Introduction. Perimesencephalic subarachnoid hemorrhage (PMSAH) accounts for approximately half of all cases of non-aneurysmal hemorrhage, has a typical pattern on computed tomography (CT) of the brain, and favorable clinical course. Moreover, in the domestic literature there are no studies devoted to this problem.

The purpose of the study: to study the frequency of occurrence, clinical and CT features of PMSAH in comparison with nonaneurismatic non-PMSAH according to the hospital register of the regional stroke center.

Materials and methods. The data of 383 patients who underwent treatment with a diagnosis of spontaneous SAH in the regional stroke center of Perm Clinical Hospital №4 in 2014–2019 were analyzed. All patients underwent a standard examination, including CT of the brain and digital selective angiography (DSA). According to the pattern of SAH on CT, patients are divided into the groups PM-1 (isolated preptine), PM-2 (traditional) and PM-3 (diffuse). Evaluation of the long-term outcome was carried out using a telephone interview, as well as according to the regional electronic medical system.

Results. Of 383 patients with SAH, aneurysms were identified in 350 patients (91,3%). Non-aneurysmal SAH was found in 20 patients (5,2%), in 8 patients (2,1%) − PMSAH. The age of patients averaged 48 years, women predominated. Intense headache in the onset of the disease was observed in the vast majority of patients. Nausea was significantly more often observed in patients with PMSAР (50%) compared with patients with non-PMSAР (8,3%). Loss of consciousness occurred in every fourth patient with PMSAР and only 8% of patients with non-PMSAH. The neurological status of the patients also did not differ and was characterized by a normal consciousness, meningeal syndrome (in 63% of patients with PMSAH) in the absence of focal symptoms. The level of neurological deficit according to NIHSS averaged 0 points, the severity of SAH on the Hunt-Hess scale averaged 2 points. At the time of completion of treatment, most patients did not have a neurological and functional deficit. According to CT, in 4 patients (50%), PM-2 was visualized, in 3 patients (38%) − PM-3, and in one patient − PM-1 (12%). On average, after 15 months, none of the treated patients developed repeated SAH, patients did not have functional limitations.

Conclusions. This study for the first time made it possible to characterize the approximate frequency of occurrence, clinical and CT picture, as well as the long-term prognosis of PMSAH in a cohort of patients from a large regional stroke center in Russia.

The article is dedicated to the issues of treatment of cerebral small vessel disease (CSVD), one of the most common pathological processes that is a leading cause of different types of cerebrovascular disorders and cognitive impairment. It also discusses the reasons for the development of small vessel pathology, which is usually referred to as the “chronic cerebral ischemia” in the Russian neurology. Emphasis is made on the etiopathogenetic factors affecting small calibre vessels, in which the metabolic-angiogenic mechanisms, in particular endothelial dysfunction and oxidative stress, are dominant.

Difficulties in studying CSVD are explained by the disease course features and the insufficient introduction of unified approaches to the terminology and diagnosis. The article presents new data on the pathogenesis of small vessel disease based on the clinical and pathological findings and achievements of neuroimaging. A modern classification is provided, the clinical manifestations of vascular cognitive disorders associated with chronic cerebrovascular insufficiency are described in detail.

The authors consider the issue of choosing and using drugs for the treatment of cerebrovascular diseases through the lens of understanding their own clinical experience and scientific research findings. They provide data of their own research on the antioxidant status and changes in the phospholipid composition of blood plasma in patients with chronic cerebral ischemia during separate and combined administration of 2-ethyl-6-methyl-3-hydroxypyridine-succinate (Neurox) and citicoline (Neupilept), which are natural metabolites and are involved in biochemical processes throughout the body. Based on the literature review and their own data, the authors conclude that complex pharmacological therapy can be effectively used in patients with CSVD, which is due to various points of “application” of pharmacological activity in the pathogenetic processes chain.

