Том 28, № 3 (2021)

Currently, only symptomatic treatment is applied to patients with cerebral edema. It is aimed at correcting intracranial hypertension as a complication of the already formed cerebral edema. Targeted pathogenetic treatment capable of affecting various molecular processes during the formation of cerebral edema is considered as a promising area. The review article presents currently available symptomatic treatments. The emphasis is placed on the hyperosmolar therapy most often used in the treatment of elevated intracranial pressure. Possible side effects of this therapy and ways to minimize them are described. Future vectors of treatment based on ultrastructural studies of the development of cerebral edema are discussed. Advances in molecular biology have made it possible not only to identify possible targets, but also to try to influence them with well-known drugs that were previously used for another purpose. In this regard, much attention in the literature is paid to the antidiabetic drug glibenclamide. The use of small doses of this drug has shown antiedematous effect at the early stages of edema formation, not only in experimental animals, but also in clinical practice. We presented the generalized data on the directions of treatment of cerebral edema both at the present time and those planned in the future in the form of a scheme.

In the context of the COVID-19 coronavirus infection pandemic, it is important to study neurological symptoms and signs associated with acute and long-term periods of the disease. The pandemic contributed to an increase in the number of patients with acute cerebrovascular accidents; asthenia became one of the serious problems in the long-term period of the disease. The review presents the mechanisms of development of oxidative stress, which negatively affects the severity of stroke, including associated with infectious diseases. The possibility of therapy and determination of targets for the use of metabolic drugs is discussed, in particular, the use of the Cytoflavin® for the relief of asthenia, which plays an important role in maintaining mental and physical health.

Background. Angiotensin II receptor antagonists (ARAII, sartans) are one of the drugs of choice in the treatment of arterial hypertension (AH). The use of antihypertensive drugs is not equally effective for all patients. Losartan is metabolized to an active metabolite by cytochrome CYP2C9. The gene encoding this enzyme has several polymorphisms that affect its activity. Objective. Assesment of the effect of CYP2C9 gene polymorphisms on the hypotensive efficacy of therapy with losartan. Methods. The study included 81 patients. At the first stage, 24-hour blood pressure monitoring and genotyping for CYP2C9*2 and CYP2C9*3 allele variants were performed. Against the background of monotherapy with losartan, the activity of the CYP2C9 isoenzyme was assessed as the E-3174 losartan metabolite/ losartan concentration in the urine ratio. Depending on the results of CYP2C9 genotyping, the patients were divided into two comparison groups: the first group - carriers of the CYP2C9*1/*1 allele and the second ones - carriers of the CYP2C9*2, CYP2C9*3 alleles. At the second stage, 3 months after, various parameters of 24-hour blood pressure monitoring and the effectiveness of the therapy between the two groups were assessed. Results. An association of CYP2C9 polymorphic alleles with ineffectiveness of losartan therapy was revealed (OR=8.13, 95% CI 2.75-23.98). Comparative analysis of 24-hour blood pressure monitoring data showed that mean and maximum systolic and diastolic blood pressure at the end of the study was significantly higher in carriers of CYP2C9*2 and *3 allele variants. The deltas between the 24-hour blood pressure monitoring values before and after therapy were significantly higher in carriers of the CYP2C9*1/*1 variant. The results of a pharmacokinetic study did not reveal any effect of CYP2C9 gene polymorphisms on the concentration of losartan and its metabolite in urine. Conclusion. Carriage of allelic variants CYP2C9*2 and CYP2C9*3 is associated with a decrease in the hypotensive effect of losartan.

