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Introduction. The Russian Phlebological Register began work in 2016 under the patronage of the Association of Phlebologists of Russia. The creation of a phlebological register in a separate municipal center of the country complements and enriches national plans. Aim. Тo investigate the trends in the organization of medical care to the population with chronic venous diseases (CVD) of a large industrial center using the phlebological register over the past 20 years. Materials and methods. The data of municipal and private medical institutions of Ekaterinburg from 2003 to 2022 are analyzed. Data on municipal hospitals (MHs) are provided by the TFOMS of the Sverdlovsk region. Data on private medical centers (PMCs) are obtained by exporting them from the electronic databases of each center. The statistics of phlebectomies (PhE), outpatient minimally invasive interventions and procedures are summarized. Results. Over the entire period of time, the number of classical phlebectomies in MHs decreased by 4 times – from 2300 (2003) to 587 (2022). At the same time, the development of minimally invasive procedures on the main veins in the PMCs increased from 313 (2003) to 4364 (2022). This made it possible to double the coverage of patients suffering from CVD with specialized medical care. In the structure of patients operated in MHs, the proportion of persons with severe chronic venous insufficiency (CVD C4–6) significantly decreased. The number of patients with superficial thrombophlebitis had a steady downward trend: the first 5 years (2003–2007) – about 200 PhE/year, then 5 years (2008–2012) – about 120 PhE/year, and from 2013 to 2022 < 100 PhE/year. Discussion. Private medical centers have consistently introduced the latest technologies, but endovasal laser coagulation remains the leader. Conclusion. The analysis of the register revealed a number of systemic changes in the organization of phlebological care.

Stroke in the arteries of the vertebrobasilar system is characterized by a variety of nonspecific symptoms, many mimickers, and often atypical clinical presentation, which, together with the low sensitivity of CT and MRI of the brain, leads to incorrect and untimely diagnosis. This article addresses in detail the issues of differential diagnosis of this disease with Guillain–Barre syndrome, myasthenic crisis, central pontine myelinolysis, multiple sclerosis, Wernicke encephalopathy, vestibular neuronitis, Meniere's disease, and vestibular migraine.

Non-cardioembolic ischemic stroke (IS) of high and very high risk includes three groups of patients: with severe extracranial atherosclerosis, with any intracranial atherosclerosis, and with aortic arch atheromatosis. This risk is also characteristic of patients with aggressive transient ischemic attack (TIA) phenotypes. Effectiveness of secondary prophylaxis can be raised by these strategies: short-term dual antiplatelet therapy using a combination of acetylsalicylic acid with clopidogrel or ticagrelor in minor IS or high-risk TIA; long-term dual antithrombotic therapy with acetylsalicylic acid and low doses of rivaroxaban for multifocal atherosclerosis with low hemorrhagic risk and non-lacunar stroke; early surgical revascularization (carotid endarterectomy or stenting) for non-disabling IS and urgent revascularization for high-risk TIA; intensive, including combined, lipid-lowering therapy with high doses of statins, ezetimibe, PCSK9 inhibitors, or inclisiran to achieve low-density lipoprotein levels

Non-cardioembolic stroke and transient ischemic attack (TIA) are heterogeneous conditions, some variants of which are associated with a high short-term and long-term risk of cardiovascular events. The article presents clinical portraits of patients in high and very high risk groups: 1) patients with extracranial atherosclerosis and severe stenosis/subocclusion/occlusion or CT signs of atherosclerotic plaque instability; 2) all patients with intracranial atherosclerosis, especially those with symptoms of hemodynamic compromise or multiple infarcts; 3) all patients with mobile/ulcerative atheroma of the aortic arch. For the timely identification of these subtypes, it is necessary to use clinical and radiological clues with necessary diagnostic search. In addition, the following patients with TIA may be at high or very high risk: those with an ABCD2 score of ≥4 points or an ABCD3-I score of ≥8 points; with TIA in the vertebrobasilar basin, "crescendo" or "limb shaking" type, orthostatic TIA, as well as patients with warning capsular and bridge syndromes. Assigning a patient to one of the considered categories requires the immediate administration of enhanced secondary prevention, which will be discussed in the second part of this article.

Infective endocarditis is a serious diagnostic and therapeutic challenge for doctors of many specialties. In order to form a structured approach to patient management, the article discusses the key points regarding the neurological aspects of the disease, which are formulated in ten rules. They cover the clinical diagnosis of endocarditis in patients with stroke, features of reperfusion therapy, approaches to prescribing antithrombotic and antibiotic therapy, as well as issues of surgical treatment.