Discogenic lumbosacral radiculopathy (DLSR) accounts for up to 5% of all cases of pain in the lumbosacral region, representing one of the most common causes of disability in the population. The issues of pathogenesis, risk factors, course, diagnosis, treatment and prevention of DLSR are discussed. It is noted that in the pathogenesis of DLSR, in addition to compression-ischemic lesions of the spinal root, an important role is played by local inflammatory and autoimmune reactions, which underlie the natural decrease in disc herniation over time. The diagnosis of DLSR is established on the basis of signs of damage to the lumbar and first sacral roots and the absence of signs that are alarming regarding the specific causes of back pain. Magnetic resonance imaging (MRI) of the lumbosacral region allows you to exclude specific causes, identify a herniated disc, but its implementation does not improve the prognosis of the disease if there are no signs of a specific disease. Of great importance is informing the patient with acute DLSR about the favorable course of the disease, the possibility of natural (without surgical intervention) regression of the herniated disc and the associated inflammatory changes. Non-drug (therapeutic gymnastics, manual therapy) and drugs (nonsteroidal anti-inflammatory drugs (NSAIDs), antiepileptic drugs, epidural administration of corticosteroids) in acute DLSR are analyzed. Own experience of management of patients with acute DLSR using meloxicam as an NSAID is presented. It is noted that in the prevention of low back pain, the avoidance of excessive physical and static stress, regular exercises in therapeutic gymnastics, swimming, walking are of leading importance.

In today ‘s world, back pain is a heavy burden and leads to a decrease in the working capacity, quality of life of people. The choice of tactics of treatment of pain in a back is defined by the pain reason: nonspecific pain, the specific pain caused by serious diseases or a compression of a root. The most frequent cause of back pain is nonspecific pain due to myofascial, muscular-tonic syndrome, facet syndrome, and sacral-iliac joint dysfunction in lower back pain. The article presents clinical symptoms of these syndrome, as well as techniques of neuroorthopedic examination, which allow to detect one or more abrasions of back pain. To prevent acute non-specific pain, it is recommended to prescribe non-steroidal anti-inflammatory drugs (NSAID) and muscle relaxants. Along with pharmacological treatments, treatment of patients with back pain should be more comprehensive and include cognitive-behavioral therapy and kinesiotherapy. Determination of the source of back pain in neuroorthopedic examination makes it possible to carry out local therapy in stages using blockages with local anesthetics and glucocorticoids. In case of insufficient effectiveness of blockades, it is possible to carry out radiofrequency denervation of facet joints or sacral-iliac). Clinical and neuroorthopedic examination of a patient with back pain with identification of sources of pain, analysis of the causes that led to its development, adequate treatment and recommendations to prevent repeated exacerbations can significantly reduce the risk of chronization of back pain and improve the quality of life of patients.

The general practitioner encounters all three forms of insomnia: idiopathic, chronic and acute. Idiopathic and chronic patients should receive specialized care by neurologist, psychiatrist or sleep disorders specialists because they require deep differential diagnosis and complex treatment. Acute insomnia patients need quick help to prevent the negative health impact and chronisation of sleep disruption. In theRussian Federation, the GP has access to three kinds of sleep drugs: benzodiazepines, melatonin receptor agonists, antihistamines. However, modern benzodiazepines are unavailable inRussiaand older benzodiazepines can lead to dependence. Melatonin receptor agonists are not effective enough for acute insomnia. Among available antihistamines, doxylamine is the most convenient option in clinical practice. Doxylamine has a good profile of safety and efficacy, it is included in the local clinical guidelines for insomnia. Also, doxylamine is the only sleep drug available for pregnant women. This paper presents a portrait of doxylamine and comments on its clinical niches and contraindications. We also discuss the pharmacology of doxylamine, drug interactions, and prescription modes. There are also three clinical case studies, presenting the typical acute insomnia patients and logic for their evaluation, underlining key clinical features of this disorder.

Introduction. Speech disorders in Parkinson’s disease are a very common clinical sign. The structure of speech disorders is at the moment not fully understood, there is no unified approach to classification, therapy effects have not been studied.

