Comparative characteristics of vascular cognitive impairment in dyscirculatory encephalopathy

The significant prevalence of cerebrovascular diseases, a high incidence of disability and mortality from them pose this problem as one of the most important, having not only medical but also national importance.

Chronic disorders of cerebral circulation (CNMC) are extremely widespread. Patients with these disorders constitute a significant part of the contingent of the neurological hospital. In the domestic classification, such conditions are described as discirculatory encephalopathy (DE). Dyscirculatory encephalopathy is a progressive multifocal disorder of brain functions due to the inadequacy of its circulation. According to the order Ministry of Health of Ukraine dated 17.08.2007 № 487 ( "Pro zatverdzhennya klіnіchnih protokolіv nadannya medichnoї Relief for spetsіalnіstyu " Neurology "") to set encephalopathy diagnosis requires the presence of cognitive and / or emotional-affective disorders, evidenced by neuropsychological research.

Traditionally, the main object of interest of the researchers was vascular dementia, which is considered to be the second most prevalent in the population after the primary degenerative one. At present, more and more attention is being paid to less severe cognitive impairment (CN).

Disorders in the cognitive sphere represent one of the most important problems of modern neurology and neuro-geriatrics, which has both medical and social significance. This reflects the general trend in modern neurosurgery to maximize the optimization of early diagnosis and therapy of cognitive impairment in order to prevent the development of dementia. Life expectancy and its quality directly depend on the preservation of cognitive functions. Cognitive impairment is an obligate clinical manifestation of all variants of acute and chronic cerebrovascular diseases (CEH). The peculiarities of cognitive impairment on the background of cerebrovascular diseases include their combination with neurological disorders (motor, speech, and coordination), which makes this problem especially urgent for neurologists.

The relevance of the problem of CNMK is determined not only by the prevalence, but also by its social significance: cognitive and neurologic disorders in discirculatory encephalopathy can be the cause of severe disability of patients. According to the state program, "Preventing mental disorders of the serous-convicts and the medina-cerebral hemorrhage in 2006-2010 pp.", Primary and secondary prevention measures, timely provision of specialized medical care, and rehabilitation measures are needed. Therefore, an important condition for the management of these patients is the early diagnosis of cognitive impairment to identify the dodement stages of the development of the process. It is necessary to organize specialized cabinets to assist patients with cognitive impairment. In modern neurology, there are opportunities for effective prevention, treatment and rehabilitation of patients with cognitive impairment in the early stages of the evolution of cognitive deficits.

The meaning of the analysis of the state of cognitive functions in clinical practice is not limited only to the need for treatment and prevention of cognitive disorders proper. The study of cognitive functions makes it possible to clarify the localization and severity of brain damage, to clarify the cause, to diagnose brain damage in neurological and somatic diseases at an earlier time, to clarify the dynamics of the development or regress of the pathological process, to increase the effectiveness of prevention, treatment, rehabilitation, and precisely formulate the prognosis.

The aim of the study was to optimize the early diagnosis and correction of cognitive impairment in patients with discirculatory encephalopathy by studying the characteristics of clinical, neuropsychological, MRI studies.

The study included 103 patients diagnosed with stage I and II dyscirculatory encephalopathy.

The inclusion criteria were as follows:

• clinically established diagnosis of DE I and II stages, confirmed by methods of neuroimaging (MRI);
• absence of severe stenosing occlusive process of large vessels of neck and head (according to ZDG data);
• clinical signs of atherosclerosis using lipidemic profile data;
• absence of signs of severe heart failure;
• absence of concomitant acute and chronic diseases in the stage of decompensation that could influence the course of the disease (diabetes mellitus, thyroid pathology, collagenoses, purulent-inflammatory diseases, syndromes of endogenous intoxication, etc.);
• absence of acute cardiac causes (myocardial infarction, arrhythmia, artificial heart valves, severe heart failure in IHD).

Among the causes of the development of the disease, 85% were long-term neuropsychic and physical overstrain at work and at home; 46% - violation of the regime of work and rest, 7% - abuse of alcohol, 35% - smoking, 68% - irrational ratio of consumption of animal fats, carbohydrates, table salt against low physical activity, 62% - hereditary cardiovascular disease IHD, atherosclerosis, arterial hypertension, myocardial infarction).

Neurologic examination was carried out according to the scheme using traditional methods of assessing the functions of cranial nerves, motor and sensitive spheres, evaluation of cerebellar functions and functions of pelvic organs. For the study of higher nervous activity, the Rating Mental State Examination (MMSE), a battery of Frontal Assessment Batary (FAB) tests were used. On the MMSE scale, the norm was 28-30 points, mild cognitive impairment - 24-27 points, mild dementia - 20-23 points, moderate dementia - 11-19 points, dementia severe - 0-10 points; on the FAB scale the norm was in the range of 17-18 points, moderate cognitive impairment - 15-16 points, severe cognitive disorders - 12-15 points, dementia - 0-12 points.