On July 6, 2022, an interdisciplinary meeting of the Expert Council was held on the topic "Control of dyslipidemia in the prevention of acute and recurrent ischemic cerebrovascular accidents". The conclusion of the Expert Council was that after verification of a lipid metabolism abnormality, in patients with ischemic stroke (IS) and transient ischemic attack (TIA) it is recommended to start or continue statin therapy as early as possible. For secondary prevention of IS, it is necessary to achieve the target level of low-density lipoprotein cholesterol (LDL-C) set for each category of cardiovascular risk, with consistent administration of the maximum tolerated dose of statins with biochemical monitoring of the effectiveness and safety of therapy in the interval of 4–12 weeks. The insufficient effectiveness of statins requires the inclusion of ezetimibe therapy and the decision to increase the dose of statins; in case of intolerance to statins and / or contraindications to their administration, early administration of proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors: evolocumab, alirocumab – or an PCSK9 synthesis inhibitor, inclisiran, should be considered. At a LDL-C level of >5.0 mmol/l in patients of the extreme or very high risk group who have had atherothrombotic IS / TIA, necessary administration of a combination including a statin, ezetimibe and an PCSK9 inhibitor (evolocumab, alirocumab) or a PCSK9 synthesis inhibitor (inclisiran) should be considered as early as possible.

Cryptogenic stroke (CS) is defined as a subtype of stroke associated with a heterogeneous group of pathogenetic mechanisms that remained undetermined in the course of advanced diagnostic research. One third or fourth of the ischemic strokes is cryptogenic. Paradoxical embolism is considered the important cause of cryptogenic stroke and transient ischaemic attack (TIA) in young patients. It may occur via the following: patent foramen ovale (PFO), atrial septal defect (ASD), and pulmonary arteriovenous malformation (PAVM). When interviewing patients with suspected paradoxical embolism to obtain their health history, a practitioner should consider factors associated with Valsalva maneuvers, deep vein thrombosis/PE or predisposing conditions or situations, as well as symptoms of hereditary hemorrhagic telangiectasia (telangiectasia of the skin and mucous membranes, hemorrhagic syndrome) and pulmonary arteriovenous malformations (PAVMs) (shortness of breath, hemoptysis). If paradoxical embolism is suspected, it is necessary to conduct a stepwise diagnostic search, including transcranial Doppler ultrasound with bubble test, contrast-enhanced transesophageal echocardiography, and CT angiopulmonography. Diagnosis of relevant clinical conditions involves a search of atrial tachyarrhythmias, deep vein thrombosis, and thrombophilia. As the pathogenetic role of ASD and PAVMs in the development of embolic cryptogenic stroke is beyond doubt, the clinical significance of PFO should be determined taking into account several factors, including the presence of deep vein thrombosis/PE, the severity of the right-left shunt, the presence of ASD, the RoPE score, and detection of thrombophilia. The secondary prevention techniques of ischemic stroke or TIA with underlying PFO should be selected on a case-by-case basis, depending on the clinical significance of the anomaly, comorbid pathology, life expectancy of the patient: endovascular occlusion, anticoagulant or antiplatelet therapy. The secondary prevention with underlying ASD and LAVM includes surgical techniques such as endovascular occlusion or open surgery followed by monitoring of their effectiveness.

The article discusses the concept of embolic stroke from an unspecified source and the role of aorto-arterial embolism in its development. Potential causes of embolic cryptogenic stroke such as aortic atheromatosis, non-stenotic atherosclerosis of the cervical arteries, carotid web and intracranial atherosclerosis are discussed in detail. The discussion of each cause covers epidemiology, pathogenesis, and current approaches to diagnosis and secondary prevention. The diagnostic search is presented in the form of an algorithm. To identify aorto-arterial sources of embolism and to determine their clinical significance, a comprehensive examination including CT angiography with targeted assessment of the aortic arch, transesophageal echocardiography, MRI of the arterial wall and transcranial Doppler is required. When mechanical thrombectomy is performed, histological examination of the thromboembolus is advisable. Given that atherosclerosis is usually systemic, the search for a possible cause of aorto-arterial embolism should be a diagnostic priority in patients with cryptogenic stroke and other arterial (coronary, lower extremity) lesions. With regard to secondary prevention of cryptogenic stroke in the presence of potential sources of aorto-arterial embolism, the principle ‘the more embologenic the source, the more aggressive the prevention’ applies. The arsenal of secondary prevention includes strategies such as strict control of vascular risk factors, achieving target blood pressure, short- and medium-term dual antiplatelet therapy, and intensive hypolipidemic therapy. Surgical prophylaxis is warranted for stroke against a carotid background, the efficacy of which in non-stenotic atherosclerosis requires early evaluation in randomised trials. Each potential cause of cryptogenic stroke considered is illustrated by a clinical example.