Materials and methods: 324 PD patients were primarily included in the study, and from those the patients showing clinically significant speech disorders (22,4%) were selected. All the patients were assessed for motor disorders (UPDRS part 3), cognitive disorders (Addenbrooke’s cognitive examination), as well as affective disorders.

Results: by means of cluster analysis we identified 4 subtypes of speech disorders as dysphasia (adynamic, disprosodic, constructive, and logopenic). None of the forms was associated with parkinsonism severity and general severity of cognitive impairment, which allowed to consider dysphasia as a separate clinical syndrome. Disprosodic dysphasia differentiated by severity of axial symptoms (F value = 3.279, p < 0,05), adynamic dysphasia was associated with more pronounced apathy (F value = 4,2, p < 0,01), constructive dysphasia – with impairment of visual-spatial functioning (F value 29,93, p<0,0001), while logopenic dysphasia was associated with more severe attention deficiency.

Conclusion: Speech disorders in PD are heterogeneous and can be regarded as manifestations of dysphasia. Identification of various subtypes will allow for optimizing the treatment of PD patients.

Multiple sclerosis (MS) ranks first for prevalence among diseases affecting the CNS white matter with 2.5 million cases estimated globally. InRussia, the number of cases is about 200 thousand. MS in most cases has a wavy course (periods of exacerbations and remissions), over time the progression of disease worses the quality of life of patients. The “gold standard” at the beginning of MS is first-line drugs disease-modifying therapies (DMT). If they are ineffective, it is necessary to strengthen the effect on the immune processes and the patient is prescribed second-line drugs (escalation of therapy). There is a method of induction therapy, when high activity of MS is recommended to start with drugs that have a strong immunosuppressive effect with a possible subsequent transition to soft supportive treatment. In patients with frequent exacerbations and signs of radiological activity of the disease, according to magnetic resonance imaging (MRI) of the brain and spinal cord, monoclonal antibody preparations are effectively used. Except of escalation and induction, it is also used the method of immune system reconstruction, which leads to a decrease in autoagression in MS. This article discusses a clinical case of using a drug of monoclonal antibodies that selectively bind to CD 52 on the surface of lymphocytes. The issues of efficacy and safety of alemtuzumab therapy in patients with MS are considered.

Introduction. The routine use of highly effective drugs that alter the course of multiple sclerosis requires careful patient selection in order to minimize the risks of possible adverse events. At present, drugs modifying the course of multiple sclerosis have been registered with different mechanisms of action. This makes it possible to implement individual selection of therapy taking into account the multifaceted pathogenesis of the disease. However, the presence of a burdened somatic anamnesis in the patient may significantly limit the choice of drugs by the attending physician. Aim: to gain experience in using ocrelizumab to treat patients with multiple sclerosis. 

Materials and methods. From 2018 ocrelizumab therapy was started in 52 MS patients: 32 patients with recurrent multiple sclerosis (MS) (23 with remitting multiple sclerosis (RMS) and 9 with secondary progressive MS with exacerbations) and 20 patients with primary progressive multiple sclerosis (PPMS). The drug was administered intravenously in drops with infusion in a dose of 600 mg every 6 months in a daytime regimen with an approved protocol of premedication and symptomatic therapy to prevent possible risks of adverse events. The initial dose was divided into 2 infusions of 300 mg at intervals of 2 weeks [5]. Before each infusion, detailed clinical blood analysis, biochemical blood tests, serological tests (HIV, hepatitis B and C, syphilis), and screening for tuberculosis (once a year) were necessarily repeated.

The results. The achieved results clearly demonstrate high efficacy of ocrelizumab in the form of reduction of exacerbations frequency, disease activity according to MRI data and slower progression, which is compared with the data from previous OPERA I, OPERA II and ORATORIO clinical trials. After analysis of the data of dynamics of disability index according to EDSS scale there was observed stabilization in PPMS patients and a slight decrease in RMS patients. No exacerbations were registered in patients with RMS during the period of treatment, as well as no objective data on progression in patients with PPMS were noted.

There is also good tolerance of therapy. However, the question remains as to how long the therapy should take into account the safety spectrum.

