatment and its efficacy, concomitant diseases, was analyzed. Results. BPPV was not timely diagnosed in 93.9% of cases. The cause of vertigo was most commonly mistakenly assumed to be cerebrovascular disease (66.6%) and cervical spine pathology (15.1%). During a primary examination, none of the patients underwent positional tests (otoneurological examination) that formed the basis for the diagnosis of BPPV. Alternatively, 90.3% of cases underwent instrumental examination: magnetic resonance imaging of the brain, X-ray of the cervical spine, and ultrasonic duplex scanning of the brachiocephalic arteries. Ineffective diagnosis led to the choice of nonoptimal treatment tactics: instead of therapeutic repositioning maneuvers (RM), the patients received therapy with drugs, such as various vasoactive agents (84.8%), nootropic and chondroprotective drugs (12%), or muscle relaxants (9.1%). After BPPV was detected, all patients underwent curative RM, which resulted in regression of the disease. One-year follow-up of the patients showed that the therapeutic effect of RM persisted. Conclusion. Lack of effective and timely diagnosis of BPPV reflects physicians’ poor awareness that this condition is the most common cause of vestibular vertigo. The role of vascular and cervicogenic factors in the development of vertigo is overestimated. Most patients with BPPV undergo unreasonable examinations and receive ineffective treatment. It is necessary to raise awareness of BPPV among of physicians and to set up specialized centers for the management of patients with dizziness.