Background. In patients with post-stroke spastic hemiparesis, daily activities and self-care are largely determined by the function of the non-paretic hand. Although it is known that there is a motor deficit in a “healthy" hand, rehabilitation programs, however, are mainly aimed at the paretic hand. Currently, there are practically no approaches to the rehabilitation of the motor functions of the ipsilesional hand, so this aspect needs to be carefully studied. Objective. Evaluation of the bioelectric activity in the cerebral cortex in patients with post-stroke paresis of the upper limb before and after a course of rehabilitation exercises with intact hand movement imagination (MI) and using the brain-computer interface+hand exoskeleton (BCIE) in comparison with healthy subjects. Methods. We examined 5 right-handed patients (age - 61.1±0.5 years) with post-stroke hemiparesis, the period from the onset of the disease - 0.4±0.3 years, with a decrease in muscle strength 2-3 points according to the 6-point scale. The control group consisted of 5 healthy individuals of a similar age. BCIE was used for rehabilitation, 10 daily sessions were carried out. The EEG study was carried out on day 0, before the start of rehabilitation procedures, and on the day 30, 2 weeks after the end of the rehabilitation course. The power of EEG rhythms in a ten-second series of consecutive one-second epochs was analyzed. Results. In patients with right-sided hemiparesis, during the MI in the intact “healthy" hand, changes in the power of the mu- and alpharhythm were revealed compared to the results of examination of healthy ones - there was a “delay" in its decrease before the course of rehabilitation, and after course of rehabilitation, there was variable power loss during 1st second in both central and, similarly, in the posterior frontal leads. Thus, after BCIE sessions with MI in an ipsilesional «healthy» hand, altered bioelectrical phenomena, but similar to those occurring in healthy individuals, were found. Conclusion. The data obtained demonstrate the need not only for paretic hand exercises and bimanual training, but also for “healthy" hand exercises in the process of rehabilitation of patients with pyramidal hemiparesis, and also confirm the effectiveness of rehabilitation using BCIE.

Background. The frequency of thrombolytic therapy (TLT) is an important indicator of the work of a stroke service in any region. Identifying the reasons limiting the frequency of TLT use is extremely important. Objective. Assessment of the efficacy and safety of the intravenous thrombolysis in patients with ischemic stroke (IS) in the vascular centers of the Republic of Tatarstan. Identification of possible factors limiting the use of TLT in IS. Methods. Observational 12-year study of treatment outcomes for patients with IS in vascular centers based on hospital registry data. Results. The study included 124 891 IS patients; 101 551 patients were treated in vascular centers. TLT was performed in 4903 patients. The frequency of intravenous thrombolysis for the period from 2008 to 2019 increased from 2.87 to 7.83% (p<0.005); among patients with baseline NIHSS score of more than 15 points at admission, the frequency of thrombolysis decreased from 8.95 to 6.78% (p<0.05). Assessment of the outcomes by the 30th day from the onset of the disease revealed that the proportion of independent in everyday activities after thrombolysis was 54.95%; among patients who did not undergo TLT, the proportion of independent in everyday activities was 30.80%. Over 12 years, the incidence of symptomatic hemorrhagic transformations after thrombolysis decreased from 7.57 to 1.51% (p<0.001). The mortality rate among patients who did not undergo TLT was 9.72%. Mortality among patients who underwent TLT was 5.10%; over the period from 2008 to 2019, mortality in this category of patients decreased from 15.15 to 5.30% (p<0.005). Conclusion. In the clinical practice of vascular centers in the Republic of Tatarstan, TLT has demonstrated its safety and efficacy in patients with IS of varying severity. Analysis of the stroke register data allows concluding about the importance of the decision-making problem at the stage of selecting patient candidates for reperfusion therapy.

Background. Currently, amiodarone is considered as one of the most effective and safe drugs used in the treatment of patients with various cardiovascular diseases. At the same time, taking amiodarone even in low doses causes side effects, and the risk of their development increases as the duration of the drug administration increases. The main ones include damage to the thyroid gland with the development of both hypo- and hyperthyroidism. The most severe complication arising during therapy with amiodarone is amiodarone-associated thyrotoxicosis (AAT). Hyperthyroidism developing in patients with coronary artery disease (CAD) negatively affects the cardiovascular system (CVS), which significantly worsens the prognosis of the disease. Objective. Assessment of the state of intracardiac hemodynamics in patients with coronary artery disease and developed AAT. Methods. The evaluation of the state of intracardiac hemodynamics in 48 CAD patients during the development of AAT, the achievement of the euthyroid state and at the end of treatment was carried out. Results. The main complaints of CAD patients with identified AAT include irregular and rapid heartbeat. 8.7% of examined patients with postinfarction cardiosclerosis (PICS) did not have any complaints, and the diagnosis of AAT was established on the basis of laboratory and instrumental tests. At the onset of AAT in patients of this group, hypo- and eukinetic types of blood circulation were noted. The further course of thyropathy in this category of patients contributed to the formation of a hypokinetic type of blood circulation. Along with this, in other examined CAD patients, the course of AAT was characterized by the formation of a hypo- and eukinetic type of blood circulation (19.0 and 78.4%, respectively) by the end of the observation. In CAD patients with PICS, there was a 3.3% increase in left ventricular end-diastolic volume (LV EDV) by the period of reaching euthyroidism, and by the end of the follow-up period, there was a 4.1% decrease from the initial parameters. At the same time, the left ventricle end-systolic volume (LV ESV) progressively increased by 6.1%. The ejection fraction (EF) after reaching normal values of basal metabolism increased by 10.1%. Subsequently, there was a significant decrease in the heart pump function (by 14.2% of the initial values). In the group of CAD patients without PICS, a gradual increase in the LV EDVand LVESV was noted. The maximum increase by 7.3 and 12.7%, respectively, was noted by the end of treatment. By the period of reaching euthyroidism, the EF decreased by 10%, by the end of follow-up - by 12.6%. Conclusion. Changes in central hemodynamics in CAD patients with developed AAT vary depending on the clinical form of the disease. In patients with PICS, a hypokinetic type of blood circulation is formed with pronounced structural and functional changes in the myocardium, even when a drug-induced euthyroid state is reached. In CAD patients without myocardial infarction with the developed AAT, changes in intracardiac hemodynamics are characterized by a gradual increase in the volumetric parameters of the left ventricle with a decrease in its pumping function.