The treatment of immuno-inflammatory rheumatic diseases has advanced significantly in recent decades due to development of biological medications, which, however, are not without some weak points. They include immunogenicity, parenteral administration, and potentially insufficient stability of the composition of the drug. Great hopes are related to a relatively new class of targeted synthetic immunomodulatory drugs, currently represented in rheumatology by JAK kinase inhibitors (tofacitinib, baricitinib, upadacitinib) and phosphodiesterase 4 inhibitor (apremilast). The most actively developed group is JAK inhibitors that influence one of the most important signal pathway of immune system. This family includes 4 subtypes: JAK1, JAK2, JAK3 и tyrosine-kinase2 (TYK2). JAK-kinases selectively aggregate with cytoplasmic domains of different cytokine receptors, activation of which includes intracellular signal pathway JAK-STAT (Signal Transducer and Activator of Transcription). STAT proteins are responsible for transduction of the signals from more than 50 cytokines, hormones and growth factors that regulate key processes of survival, proliferation and differentiation of immune cells. The greatest practical experience achieved on tofacitinib. This medication approved inRussiafor several indications: rheumatoid arthritis, psoriatic arthritis, psoriasis, ulcerative colitis. Clinical trials of III phase of ORAL series in rheumatoid arthritis and OPAL series in psoriatic arthritis showed high efficacy of Tofacitinib in different clinical situations. In Russian strategic trial REMARKA after treatment with Tofacitinib very fast improvement of the signs of activity was observed, 68,8% patients achieved low disease activity or remission at 6th month of follow-up. Russian open multi-center observational study of Tofacitinib in 101 patients with rheumatoid arthritis and insufficient efficacy of basic and biologic drugs showed achievement of low disease activity or remission in 60% patients, as well as significant improvement of quality of life with a very low frequency of withdrawals due to adverse events (less than 2%).

Osteoarthritis (OA) is one of the most common diseases of the musculoskeletal system.

The main symptoms of osteoarthritis are pain, stiffness, joint swelling. According to epidemiological studies, about one-third of the chronic moderate and severe pain is associated with OA. Currently, OA is considered as a multifactorial disease resulting from the interaction of various genetic, biological, mechanical, and metabolic factors. Inflammation plays a central role in development and progression of ОА. In patients with OA, histological studies of the synovial membrane detected signs of chronic inflammation. The level of some proinflammatory cytokines may increased and the level of anti-inflammatory cytokines may decreased in blood serum, synovial fluid and joint tissue. Also, adaptive immune cell responses are detected in the joint tissues in patients of OA. Due to its high effectiveness, non-steroidal anti-inflammatory drugs (NSAIDs) are widely used in OA. Oral or local forms of NSAIDs are the drugs of choice in the initial stages of therapy in all guidelines. Etoricoxib is a selective inhibitor of cyclooxygenase 2 (COX-2) and is used for the treatment of OA and other rheumatic diseases. The article discusses the use of etoricoxib in patients with OA.

Interview with a leading expert in the treatment of gout, head of the laboratory of microcrystalline arthritis of the Federal State Budget Scientific Institution “Scientific Research Institute of Rheumatology named after V.A. Nasonova“ candidate of medical sciences Maxim Sergeevich Eliseev.

Introduction. Knee osteoarthritis (gonarthrosis) of different etiology is the most common age-related joint disease affecting over 80% people beyond 55 years of age. The use of hyaluronic acid “replacement” intraarticular injections is the priority method for treating gonarthrosis. Implants with human synovial fluid containing hyaluronic acid with a concentration of 10 mg/ml are the most commonly used therapy in world practice.

Objective of the study: compare the efficacy of RIPART hyaluronic acid, 3.0 ml (Ingal LLC, Russia) and the standard Mucosat chondroprotector therapy (chondroitin sodium sulfate 100 mg, Russia) in patients with degree 1–3 gonarthrosis in the outpatient setting.