Introduction. Transcranial electrical stimulation is a neurophysiological method that is used intraoperatively for evaluating the conduct of a nerve impulse through the cortical-spinal tract. However, the results obtained during registration of this modality do not always correlate with the neurological status of the patient after surgery. The purpose of the study is to determine the prognostic significance of motor evoked potentials in surgical interventions for the elimination of spinal stenosis at the cervical level. Materials and methods. The study analyzed the results of 20 microsurgical root decompressions at the cervical level by eliminating spinal stenosis. Surgical interventions were performed in the neurosurgical Department of National medical and surgical center named after N.I. Pirogov from august 2018 to march 2019. Intraoperatively there were used the following modalities: motor evoked potentials, 3-channel registration of somatosensory evoked potentials from the median nerves, 8-channel electroencephalography, and train-of-four monitoring. The patients were divided into 2 groups: in the 1st group was used inhalant anesthetics, in the 2nd the anesthesia was conducted according to the protocol “Total intravenous anesthesia”. Results. Within each group, in a number of cases, there was a decrease in the response amplitude (by 80 % or more), as well as a loss of motor evoked potentials. In the “Total intravenous anesthesia” group, the current stimulation forces used to obtain motor evoked potentials did not exceed 150 mA, while in the group of inhaled anesthetics, the maximum value was 300 mA, and the average value was 170 mA. In the “Total intravenous anesthesia” group, in 2 cases, a loss of response from one myotome at the decompression phase was registered without recovery during intraoperation monitoring, in 2 cases there was the amplitude loss by 80 % or more with subsequent recovery. In the “Total intravenous anesthesia” group, the results were comparable. Conclusion. During neurophysiological monitoring in surgeries at the cervical level, the loss of motor evoked potentials from one myotome, as well as a decrease the response amplitude by 80 % or more are doubtful as a criteria for predicting neurological deficit.

Introduction. Neurophysiological examination in patients with spinal cord injury is advisable to determine the end of the period of spinal shock. F-wave is a late electromyographic phenomenon realized by activating a pool of motor neurons of the anterior horns of the spinal cord. In the state of spinal shock, the duration of which is variable, F-waves are not recorded. The presence of F-waves from the tibial nerves indicates the completion of spinal shock and restoration of electrical excitability of motor neurons of the anterior horn of the spinal cord. The appearance of F-waves is a marker for diagnostic transcranial magnetic stimulation to assess the viability of the cortical-spinal tract in the early stages of spinal shock.Study aim. To analyze the representation of F-waves in patients in different periods of spinal shock, depending on the level, volume and duration of the lesion.Materials and methods. There were a total of 15 patients with spinal trauma in age from 19 to 29 years enrolled. All patients affected were localized in segments C4–C7. The examination included stimulation electroneuromyography: registration of motor responses, sensory responses and F-waves from the median, ulnar, fibular and tibial nerves on both sides.Results. In 5 patients: 3 in acute, 1 in early and 1 in late periods of spinal cord injury, spinal shock was clinically diagnosed: electromyographic revealed the absence of F-waves for all tested nerves. In 4 patients in the early period of spinal cord injury F-waves were registered only with n. tibialis, the first spontaneous movements in the limbs were clinically observed; in 6 patients in the intermediate and late periods of spinal cord injury f-waves were recorded from all the nerves under study with constant latency. The end of spinal shock was clinically verified, with the presence of a minimum volume of movements and restoration of sensitivity in individual segments.Conclusion. Registration of F-wave should be a mandatory component of stimulation electromyographic in the verification of spinal shock, the duration of which is not correlated with the periods of spinal cord injury. The presence of f-waves is a diagnostic marker for transcranial magnetic stimulation to assess the viability of the cortical-spinal tract.