Orofacial pain is a medical, dental, social and psychological problem. Trigeminal neuralgia (TN) is the most severe and common form of orofacial pain. Most researchers dealing with the problem of facial pain believe that the cause of the development of the primary «classic» TN is a neurovascular conflict associated with compression of the trigeminal nerve by dilated, loop-like convoluted superior or anterior inferior cerebellar arteries in the area where its root enters the pons. The diagnosis of TN is based on typical attacks of paroxysmal, electric shock-like pain in the innervation area of the second and/or third branches of the trigeminal nerve and the exclusion of other pain syndromes. The elimination of the symptomatic nature of facial pain requires the participation of an expert group consisting of a neurologist, neurosurgeon, neuroradiologist, maxillofacial surgeon, and dentist. The most commonly used drug therapy is effective for 80% of patients with TN. Surgical treatment is indicated in pharmacoresistant (refractory) TN.

Rehabilitation of patients after acute cerebrovascular accident (ACVA) is one of the most pressing problems in modern medicine. Timely and continuous rehabilitation support of the patient at all stages of treatment is an essential factor for social, everyday life and occupational adaptation. Involving family members in the recovery process, training the skills and rules for setting goals are also essential components of successful rehabilitation. The wide spreading and implementation of telemedicine technologies can play a leading role in achieving these goals. Based on the data of domestic and foreign literature, the current trends in the rehabilitation of stroke patients with the use of telemedicine technologies were determined. The effectiveness of telemedicine rehabilitation was assessed based on the analysis of various studies and personal experience, and the possibility of using such remote methods and approaches after the COVID-19 pandemic was considered.

Background. Every year there is an increase in the number of patients with post-stress compensatory functional neuroendocrine disorders caused by chronic psycho-emotional overstrain and stress. These patients are characterized by a wide variety of clinical manifestations that are beyond a pale of single medical specialty. This entails ineffectiveness or a significant decrease in the effectiveness of diagnostic and treatment measures, which are attributable to the management of this group of patients by several specialists without a general plan of examination and treatment, as well as polypharmacy. Description of the clinical case. The presented clinical case belongs to the category of “difficult diagnoses", since its solution lies in the interdisciplinary field. The leading syndromes included dyssomnic syndrome and asthenic syndrome, autonomic dysfunction. These syndromes were the reason why the patient could no longer lead an active life and work intensively. That is, in this case, we observe a functional multisystem pathology, which acquires medical and social significance. In this clinical case, the drug of choice for the beginning of the correction of the dissomnic syndrome in combination with psychoemotional disorders was the drug Cellex containing as an active substance polypeptides from the brain of pig embryos, as a result of treatment the patient experienced a decrease in symptoms 5 days after. The patient also showed a manifestation of hormonal imbalance: an increase in the sex hormone-binding globulin level, which led to a sex steroid deficiency. The drug of choice for the correction of hormonal dysfunction (improvement of endogenous synthesis of sex hormones) has become a human placenta polypeptide preparation (trade name «Laennek»). By the decision of the board of doctors (neurologist, endocrinologist and gynecologist), compliance with sleep-wake regimen, occupational and rest hygiene, exclusion of flights for the period of treatment, and the use of multivitamin-mineral complex preparations and vitamin D3 were recommended. Conclusion. Treatment of young patients with post-stress compensatory functional neuroendocrine disorders requires a highly qualified physician or collegial interaction of doctors of different specialties (interdisciplinary approach). The presented clinical case confirms the effectiveness of polypeptide drugs for young patients in the presence of functional multisyndromic pathology.