Materials and methods. A total of 90 patients with degree 1–3 gonarthrosis were included in the study. The patients had not previously received any treatment with Mucosat chondroprotector and RIPART hyaluronic acid. The drugs for the treatment of patients with gonarthrosis were selected in accordance with the clinical guidelines for the management of osteoarthritis, taking into account the age and comorbidity of patients. Of the non-steroidal anti-inflammatory drugs, Nimesulide, 100 mg was selected at a standard dosage of 200 mg/day for 14 days, followed by reduction of the dose to 100 mg/day for a period of 14 days to 1 month. Mucosat was used as a chondroprotector in two comparison groups No. 1 and No. 3 (n = 60) at a dose of 2.0 ml intramuscularly No. 30 ampoules every other day for 8 weeks. In comparison groups No. 2 and No. 3, a local injection of RIPART 3.0 hyaluronic acid preparation was made into the knee joint (a single injection per week, 3 in total). In comparison group No. 3 (n = 30), the patients with degree 1–3 gonarthrosis received a combined course of local therapy with RIPART 3.0 No. 3 hyaluronic acid and Mucosat injection IM.

In addition to clinical examination, the time required for an individual to climb the 10-step stairs and the time required for an individual to walk the 30-m distance were used to assess the effectiveness of treatment (с). The knee joint volume was measured using a centimeter tape in the middle third of the joint, the knee range of motion was measured with electrogoniometers, the joint swelling was assessed in points (0 to 2 points), pain during palpation along the joint gap was assessed in points (0 to 2). The pain level was assessed using a visual analogue scale, and the functional WOMAC index and Leken index were determined based on the patient-reported outcomes.

Results. In study group No. 1 (nimesulide + Mucosate), 30 patients with degree 1–2 gonarthrosis received nimesulide and Mucosate therapy for 6 months, which resulted in the reduction of pain on a visual-analogue scale on Days 8–9. After 6-month observation, the level of pain on the visual analogue scale in patients with degree 1–2 gonarthrosis did not exceed 20–25 mm, in patients with degree 3 gonarthrosis, the pain level on the pain visual analogue scale did not reduce less than 35–40 mm. The Leken index decreased to 2 points in degree 1–2 gonarthrosis and to 5 points in degree 3 gonarthrosis.

In comparison group No. 2, the effectiveness of local RIPART hyaluronic acid therapy exceeded the indicators in group 1, which made itself evident in the fact that pain decreased on a visual-analogue scale after the first knee joint injection in patients with degree 1 and 2 gonarthrosis and resulted in a decrease of nimesulide doses on Day 2–3 followed by its cancellation. Local RIPART hyaluronic acid therapy in patients with degree 3 gonarthrosis resulted in the reduction of nimesulide dose on Day 22 after the third knee joint injection.

After 6-month observation, the level of pain did not exceed 20–25 mm on the pain visual-analogue scale in patients with degree 1–2 of gonarthrosis and did not decrease less than 35–40 mm on the pain visual-analogue scale in patients with degree 3 gonarthrosis. The Leken index decreased to 5 points.

In comparison group No. 3, the combined treatment “nimesulide + Mucosat + RIPART” in 30 patients with degree 1–3 gonarthrosis showed a significant and noticeable reduction in pain to 15–20 mm on the visual-analogue scale in degree 1–2 gonarthrosis and to35 mmin degree 3 gonarthrosis, the Leken index decreased to 1–2 and 5–6 points, respectively.

Patients with degree 3 gonarthrosis continued to administer nimesulide at a dose of 200 mg/day for 21–23 days, followed by switching to on-demand therapy during the entire observation period (before exercise, after exercise). The pain level on the visual analogue scale in patients with degree 3 gonarthrosis decreased on day 20–23 from the baseline figures of 80–85 mm to 35–40 mm; the relapse rate of pain and reactive synovitis decreased. In patients with degree 1–2 gonarthrosis, nimesulide was cancelled on Day 8, pain level after 6 months did not exceed 15–20 mm on the visual-analogue scale. Changes in the Leken index and WOMAC index correlated with an indicator of pain level of the visual analogue scale.