In the diagnosis of dementia with a predominant lesion of the frontal lobes, the comparison of the EAV and MMSE results is important: frontal dementia is indicated by an extremely low FAB score (less than 11 points) with a relatively high MMSE result (24 or more points).

In dementia of the Alzheimer's type of mild manifestation, on the contrary, the MMSE (20-24 points) decreases primarily, while the EIA index remains maximal or decreases insignificantly (more than 11 points). Finally, with moderate and severe dementia of the Alzheimer's type, both the MMSE indicator and the EAV index decrease.

The choice of these scales is due to the fact that cognitive impairment of vascular genesis is often combined with degenerative processes.

The study included 21 (20.4%) patients with stage I dyscirculatory encephalopathy (the first group) and 82 (79.6%) patients with stage II dyscirculatory encephalopathy (the second group).

Clinical neurologic disorders with discirculatory encephalopathy of stage I-II are manifested by cephalgic (97.9%), vestibulo-atactic (62.6%), cerebrospinal fluid (43.9%), asthenic (32%), pseudobulbar (11% ) syndromes, autonomic dysfunction in the form of panic attacks, mixed paroxysms (27%), emotional dysfunction (12%), sensitive disorders (13.9%), pyramidal insufficiency (41.2%).

In the neuropsychological study on the MMSE scale in the first group, the assessment was on average 28.8 ± 1.2 points, in the second group in patients aged 51-60 years - 24.5-27.8 points; at the age of 61-85 years - 23,5-26,8 points.

The results were reduced by the following parameters: orientation in place and in time, fixing in memory, concentration of attention, copying of the drawing, repetition of simple proverbs.

The number of patients with values bordering on dementia in the first group was 2.7%, in the second group - 6%. Boundary with dementia assessment (23.5 points) was expressed by a decrease in the indicators for all items of the MMSE scale.

In the first group, the result of the test was reduced due to incorrect copying of the picture or memory loss (words were fixed in memory, but in a subsequent check of 3 words in 15% of cases the patients either did not call a single word or called words in the wrong order, replacing the forgotten ones) .

In the second group, the result of the test was reduced by incorrect copying in 75% of cases. Patients found it difficult to repeat the complex phrase, more than 60% of the serial count was broken. In patients aged 51-60 years, the memory test rates declined in 74%; on the orientation in time and the writing of the proposal - in 24%.

Patients aged 61-70 years - for orientation on the spot - in 43.1%, perception - in 58.7%, memory - in 74% of cases. At the age of 71-85 years, difficulties were found when naming objects, performing a three-stage command, 81% of patients experienced a sharp decrease in memory rates.

Neuropsychological testing for EAV in the first group showed a result of 17.1 ± 0.9 points, in the second group - 15.4 + 0.18 points (51-60 years), 12-15 points (61-85 years).
In patients in the second group, fluency of speech was difficult (1.66-1.85, p <0.05) and the selection reaction (1.75-1.88, p <0.05). When performing a three-stage motor program, 15% experienced difficulties or dynamic apraxia.

Thus, the MMSE and FAB scores were not identical. 34% of patients with normal MMSE cognitive functions had FAB symptomatology (conceptualization, fluency, praxis, choice reaction). The obtained results underscore the need to determine sensitive test scales, the use of which makes it possible to detect mild cognitive impairments related to individual cognitive functions.

In the first group, the quality of sampling for praxis, the selection reaction, speech functions, and optical-spatial activity decreased. In the second case, moderate cognitive impairment was observed in the form of reduction and disturbance of regulatory components (control over activity, its programming and arbitrary regulation), operational components (praxis, speech function, optical-spatial activity).

According to MRI data, foci are symmetrical, hyperintensive on T2-weighted images, localized mainly in white matter, less often in basal ganglia. An external and / or internal hydrocephalus with signs of cortical atrophy was detected.

The lack of identity indicators in the assessment of cognitive status on the scale indicates the need for joint use of screening scales for the detection of cognitive impairment. In patients with discirculatory encephalopathy of the I and II stages, the nucleus of the clinical picture should be recognized as cognitive impairment. Management of patients with cognitive impairment should be based on a number of general provisions: early detection of cognitive impairment; determination of their severity in the dynamic observation of patients; clarification of the nature and pathophysiology of cognitive impairment; early onset with the use of symptomatic and, if possible, etiopathogenetic drug and non-drug therapy with its long duration and continuity; treatment of concomitant neurological, neuropsychiatric and somatic disorders; medical, professional and domestic rehabilitation; with severe cognitive impairment - medical social assistance to family members of patients.

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