Background. Peripheral magnetic stimulation (PMS) is applied over spinal roots, peripheral nerves, terminal motor nerve branches. PMS has been used as a method of diagnosis and treatment for two decades. Despite the considerable amount of PMS studies, there is no consensus on the approach to determine the intensity of the magnetic stimulus in the treatment stimulation, the need for the differentiated activation of the different parts of the peripheral nervous system. This was the prerequisite for carrying out this study. Objective: to investigate the PMS intensity required to activate spinal roots and terminal nerve branches, the second object was the comparison of the threshold values among volunteers. Materials and methods. Thirty four healthy subjects with no neuromuscular diseases were enrolled in the study (mean age 31.0 ± 8.6 years). PNS was applied by Magstim 200 magnetic stimulator (Great Britain). During the research the subjective threshold, the threshold of muscle contraction, the threshold of the root activation (according to motor evoked potential) were estimated. Stimulation-induced muscle activity was recorded via surface EMG system (Neurosoft, Russia) synchronized with the magnetic stimulator. Results. The analysis of data identified the significant differences (p 0.05). There were no significant differences between right and left limbs (p >0.05) in the comparison of all parameters. Conclusion. The results of the present study can indicate the possibility of the individual approach of the determination the intensity of the magnetic stimulus for each patient. The findings of our study provide an opportunity for a better understanding of the action mechanism of PMS and can be used in order to develop the treatment algorithm for the use in the clinical settings.

The atrial fibrillation (AF) is the most common disturbance of cardiac rhythm. The AF is associated with an increase in the rate of hospitalization, mortality, stroke development, heart failure. Oral anticoagulants are the basis for prevention of cardiovascular complications in the AF patients. However, the use of anticoagulants increases the risk of intracerebral hematoma. A special group of patients with hemorrhagic strokes are AF patients. Anticoagulant therapy is indicated for this category of patients, on the one hand, due to high risk of development of thromboembolic complications, on the other hand, it is contraindicated in connection with the development of hemorrhagic stroke. The optimum mode of antithrombotic therapy remains unknown. Current approaches to the AF therapy for patients with hemorrhagic stroke are being discussed.

Objective: using magnetic resonance imaging (MRI) to evaluate the characteristics of pathological changes of fibro-cartilage of the knee in patients with Baker cyst, to assess the compliance of degrees of damage stages of osteoarthritis on a scale of Kellgren–Lawrence (K–L), and compare the results with the data of other researchers.Material and methods. This study included patients (38–82 years) with a cyst Baker accidentally detected during ultrasound veins of the lower extremities. The subjects underwent a single knee MRI. MRI was made in three dimensions using 3D gradient-echo protocol. Independent radiologist evaluated the presence and severity of chondral defect osteophytosis, damage to the menisci and ligaments, intraosseous edema and subchondral cysts. The osteoarthritis stage of the knee were identified by X-ray performed in a standing position in the standard two projections, with K–L scale.Results. In this study, the results of a survey of 20 people, whose average age was 57.2 years. According to the radiological scale of K–L two patients were assigned to the stage 0 degree, 5 people to stage 1, 2, 4 each, and 3 – to stage 3. Synovitis of various severity was detected in 85% of the studies. Nineteen visualized the patellar cartilage damage, the condyles of the femur and tibia are most commonly affects the joint area. Among the most commonly injured ligament anterior cruciate ligament was determined – 9 (45%) patients in the same amount of detected intramedullary edema condyles femur and tibia. Eighteen subjects had at least one anomaly meniscus detectable by MRI, while in 11 (55%) persons were deviations, at least two or more regions of the knee examined.Conclusions. Our results suggest that not all visualized on MRI degenerative damage to intra fibro-cartilaginous tissue correlate positively with the stages of osteoarthritis of the knee, identified by standard radiographs and may not significantly affect the onset and progression of synovial cyst of the popliteal region.

Aim. To study pharmacokinetics of apixaban in patients with atrial fibrillation and cardioembolic stroke in acute phase. Material and methods. 17 patients (14 women and 3 men), aged 76.6±9.5 years with atrial fibrillation and cardioembolic stroke in acute phase were enrolled into the study. High performance liquid chromatography mass spectrometry analysis was used to determine apixaban plasma concentration. Results. Intake of a single dose of apixaban 5 mg is described by the following pharmacokinetic parameters: geometric mean of Cmax 124.5 ng/mL (CV%=48), AUC (0, τ) 1008.0 ng•h/mL (CV%=48), AUC (0, ∞) 2751.6 ng•h/mL (CV%=82), median Tmax 3 hours (min 1, max 4), mean t½ 16.9 h (SD 13.6). Negative correlation between NIHSS stroke severity score and Tmax was found (r=-0.628, p=0.007) as well as positive correlation between apixaban t½ and patient age (r=0.638, p=0.01). A tendency to increase in AUC (0, ∞) was observed according to CHA2DS2-VASc points amount but it did not reach the statistical significance (r=0.620, p=0.14). Conclusion. For the first time in Russia pharmacokinetic data of apixaban were obtained in patients with cardioembolic stroke in acute phase. It could be the basis for the development of new personalized approaches to anticoagulation therapy in these patients. Keywords: new oral anticoagulants, apixaban, pharmacokinetics, atrial fibrillation, cardioembolic stroke