Conclusions. The study findings showed that the outpatient local therapy with RIPART hyaluronic acid combined with Mucosat chondroprotector and a short course of nimesulide as non-steroidal anti-inflammatory drugs may be recommenced as the preferred treatment method compared to the prescription of any of the chondroprotectors in degree 1–3 gonarthrosis.

The representation of pain syndromes of various localization is very extensive: in the knee and hip joints, this figure reaches 57,8% of the general population, in the shoulder joint 48–84%, and pain in the lower back is experienced by up to 85%. The prevalence of osteoarthritis (OA) increases with age. OA occupies a leading position among all rheumatological diseases, accounting for more than 60–70 % of their total number, and is the leading cause of chronic pain syndrome in the older age group. Clinical symptoms of OA are observed in 30–50% of the population in people over 65 years. Non-steroidal anti-inflammatory drugs (NSAIDs) are the most commonly used drugs for the treatment of pain syndromes. NSAIDs are characterized by a good analgesic effect, but are often the cause of the development of adverse events (NSAIDS). Alternative for the treatment of degenerative-dystrophic lesions of the joints is chondroprotectors (CP). CPS belong to the group of drugs of delayed action of symptomatic therapy (SYSADOA). Among CP, chondroitin sulfate (CS) is considered to be the most acceptable means that can affect metabolic processes in cartilage, synovial and bone tissue, suppressing the synthesis of proinflammatory mediators. The main effects that CS has on the joint in OA are: anti-inflammatory, analgesic, and protective. CS improves the phosphorus-calcium metabolism in cartilage, inhibits enzymes that violate the structure and function of articular cartilage, inhibits the degeneration of cartilage; stimulates the synthesis of glycosaminoglycans (GAG), normalizes the metabolism of hyaline tissue, promotes the regeneration of cartilage surfaces and the articular bag. The main effects that show CS on the joint in OA: anti-inflammatory, analgesic, protective. Slowing bone resorption, reduces the loss of Ca2+ and accelerates the processes of bone repair, inhibits the progression of OA. It has analgesic effect, reduces joint pain, pain at rest and when walking, the severity of inflammation, reduces the need for non-steroidal anti-inflammatory drugs (NSAIDs). One of the representatives of medicinal products based on CS is Mucosate (ampoules 1 and 2 ml) containing 100mg of CS in 1ml. A number of studies have demonstrated the effectiveness of therapy with Mucosat in the treatment of patients with low back pain (LBP) using the 2 ml intramuscularly every other day, a course of 25 injections, as well as in the treatment of OA using the 1 ml intramuscularly every other day, starting with the 4th injection – 2 ml every other day, also a course of 25 injections. Recent developments – a new oral form of Mucosate (capsule) containing harpagophytum and the NEM® complex can serve as a supplement to the injectable course of therapy.

Introduction. The independent role of the atrial septal aneurysm in the occurrence of ischemic stroke remains controversial. In addition to the mechanism of paradoxical embolism against the background of a patent foramen ovale associated with an aneurysm, a number of studies have demonstrated that ischemic stroke can develop due to in situ thrombosis in the aneurysm region.

Materials and methods. Description of the clinical case of a patient with atrial septal aneurysm and ischemic stroke while taking hormonal contraceptives. Analyzed all available publications in PubMed on this topic.

Results and discussion. Among publications suitable for the criteria, in addition to direct visualization of a blood clot in the area of the atrial septal aneurysm, its independent effect on the occurrence of embolic events was demonstrated. In all analyzed cases, anticoagulants were prescribed for secondary prevention, which is justified on the basis of the hypothesis of in situ thrombosis in the aneurysm region.

Conclusion. The analysis of scientific publications showed that the knowledge of this problem is still extremely small. There are no clear criteria, in addition to direct visualization of a blood clot, allowing the atrial septal aneurysm to be considered as a direct cause of ischemic stroke. Nevertheless, the presence of this cardiac abnormality and in combination with risk factors or evidence of prothrombotic status make it possible to regard it as an independent cause of stroke, and qualify the stroke as cardioembolic, which justifies the advisability of prescribing anticoagulants for secondary prevention.